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August 22, 2014

A fashionable, hip operation

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Dr Ruairi Hanley

Dr Ruairi Hanley is concerned that unnecessary ‘Premiership footballer treatment’ is being carried out on a significant number of all-too-willing private patients.

Orthopaedic surgeons tend to get a hard time from other doctors. This typically manifests itself in jokes implying that our eminent colleagues are basically chisel-wielding, dribbling morons. I have always thought this form of ‘comedy’ grossly unjustified. In my experience, unlike practitioners in some other branches of medicine, orthopaedic surgeons typically prefer to solve problems rather than talk about them.

This is an admirable philosophy that goes down well with most sensible patients — e.g. ‘Mr Smith, there is no point in debating this. You need a new hip. Leave it to me’. Personally, I think our profession needs a lot more of this no-nonsense style.

Furthermore, I have always found orthopods to be just as intelligent as their physician counterparts. The only difference is, they don’t feel the need to prove it by pontificating and engaging in meaningless, attention seeking research.

Now, having established that I do not harbour any hostile feelings towards my bone-fixing buddies, I must say that I am increasingly concerned about what has been going on in their specialty. In particular, it appears that a massive private knee surgery industry is emerging in Ireland. It seems everyone with what might have once been called a sprain or a soft tissue injury is now demanding (and getting) what I have christened the ‘Premiership footballer treatment’.

Public patient
It works as follows. A public patient with a knee injury is treated with anti-inflammatories and (if they are lucky) physiotherapy. Recovery can take months, and if it does not happen they then go on the public waiting list for an orthopaedic outpatient appointment. This might happen a year later, by which time a significant proportion of patients no longer have any pain.

However, for the ‘Vhi-positive’ knee injury sufferer, things seem to work out very differently. These patients often rock up in the GP surgery demanding an MRI scan and a letter for a private orthopaedic surgeon. The concept of actually taking the tablets and waiting for natural healing is seemingly no longer acceptable. Instant gratification is demanded and surgery can happen within a matter of weeks.

Call me a cynic, but I have found there to be very little difference in long-term outcome for these two groups of patients. Obviously, for high-performance athletic types, surgery is vital and necessary. However, for the average Seán Citizen playing five-a-side football once a month with his overweight mates, I personally think it is hard to justify. Unfortunately, Seán tends not to see things that way.

Rest assured, I am not blaming the orthopaedic surgeons for this. After all, they are merely responding to (occasionally irrational) patient demands. It is also very unlikely their interventions will make the situation any worse; it just might not be much better than eight weeks of Diclofenac and a few exercises.

Fashionable
As a GP, I have tried to explain this to patients, with limited success. I have begun to suspect that knee operations have become fashionable, almost glamorous, badges of honour for some people in our society. But we are all paying for them in our ridiculously high Vhi premiums.

Over the past few years, I have noticed a similar pattern creeping into the management of back pain. Here, some back surgeons appear to have become big fans of the surgical removal of discs from the spines of private patients.

I have no doubt this is of enormous benefit to those people with intractable symptoms of disc prolapse. Nonetheless, I find it strange that this procedure appears to occur far less frequently in medical card holders attending public clinics, where excellent oral medications seem to be the preferred treatment.

Again, and at the risk of sounding cynical, I have not noticed a major difference in the level of suffering between these two groups over time. However, I would dearly love to see some statistics on the matter.

Another, somewhat amusing, phenomenon is the rise and rise of the MRI scanner. When I went to college in 1994, I think there were only a small number of these machines in the State.

Now they seem to be everywhere, even popping up near shopping centres. I suspect this is due almost entirely to patient demand and the indulgence of health insurance companies. However, I genuinely wonder, has the widespread use of the private scan had any demonstrable, positive impact on public health?

Now, let me be clear here — I am not a communist. I would have little problem with any of this except for the fact that I see so many elderly patients suffering from agonising pain due to advanced arthritis in many parts of their bodies. These people can often wait years to see a specialist, due to the epic mismanagement of our public health system.

I am sure the vast majority of expert colleagues would prefer to be working on these more worthy cases, but are simply unable to do so because our hospitals primarily exist to provide cushy jobs for unionised administrators, and not theatre time for surgeons. Thus, consultants are effectively forced to keep their skills up by doing fashionable operations on healthy younger men and women, who effectively are demanding these procedures.

Naturally, my socialist readers would respond to this with some idiotic plan to ‘clamp down’ on consultants’ private practice. This would do nothing whatsoever to address the problem of surgeons sitting around public hospitals waiting to operate, but being denied the right to do so by pen-pushers under the protection of left-wing politicians and unions.

I therefore have a suggestion for the Minister for Health. Pay the lads in the flashy new clinics to do the MRI scans and the surgical procedures for every arthritic, suffering individual in the State. The Labour Party and their union buddies will squeal in outrage. Let them.

Trust me, Dr Reilly, this is the only way to get the job done.