For patients who are candidates for spinal surgery, the next obvious step is for them to ask their treating physician for a referral to a spine surgeon. However, getting a referral to an appropriate spine surgeon may not always be as straightforward as it may sound. The difficulties are due to several issues, including:
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There are many peripheral factors that often impact the referral (other than simply who is the best spine surgeon to do a patient’s surgery)
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Many patients are not sure what type of surgeon is best qualified to perform a particular type of back surgery
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Due to lack of objective information, it may be difficult for patients to evaluate and determine who is the best spine surgeon.
This article addresses the above issues and provides guidance to help patients play a proactive role in finding, evaluating and deciding on a spine surgeon prior to having back surgery.
Influences on spine surgeon referrals
There are several factors that may affect which spine surgeon a patient is referred to, including:
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Market forces. Health care in the US is a business and there are often market factors (such as financial incentives) that influence a physician’s referral pattern.
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Insurance. Many patients are enrolled in managed care programs and there may only be a select number of spine surgeons in the program who are available to do spine surgery. Not using one of the contracted spine surgeons can result in steep financial consequences.
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Large practices. Many physicians are part of a large multi-specialty group practice or network and they may be financially or otherwise encouraged to refer patients to a spine surgeon within their own practice or network.
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Personal factors. Some physicians may be more inclined to support a local spine surgeon - especially if they live and work in a small community - and some physicians may favor referring patients to spine surgeons whom they know personally.
One problem referring physicians have is that there is no good way for them to absolutely evaluate the competence of a spine surgeon. Typically, physicians use the same criteria as the general public to evaluate surgeons – that is, word of mouth and anecdotal data.
A spine surgeon’s reputation is developed over time and is based mainly on word of mouth and anecdotal data. Referring physicians can get a sense of whether or not a certain spine surgeon has a high or low complication rate, and what their success rate has been. There is, however, no source (such as a database) that allows a heads up comparison of one spine surgeon to another.
Types of spine surgeons
Both an orthopedic surgeon and a neurosurgeon may have been extensively trained in and be qualified to perform most types of spine surgery. While an orthopedic surgeon is likely to have done fellowship training in orthopedic spine surgery and a neurosurgeon in neurosurgical spine surgery, most of the residency training is similar for both specialties. For the most part, the qualifications of the surgeon to do spine surgery are more driven by the amount of training in spine surgery and the amount of the surgeon’s practice devoted to spine surgery (for example, vs. brain surgery for neurosurgeons, or vs. hip surgery for orthopedic surgeons), rather than by whether or not the surgeon is a neurosurgeon or orthopedic surgeon.
In some specific instances, either a neurosurgeon or an orthopedic spine surgeon may be the more appropriate choice. For example, an orthopedic surgeon is more capable of doing spine deformity surgery (such as surgery for scoliosis and other large spinal deformities), whereas a neurosurgeon can better treat intradural tumors, i.e. tumors that are inside the central nervous system.
Guidelines for evaluating a spine surgeon
While there is no source of clear-cut criteria to compare spine surgeons, there are a number of ways patients can evaluate the surgeon they are being referred to. For example, patients can ask their referring physician several questions about the spine surgeon they are being referred to, they can ask the surgeon questions, and they can use third party information sources.
Questions for patients to ask their referring physician
Relevant questions that patients can ask their referring physician about the spine surgeon include:
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Does the referring physician think that the spine surgeon is the most appropriate for the patient’s particular condition, or is there someone else who may be more qualified?
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Is the spine surgeon fellowship trained in spine surgery? (Fellowship-trained surgeons usually have a high level of specialization and consequent tendency toward having lower complication rates - especially for more complicated surgeries such as spine fusion surgery)
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Is the spine surgeon trained in microsurgery and other minimally invasive techniques?
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Is spine surgery a big part of the surgeon’s practice, or is he or she more of a general orthopedic surgeon or neurosurgeon? How many patients has the surgeon operated on? (A physician who focuses on spinal surgery is likely to be far more adept and current in newer surgical techniques than one who only occasionally performs spine surgery.)
Often a good way to test the referring physician’s true feelings on the subject is to ask if he or she would let the spine surgeon do surgery on one of his or her own family members.
Questions for patients to ask the spine surgeon
When seeing the surgeon, patients should also inquire:
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What is the cause of my pain? (An accurate clinical diagnosis about the cause of the pain is critical to a successful surgical outcome.)
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What is the full range of treatment choices available? (Often the patient may still have several non-surgical care alternatives available, which may help the patient avoid unnecessary surgery.)
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If surgery is recommended, patients should ask what the spine surgeon’s own complication rate and success rate are for that particular surgery. What is the surgeon’s history of results? (The best surgeons often keep in touch with their former patients after the surgery, thus monitoring results and gathering data that they can share with potential new patients.)
Comparing the surgeon’s opinion and information to that published in reliable sources (such as physician-written, independent, peer reviewed sites on the Internet) can help a patient then determine if the treatment options are reasonable and better understand the advantages and disadvantages of each treatment option.
If there are still questions, patients should always feel free to ask for a second (or third...) opinion from another spine surgeon, and they should feel free to ask the spine surgeon whom he or she would get a second opinion from if the surgeon were having the spine surgery. A reputable spine surgeon will not be offended by a patient requesting a recommendation for a second opinion from another spine surgeon, and patients should feel quite comfortable requesting this assistance. However, patients should keep in mind that the second opinion may or may not be more accurate than the original opinion.
It is also important for patients to ask the spine surgeon to explain the proposed back surgery in terms they can understand. In general, patients should feel comfortable with their surgeon and feel that all of their questions have been satisfactorily addressed prior to the spine surgery.
Third party information sources for choosing a spine surgeon
In addition to asking questions, patients can also use several sources to try to evaluate the spine surgeon they have been referred to. For example, some surgeons will let you contact other patients who had a particular surgery. Prior to seeing a surgeon, a patient can also use the Internet to start their evaluation of a particular spine surgeon. Sometimes a spine surgeon’s webpage will profile his or her training and areas of specialty in spine care. Many professional medical associations also list information on spine surgeons who are members (as part of the association’s website).
Patients can also use third party information sources to evaluate information on their diagnosis, condition and treatment options. Examples of third party information sources can include patient education handouts, books, and reliable, non-commercially biased Internet sites.
The bottom line is that deciding whether or not to have back surgery, and deciding which surgeon is best suited to do the surgery, are both important decisions and patients are well advised to play a proactive role. Patients need to remember that there are market forces that influence referral patterns, as well as personal forces, such as friendships and familiarity. After being referred to a particular spine surgeon, patients have the right to inquire further as to why a particular surgeon has been recommended and are often well served by doing some independent research.
By: Peter F. Ullrich, Jr., MD
October 23, 2002 (updated July 21, 2005)
http://www.spine-health.com/topics/surg/referral/refer01.html
I hope that helps you with your decision.
Kerry
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Kerry, RN
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