Welcome And Guest Introduction

Dr Andrew Greenland 0:00

Welcome back to Voices and Health and Howard. This is the podcast where we explore on the conversation for founders of professionals and innovators who are reshaping what care really looks like today. Today I'm joined by David Glick, a paint professor with over 36 years of experience, medical director of Health Q2, and someone who's taken a very different path in how he approaches chronic complex cases. David's work focuses on patients that often fall through the crack, cases like failed back surgery, participant pain syndromes. And what's really interesting is how he's built a model around deep time-intensive care, education, and clinical clarity in a system that typically rewards the opposite. So with that, David, I'd like to welcome you to the show and thank you very much for joining us today.

Building A Roadmap For Nerves

David Glick 0:41

Oh, thank you for that amazing introduction, actually. I think I need to like quote that. That was beautiful. I have to use that. Um, I I really appreciate that. It's an honor and a pleasure to be with you. And I see all the work that you're doing to help promote and educate and inform providers and patients around the world. And I'm I'm impressed by that. So it's an honor to be part of it. Well, thank you too.

Dr Andrew Greenland 1:03

Now, you've been in pain management for over three decades, which is incredible, which is incredible in itself. But can you walk us through your journey and how that led you to focus specifically on complex chronic cases?

Teaching Patients With Real Clarity

Neuroplastic Pain And Slow Recovery

Medication Expectations And Safer Dosing

David Glick 1:14

Yeah, so it was kind of a I had a very interesting background. Um, and that started with the idea of electrodiagnosis. So I was looking at ways of being able to better evaluate nerve function. I mean, from my personal background, I tend to be very mechanically inclined. I mean, my hobby is behind me. Um, so you'll find me in the garage when I'm not with patients. But I always like to take things apart, see how they work, and understand function, physiology, pathophysiology. So when I started in practice, the first patients that I was getting referred to me were those that were failing other interventions, um, such as low back surgery, neck surgery, and strangely enough, carpal tunnel syndrome. Because about that time in 1990, carpal tunnel syndrome was running rampant around the world. Remember the idea of keyboards causing carpal tunnel and things like that? So, what I was finding out is as I'm seeing all these patients diagnosed with carpal tunnel for repetitive stress injuries, and I started evaluating them, I'm finding that there the problem is not even at the risk, that there's underlying plexopathies or ridiculopathies. I mean, in non-medical terms, that's the a problem in the neck or a problem in the shoulder. And then not only was I able to identify the problem, but the one test that I do that's very unique these days is actually called the somatosensory evoke potential. It allows you to directly evaluate the nerve from all the way in the periphery, let's say from your fingertips all the way to your brain. So you're going through the peripheral nerve, the plexus, the nerve root, the spinal pathways, and then the brain. So you can identify where in the pathway the problem is. And if you monitor the test in a certain way so your recording parameters are consistent, you can compare one nerve to the other, and you can also then quantify the degree of pathology in addition to the specific location. So it's like creating a roadmap for nerve function. So I'd be able to not only look at a patient and say, wait a second, you have a cervical ridiculopathy involving C8, but it's inflammatory versus compressive into this degree of severity. So that extra window into the pathophysiology of the patient's complaints allowed us to target treatment in a way totally different from just where the symptoms are coming from, or what the imaging study said, or the or the typical EMG neuroconduction study said. And then all of a sudden, those patients started getting better, even though they had failed that intervention. And the attention caught, well, my outcomes caught the attention of an interventional pain practice out in Shenandoah Valley. And they started sending me more patients, but they were two, two and a half hours away. And uh one day they called me up and said, Look, we're not offering, you know, we're not using this office on Thursday. Please use it yourself. We want you to see our patients, we know you see others, and they let me use their office space. So that increased my ability of seeing referrals from them and other physicians in their area. And then after a few months of doing that, they invited me into the practice. So I became sort of the diagnostic secret weapon triage person. So, you know, I get involved in treatment if it's involving manipulation and some other things, but my primary goal is I'm the diagnosis guy. So I can take that patient, do a real thorough exam, which is another problem these days, because you've had speakers on and guests on too, where they talk about the time that you have for a consultation. So you have this narrow window of time, and yet you're supposed to do this full history and this examination and review test results and treatments. And you can't do that in five, 10, 15 minutes. So I would essentially draw a bullseye on the target, these guys would treat it, and we get a beautiful outcome. And that's how it all started. And then we started, I started lecturing on that and speaking at pain meetings, and it just grew. Um, and and the other problem you have, because you mentioned patient education as an aspect. Well, let's say you're the patient and you've had a procedure done like surgery, and you've already been to see five or six physicians, clinicians, healthcare providers, even after the surgery, and yet you're still symptomatic and no one knows what to do. By this point, if you're the patient, don't you feel like that's the lost cause and there's no answers, and every physician you see has something different to try and nothing works. So, what makes you more confident in what I tell you? So you just don't ignore everything that I'm telling you and not take advantage of that information and that I mean I hate to say wisdom, but that different clinical approach. So I started explaining things to patients in ways that they would understand, so that not only would they understand it, but they would also have more confidence in what I'm telling them so they're willing to undergo whatever I'm recommending. And then it all took off from there. Um I was very active in the American the uh American Academy of Pain Management for a while, and then an offshoot of that became the American Society of Pain Educators. It was a wonderful idea. The ASPE was basically meant to help people learn, like other healthcare providers learn how to understand how to not only teach patients, but how to teach other healthcare providers. You know, and it even completely changed the way that I spoke and lectured or presented because the whole thing was we looked at adult learning theory, how people understand. And the goal was not for me to stand up on a stage and tell you how smart I think I am. The goal for me was how much information can I make sure you leave the room with so that you understand in a way that you can explain it to other people, and or use it in your clinical practice the next day when you get home, or something along those lines. If you're the patient, explain it to whoever, your family members. And it kind of worked, so that changed the entire dynamic. And the ASPE essentially became today what we call Pain Week. It went under the ASP umbrella, the Pain Educators Forum, for about a year or two, and then they switched over to the Pain Week label, and Pain Week is still in existence today. As a matter of fact, this is the first year, 20th year for Pain Week, 22nd year, if you consider the ASP meetings that I'm actually not speaking because I've been a part of it the whole entire time, and I feel like I'm gonna be left out now. But you know, that's another story. So over time, patients became sicker, they became more and more complicated. Um, a an orthopedic surgeon friend of mine, uh Heshi Klein, always said the patients that you can help are the ones that seem to be attracted to you. And that seems to be the ones like, yeah, which are the train wrecks. So, what we do is we essentially take a step backwards, we look at all that's been done, we provide or I provide a really good thorough exam. We want to look at the ins and outs, what's tender, what's not, what are the orthopedic neurological things that you see, put all the pieces together, we'll review imaging studies. If it's a post-op patient, I'm probably doing my little evoked potential study still, which is tailored to the patient. And um, then we put all the pieces together, and those evals are usually three to four hours face to face with a patient. So, do you have an outcome for that? Yeah, but look at the time you're putting in. And my records then have to read like a book because we've talked about so much information in such a short period of time, it goes in one ear and out the other. There's only so much you can grasp. And um, even for other physicians or other healthcare providers, when they see the record, where my practice actually became 90% workers' comp at some point. So even those looking at the file from the comp side have to look at oversight and understand what's being requested or what's being done and why. So the record has to be understood by patients, by insurance adjusters, by legal professions, by other medical providers. So the record comes out like a book. It's got a really thorough history in it. It's got, if we talk about imaging studies, the actual images of the MRI or CT or X-rays are actually in the record. So you can you can see them. Um, we take pictures of patients. It's amazing what you can see by snapping a picture. I probably have the world's largest collection of patients' back pictures. You know, like here's a good example. If I ask you to make a muscle, you can show me your biceps, right? If I asked you to contract your quadratus lumborum or your longissimus muscles in your back, you'd look at me like I was, you know, like a deer in headlights, which is what those aren't muscles that we voluntarily control, right? But if you if a patient has a problem in the back, those are among the muscles that go into spasm immediately, whether as a guarding mechanism to stabilize what the problem is, uh, andor because the nerve that goes to those muscles are being irritated, causing it to become hypertonic as well. But I can snap a picture of that and you can actually see the asymmetrical muscle tone in the patient's back, and then what you palpate and what you see, you can actually label and identify the muscle. So those pictures that then identify a muscle spasm also work at another level, which is pretty cool, which is to demonstrate the outcome or the successful outcome of the treatment. So here's an interesting concept, if you don't mind me running off the rail on this one. One of the familiar terms we hear now is neuroplastic pain or gnosyplastic pain, is a common term. So what happens is when the body is in a constant state of pain for a long period of time, it makes physiologic changes to the way the nervous system functions based on the chronic state of being in pain. And those changes are called neuroplasticity or neuroplastic changes. And that takes time to set in, right? So let's say that I took a step backwards, I came up with a revised clinical diagnosis, I now know what to do for you in a highly patient-centered, problem-focused manner. It's like drawing a bullseye on a target to say this is what we need to do for Dr. Greenland for this for his problem. So we treat it, but because the body's been in a constensated pain for so long, how often do you think the patient might feel a little bit better, but that whole sensation of pain goes away immediately? Rarely, because you hardwired that pain sensation. So the example I use is let's say you wanted to develop your cardiovascular system. We had a cool commercial here in the US where somebody would do like one sit-up and they were good to go. Well, but that doesn't work, right? You have to exercise over a period of time. So you develop your cardiovascular system. So let's call that a cardiovastic change. Okay. So what happens if you wake up a year later and you say, you know what, I've been doing all this exercising and I don't want to do it anymore, and I just stop. Does your body immediately go back to that pre-cardioplastic chain state overnight, or does it take time for it to wean back down? Well, pain does the same way. So what happens is, even though we talk about neuroplastic changes as a one-way street, often it's a two-way street. You have to understand that and explain that to patients. And that's a common example that I use. So let's say we have this patient who comes in and we treated the problem, and all of a sudden they come in for a follow-up two weeks later, and every single muscle spasm in their back that was there beforehand is gone. And every single orthopedic maneuver that you did on them or neurological tests to identify it, including palpatory changes and everything else, are gone. So I'm looking at the patient thinking we're doing pretty well, and you and you ask the patient how they're feeling, and they say, I don't know, I don't feel any different. Especially if you've been managing the medications and you've been modulating pain with medications like um SSRIs and the gavapentenoids and things like that, because that helps modulate pain as well. So that's when you're showing the patient that you have to walk the patient through all the different things that were positive before, show them the pictures of what they look like before and after, which are clearly different, put your hand on their shoulder, explain to them how much better they're doing, and tell them why you're going to be weaning them off their meds. So you need to really leverage that education component because even the response to treatment sometimes is a lot longer than the treatment itself, which is kind of strange, you know. And even on patients that we're just talking about managing, the whole idea of meet managing expectations was something we talked about. In the UK, you don't have commercials for for pharmaceutical medications, do you?

Dr Andrew Greenland 14:43

Limited, but probably not to the same extent that you have them on your uh commercial stations in the US.

Why Imaging Leads To Wrong Surgery

Telemedicine Second Opinions That Work

David Glick 14:49

You know, every time you turn around, there's a new medication. So those commercials are actually engineered to get people's attention, right? They're showing you with a condition, living or somebody with it with a condition living a happy, nice, great lifestyle. So you put yourself into the place of that patient. So you now assume that if you take that medication, you're gonna be just as nice and just as perfect and well as the person in that little TV commercial. The problem is you've looked at all the research data for clinical trials and studies and outcomes that I've looked at. How often do you see your drug work 100% of the time on 100% of the patients? Pretty rare. I've gotten one that's close, and we can have a conversation about that one day. But usually it's they work on 40 to 60 percent of the patients to the degree of about 40 to 60 percent. And that's kind of what I think a realistic range. So a lot of times when a doctor says, Okay, I'm gonna try you on this medication. Well, because you saw it on TV, you expect 100% success and you're in pain. So the doctor comes in, um, or the patient comes in a couple weeks later, and the doctor says, So how are you doing? And the patient who is expecting 100% relief for their pain says, I don't think it's working. Even though it might have taken the edge off and they might have gotten a 50 to 60 percent improvement, but nobody ever explained to them what to look for. So the patient says it doesn't work. So now the doctor or the physician or the prescriber increases the dose, thinking that might help, but now you increase the potential, you just you just basically steamrolled over the clinically effective dose for this patient. Now you increase the likelihood for tolerability and side effect issues. You know, gavapentin was a great one because gavapentin, as you increase the dosing, the bio bioavailability goes down. It's kind of counterintuitive, but you have a greater likelihood of having swelling in your feet, maybe some memory losses and somulence, and now early onset of dementia is the one that everyone's talking about, you know. So that's why, even when it comes to medications, I try and explain to patients what that medication is doing and why, andor why it's important, and then what to look for for clinical outcomes, because you're more likely to actually reach a point where they get to someplace where it is more clinically effective, and they understand that. Um, sometimes it's a matter of just rotating medication schedules or something just to correlate with the patient's problem, but there's a lot of unique considerations that I think get overlooked in that three to five-minute consult that everyone seems to do. Um so I think the other aspect we talked about was imaging studies. So interesting concept here, if you think about this. Now, when you go in, like we had one the other day, I was just kind of laughing. Um, uh a friend walked into their primary care office, and they're having back pain with some radiation down the posterior aspect of the legs to the back of the knee. So the uh the treating physician, primary care, orders an MRI of the low back, pretty common, to rule out cauda equina syndrome. Well, that's a severe immediate compressive disorder of this, you know, of the of the cord or the cauda equina that can be problematic. Well, that's one, you scare the patient, uh, who didn't know what it was until they looked it up on Dr. Google and then got really panicky. Um, but two, it really didn't even make clinical sense because that didn't core that clinical indication didn't correlate with what the patient has. But this brings to mind a major, major deficit we have with imaging studies, which is a disconnect. You've seen, I guess I'm assuming the UK is the same because I've seen patients from the EU and the UK, and I get their MRI reports, and they they basically read like imagine looking at a picture like the pictures behind me, and I'm asking you to describe every single intricacy about that picture. So you do that, but that intricacy and everything that you see is not necessarily clinically correlated, but all of a sudden you pick up those findings and everyone tends to act on them. A perfect example would be, excuse me, because we see a lot of injury cases, right? Workers' comp and car accident cases. So let's say John Smith is 50 years old and he's in a car accident. He didn't have any neck pain or any upper extremity complaints before, but now he's got neck pain and some numbness and tingling in the fourth and fifth digits. All right, so you do an MRI, and the MRI shows um severe degenerative disc disease C3 through C7. All right, well, the MRI for the cervical spine might even stop at C7 here. But for the nerves for the upper extremity, the brachial plexus, include the C8 and T1 nerve roots, you know, and C8 comes out between C7 and T1, T1 comes out between T1 and T2, and the the distribution of C8, T1 medial cord innervates the ulnar nerve completely and gives a branch to the median nerve. Well, the ulnar nerve is responsible for any muscles that are innervated from the medial epicondyle and then sensory innervation to the fourth and fifth digits. So in my mind, as soon as the patient's telling me numbness and tingling the fourth and fifth digits, maybe decreased grip strength, my mind's going to C8 and C1, right? But the MRI showed degenerative disc disease, C4, C5, C6, and immediately everyone starts treating that. But the timeline didn't work for that, right? Because the patient was asymptomatic before the accident, and that degenerative disc disease took years to set in. No one pays attention to that. And then they so the conservative physical therapy doesn't help. They do a bunch of injections. It's typical here to do facet blocks, um, medial branch facet blocks, maybe an epidural, and nothing works. So they tell the patient, Well, we're gonna have to do surgery. We can do an anterior fusion, we can do a decompression, and these patients end up often getting an anterior cervical fusion. Let's say from C4, C5, C5, C6, maybe if it's a three-level, C6, C7, but what level do they say the problem was at? So then they come in post-surgically and it's like, wait a second, because no one ever bothered to correlate the patient's clinical symptoms with the imaging studies. And if you look at the literature for imaging, it's amazing. My first favorite study that I saw was in the 1990s, and basically they took a hundred people that have no back pain whatsoever and they did MRI so their low back. 52% or 50 52% had disc bulges and herniations, at least one. Well, that's interesting because that's supposed to be an asymptomatic population, but yet 50-50, right? Um, someone did a study a little bit after that where they said, okay, let's take those patients that had disc pathologies that were asymptomatic, and let's see what happens 10 years ago, because we're going to bet they're more likely to have back pain 10 years later. Well, the study results showed that you were less likely to have back pain if you had a disc pathology and were asymptomatic 10 years before. So theoretically, you can assume that a disc pathology is a protection against back pain. It makes no sense, but that's what the study showed. The corollary to that wasn't done for BACs until 2016. It was a Chinese study where they took 3,107 patients. Don't ask me why I can't get that number out of my head, who were symptomatic, who visited two ERs in China during the month of January in the test year. Out of that, 42% had pathologies. The other 60, well, 58% did not. So asymptom, you know, no pathology on imaging studies, even though they presented with symptoms. And then that they said that of the 42 that had pathologies, there was poor clinical correlation to the level of the pathology determined by examination and patient complaint. And it's not just backs and it's not just necks, it's shoulders. There was a great study where they took um, they did shoulder MRIs on uh patient population from 20 years old to 80 some, and this the data showed that 86 to 89 percent male and female of patients over 60 years old had rotator cuff tears. Two-thirds of them were asymptomatic. So just because you have symptoms in the shoulder and you have a rotator cuff torrent imaging studies, that doesn't mean that the rotator cuff tear is your problem. So I can't tell you how many patients we see over the years that get rotator cuff tears, get surgery, and then they're the same or worse off after the pathology because they had any one of another dozens of shoulder pathologies that nobody actually did a clinical exam to see. And it's very frustrating because these patients are being operated on based on imaging alone, because no one's taken the time to do an adequate exam, and that's what I find so frustrating. Um, I I I looked at a case on Thursday evening. All right, there's only six clinical visits in this, but there's about a hundred pages of medical records. So, what I look for is give me the detailed presenting complaints because, like we talked about the patient that talked about the distribution of their pain, fourth and fifth digits, you're getting an anatomical idea of where to go right away. So give me the detail of what the complaints are, what makes them better, what makes them worse, what's the distribution, how it happened. And give me some examination findings so I can look in this record and try and come up with something that might give me an idea to what's going on. So I'm looking at these hundred pages of records with the present complaint of back pain following a lifting injury. I can't find any clinical exams, not in the ER, other than deep tendon reflexes being normal, and the patient was able to stand on their heels and toes. And then one record for an office visit said motor function was intact, but motor function was dorsiflexion of the feet, not all the different motor distributions that you evaluate. So you have six off, well, one ER and five office visits, and there's nothing in the record. It's the same pages rehashed about the patient's history, their family history, their whatever. There's no clinical data in this record at all. How do you even work with that? And that's what I find ridiculously frustrating. And I think you got you're on the fee-for-service model, right? So don't you have to explain things to justify what that cost is going to be? And it's amazing how people will do that for their cars, like you know, cars. You take your car into the dealer for service, and the dealer says, Hey, we need to do this, this, and this. This is what's going to cost you. And what's when when they give you a bill of a couple thousand dollars, what's the first question you ask the dealer? Do I need it? Is there an option? Can we do something less expensive? Right? People don't watch their own dollars here when they expect insurance to cover everything. They just automatically assume that you know insurance should pay for it, doctors should do it, and the healthcare system should take that burden. But sometimes the outcome could be worse. I mean, if you look at man, I did a I did a presentation one day on failed low-back surgeries, where the surgeries were so badly butchered that they left patients far more disabled than they were before the surgery happened. And some of them, you know, you look at the case and you just want to cry. It's really bad. Um, so I view that whole concept as like near criminal because just because you didn't question it, you might get something you don't need that has a risk to it that no one ever explained. You know, what happens if it's something as simple? I remember one patient. Um, I I begged him not to go for surgery. I really did, because I didn't think it was the problem. But you know, the surgeon was trained at a major institution, at a well-known hospital, thinks he's one of the best in the world. It's like, but he never examined you. That's not what your problem is, it's not gonna help. And I figured, okay, after surgery, it's not gonna work. We're gonna have a nice little conversation. I'm gonna, you're gonna end up following what I wanted you to do anyway. Well, he had an adverse event to the anesthesia on the operating table and never made it out of the OR. So, what's the potential for doing the wrong thing? I, you know, I don't know. It could be pretty problematic, but you know, I I'm very frustrated with the entire system right now. I see very few patients. I do a lot of second opinion telemedicine consults. So here's an interesting concept. When I, because my examinations are legendary, right? Being really thorough, we we really look at everything. Um, one of my favorite textbooks was this book, about you know, an inch thick, that had hundreds of different orthopedic and neurological tests in it, Maseon. And I would use the ones that I think are important to evaluate the patient for whatever I think they have. So, you know, I have some core ones that I use, but I sometimes go off in a different tangent based on my clinical exam findings as well. So the exams are thorough, everything's there. So now all of a sudden, you migrate this to telemedicine. So I don't get to do my test, I don't get to do my hands-on exam, and yet on the telemedicine side, we have great outcomes. And I had to think about that. And it you get good at what you do, and I think it's because I've seen the same similar patterns over and over again. I think I'm I tend to be really good at picking out the things that others might miss clinically, because remember, everyone's looking at the lion share of patients, I'm looking at the outliers, and if your patient failed treatment, it can be an outlier, and that's what I seem to be good at finding. So I recognize them. So I get pretty close, even with a telemedicine consult, which I've always found kind of remarkable. And that whole mess started in 2000, around 2010, 2011, because physicians or healthcare providers that were sitting through some of my sessions at Pain Week would call me afterwards or come up during and say, look, I'm having a problem, or my wife is having a problem, or my father or mother is having a problem. Can you know, can you look at the case with me? And that's how that whole thing got started. So I was doing telemedicine second opinions long before COVID, but we were getting somewhere with it. And I think one of the funniest ones I've ever had, which which says something because it puts all the pieces together. I had a pain doc in Dallas who says, I got a problem patient. I have tried everything on him, I am out of ideas. Um, so you always like challenging cases. How you know you're willing to talk with him? So I do this, my telemedicine consult, I reviewed his imaging studies. It was kind of funny because even I had a couple of clinical questions. So I had his wife act as my hands, performing, like pushing on things that I asked her to and bending and twisting a few things that I needed. So I kind of got part of my exam in there, and then I spent the rest of the time explaining. You know, I reviewed his imaging studies with him, so I handled it just like he was face to face. I said, okay, here's what I think you have, here's what I think is causing your symptoms, this is why it's occurring, and here's what I would recommend as a roadmap to help treat the problem. Because he was looking at spending the rest of his life in misery and panicking about that. So he shows up at the referring physician's office a couple of days later, and he's and uh the doc says to the patient, How are you doing? And he says, Well, I think I'm about 40-50 percent better. And he said, That the the appointment with Dr. Glick was great. He says, That was by telemedicine, right? You did it by computer, Zoom, and he said, Yeah, he says, Hold that thought. So the doc comes out of the room, calls me up, and says, Dave, you did see my patient by telemedicine, right? He says, Yeah. I says, Well, what did you do? Because he's coming in here thinking, saying he's 40, 50 percent better. I said, I didn't do anything other than take the time to explain things to him why he think the problem was there, validated what his complaints were, gave him a map for treatment. Well, you know, that burden of relieving catastrophizing and giving someone that comfort of knowing that there is a light at the end of the tunnel when you've been in chronic pain for so long is an amazing burden off your shoulders, isn't it? So, what did I do to take how many how many healthcare providers would kill to get 50% improvement on a patient that had severe chronic pain by some treatment intervention? Because you know, our goal is okay, we want to eliminate it, definitely. If we can eliminate it, we want to stop it from you know, we want to make it less severe. And if we, you know, our final stopping game or final stops, you know, final stopping goal is stop it from at least getting worse. But we have our goals of trying to provide some treatment in the middle, and many patients would be quite happy with a 50% improvement, especially since pain is cumulative, right? If you have one pain and you get another, one plus one isn't two, it's one plus one equals three. Plus a third pain is like seven, plus another is on a scale from one to ten is a hundred. So if you can just take off one little part of that puzzle, all too often those patients are dramatically better, even though it's only like one third of the problem, but now they feel 50, 70 percent improved. So that one patient was, I think, a really good, interesting example of how all the pieces come together for educating a patient, giving them expectations, adjusting with the cognitive behavioral side of the of the equation, you know, and ultimately the uh the physician, he and I worked together, he did what I was recommending, and the patient was doing great. You know, he was all too happy to be about 80% better overall, and you know, getting back to his normal life and spending time with family. And I think for him, the the epitome was I was able to swing a golf club, and I said, more power to you. I'm not allowed to do that. My wife doesn't like me, doesn't like the idea of playing golf.

Dr Andrew Greenland 34:14

But I mean, I'm just curious because four-hour consult for complex cases are probably almost unheard of outside of your technical. Trying to look at from a kind of a clinical business perspective. How do you make that model work? I can see the advantages of it and you know the uh results and the things that you can achieve, but how do you make and make this work as a model?

David Glick 34:35

So it's hard. Um, I can tell you some of the different aspects of that that become difficult. So my practice did become about 90% workers' comp between so I I I pretty much said goodbye to insurance. I started that in '99 and then started phasing things out. So the last few to go were in 2004. So between 2004 and 2014, my practice became 90% workers' compensation. And the reason for that was because workers' comp carriers were the only ones willing to pay my rather large bill. And I didn't um I didn't accept workers' comp fee schedule either. So you had to pay me. Well, they at the time they didn't have the schedule that went into Virginia in 2016, but had UCR charges, and I didn't care what UCR fees were, you had to pay me what my fee was, or I wouldn't see the patient. And yet half my patient population was brought to me by nurse case managers and insurance carriers, and the other half were physician referral. And then the problem that stems from that on the patient pay side, if somebody found me on the internet or a friend told them about me, and even if I would discount it for cash, which I usually would try and do to try and help people out, um they were not really likely to spend the money out of pocket. But if they were referred to me by another healthcare provider, they were all too happy to write that check. You know, like if Dr. Greenland said that, hey, you're like my last resort, you're the best person I need to see, and there I'm hoping you can help me. I don't care what the cost is, you're writing that check. You found me on the internet, no, I'm not gonna, you know, whatever. And but there was something that came out of this that I think is a sad state of affairs, too, if you you like me to elaborate. So, one of the first when I stopped taking insurance, I never wanted not to see anybody for the inability to pay. Because, you know, it used to be you had really good payers, you had really crappy payers, and then you had everything in the middle, but the middle was a decent salary you can live on. As the good payers went down, the bad and no payers went up. You you not only, I mean, I remember one year I looked at my accounting and said, I could have made more money flipping burgers at McDonald's. This this isn't working. So that's when I started leaving insurance. So I decided I would never refuse to see anybody for the inability to pay. So I came up with a model. The model was I'll see you, but you have to give something back to society. Pay it forward. You give me like 15 hours of volunteer work. Sounds great, right? Don't come paint my fence, pick the charity of your choice. So the very first patient I did this with was a lovely woman. Um I she was she had lost her job because she had a back injury, she was missing work all the time. And the employer said, because it wasn't work related, look, if you can't be here, I have to hire somebody else, you know. So they fired her. Well, if you get fired in Virginia, you didn't collect unemployment. So she already had gotten evicted from her apartment. She was this close to getting her car repossessed, and she was living on a friend's couch. And um, I don't I don't remember how she got to me, but I talked to her and I said, Look, I'll see you. Here's the rule. And she said, Okay. So she comes in, I evaluated it. It was a very simple problem. You know, it was like a combination of like an L5S1 facet joint and a little bit of sacralitis. So the two. What probably happened is the sacral iliac joint got inflamed. You get muscles that go into spasm that start to restrict movement in the joint. So now every time you take a step, you're putting too much movement into the facet joint at L5S1, so it cascades. So I called up a friend of mine who is an interventional pain doc and said, Can you do me a favor and inject her SI joint and her L5S1 facet joint on the same side? It's gratis, she can't afford the care, you're doing it as a favor from me. And he said, No problem. Brought her in, injected her. That fixed the problem. You know, you see the patient two weeks later for a follow-up, and she's got a big smile on her face, and she's really happy. And she says, Well, um, is it okay? I really want to get my volunteer hours in. Can I volunteer at the food bank? Because they've been really helping me in my hours of need. And I said, Absolutely, that's the way it's supposed to work. So she started volunteering at the food bank, met somebody on the west end of town that had a small florist shop. So they became friends, she got a job at the florist shop, and five years later, I'm my wife and I were in Target here shopping, and this woman runs down the aisle and like practically jumps in it, jumps to grab me and hug me and thanking me, and like tears coming out of her eyes because of everything I did for her. And the fun part was she was still working at the flora shop, still best friends with the person she had met, and still volunteering at the food bank. So I'm thinking this is gonna work, I you know, but the whole idea that the whole first case went so well, I was really happy about that. Do you know I made that offer to three or four hundred patients, like somewhere between 350 or something like that, maybe 340 patients over the course of 10 years? How many patients took me up on that offer, do you think? A handful. A handful, literally a couple of dozen. And one guy, nicest guy in the world, I felt so bad because this was one of those cases that I could do nothing for. So I sat him down, I explained to him what the problem was, and because of the post-surgical changes that he had with this excess hyperostosis now causing compression of nerve roots, it was really bad. I said, There's just nothing you can do. Um, and and he so I said, since I can't help you, and you're in such you have such a problem, you know what? This one's on me. Don't, don't, don't, you don't have to worry about volunteering or anything. We're good. He says to me, No, I I have to do this. And I said, Trust me, you don't. He says, No, I really have to for other reasons. And I said, Okay, what's that? Well, first of all, he said, What do you want to do to volunteer? He said, mind you, this is a 60-year-old guy. He says, Um, I said, What do you want to do to volunteer? Because I don't want anything stressful. He said, I want to be a candy striper. And I said, Excuse me, you know, candy stripers were like the young girls that would go into nursing homes and hospitals and just help out. So he said, When my wife recently passed away, and she, you know, she had been declining for a couple of years, and she had lost her vision. Um, it was just really bad. But the thing she looked forward to the most was having the candy stripers come in and read to her in the morning. So I have to do that for somebody else. You know, so you get those. Um, I had one we probably shouldn't talk about, where a young kid, I completely took care of his problem, a college kid, but he never did his volunteer work. His problem came back a couple of years later. So he went to see another doc. He called me on the phone and said, I'd pick out your patient in front of me. And you know, we talked about the idea that he never did his volunteer work. So I said I refuse to see him again. And he just walked back into the room and said, Dr. Glick is the one who probably could help you, not me. He's not going to see you again, so you're on your own. So karma is a really bad thing. So, you know, it it was just to me, the whole idea of it was a sad state of human nature and what people are used to for this system. Um, I will tell you today that because my name and number are still out, even though I'm very part-time when it comes to clinical practice these days, I don't mind the second opinion telemedicine consults, but I really don't want to see more than a couple of patients a month at this point. And I'd like to work more behind the scenes, I think, to help guide care in a better way. But um so I'll get patients calling looking for pain docs because you know what happens now is everyone is letting these patients out on the street because they've gone through whatever insurance is going to pay for, like whatever injections or series of treatments they get. And then once that's over, which are their profit points, nobody wants to do medication management of these patients, so they're falling through the cracks. So now these patients are calling around looking for someone to write their prescriptions, and no one wants to take that on. So typically, if the patient sounds honest, sincere, needy, and appreciative, so I'm I'm I guess I'm having a little bias here where I try and read the patient. I'll talk to them for a few minutes and I'll tell them look, I because of the regulations around here when it comes to pain management and prescription drugs and opioids, you're really not going to find anybody by calling around on the phone. So you're kind of wasting your time. You need a physician referral to somebody if you're gonna stand any chance of seeing. Anybody. But that being said, if you want to take the time to give me a little bit of information about what your problem is, what's bothering you, how it happened, if I can think of something to give you better direction for clinical direction that might bring you to either leading less medication or maybe not needing medication at all, I'm willing to do that. And you'll have some people that say that's okay and click and hang up. And others that'll say, Will you? You know, and we'll end up being on the phone for I don't know, half an hour, an hour, all too often. And out of those, I'd say at least a third of them get back with me somehow and call me up or send me an email and say just wanted to say thank you. I did that, I asked this, I got that, I'm doing a lot better now. You know, or just I appreciate the fact that you took the time to explain things to me when no one else did. So even though it's a little bit of a non-reimbursement, just you know, occupying of my time, there's value in that when you know you can help someone. So I I continue on my uh on my voyage there. But we'll see, you know, because the other problem you have with that is if you don't put a dollar value on it, many people don't appreciate it.

Dr Andrew Greenland 45:20

You know the flip side of the one. So you mentioned there's three insights I wanted to um reflect on that you mentioned in the school. First thing you mentioned around the issue with medical records that they're often full of fluff rather than charity. You also mentioned that um some patients are getting surgery without even being fully examined, and then there's also there's also this expectation that especially given by farmer where people are expecting 100% relief. So, do you think clinicians are constrained by the system or are they contributing to it, or both based on those kind of insights?

David Glick 45:52

Both, because you have physicians that work for institutions that are being forced to see so many patients in a short period of time and they feel like their hands are tied, and that creates burnout, it creates frustration, um, it creates a whole multitude of problems because it's not you people are not looking at like in here in this country, we always talk about the you know insurance model for care, like the Affordable Care Act, things like that. So you're talking about access or availability, but you're not talking about quality of care. And quality of care makes a difference. Um, there was a study that I I stopped using it because I was upsetting people when I used it and in a couple of you know presentations, where this came out I think in 2023, they looked at 500 patients that had um rotator cuff surgery um pre like uh with a telemedicine consult before the surgery versus a live in-person evaluation. So, what the study data showed was that there was no change in outcomes between the telemedicine group or the clinical evaluation group. Therefore, we don't really need to do the clinical evaluations anymore. That was the conclusion. Well, if you get into the weeds of the study, they didn't do clinical exams for the face-to-face visits. The surgeon walks in, looks at the imaging study, shows the patient this is the terror you have, we're gonna fix that. So, what guides medicine, unfortunately, is the need to do procedures that generate revenue. So patients are thought of more like a cash register or an opportunity to bill. And I think those are the things that really create this problem with the model. Um, we see a little bit of quality of care with um the concierge model here. Um, there was another about 10-15 years ago, the model they were talking about was direct to primary care as well, similar idea. So, you know, way back before the Affordable Care Act, they had high deductible policies, let's say, but a high deductible policy was nothing compared to what they are for today. And then you would take, you would get a medical savings account or a health savings account that you can budget your money up to a certain level on anything that you haven't spent at the end of the year, you bank. I can tell you, any people that had those were always asking everything. When they knew the money was coming out of their pocket, they want to know what it costs, why you need it, um, what the expectations are. And it's a totally different mentality. So those patients have greater outcomes, and then you'll you see that those models where you have that the true concierge model, not a fake concierge model, but the true concierge model, where people are paying for that more time with a physician who are dedicating time to them and their condition, they tend to have better outcomes. You know, and there are some studies that claim that that's a socioeconomic thing, but it's not because regardless of your socioeconomic status, even patients who are given that model, they'll do better with somebody guiding them through it, if that makes sense.

Dr Andrew Greenland 49:05

So, what does the future hold for you, David, going forward and next 12 months or so? Anything on the cards, anything you're working towards, any plans that you have for practice or otherwise?

David Glick 49:14

To be honest, there they're what I'd like to do, you're gonna laugh because so we all we view insurance companies as the great nemesis, right? But the fact is there are certain things you can do behind the scenes to change that. I don't think I'm gonna be able to have an effect on the on the normal primary care market, except to say, look, here's a higher quality care. If you can provide it, these are the things you do. You know, the most of the attendees at Pain Week historically, I'd say about 70% have been primary care providers. Um, so I used to love the fact that we're teaching these people that are essentially in the trenches, that are seeing these patients as their front line for patient care, to give them the tips, tricks, and tools they need to better evaluate and treat these patients in a more highly patient-centered, problem-focused manner. So, you know, I'd like to be able to do that, but that's getting harder and harder to do. Um, 2019, I think I was in a different city every other weekend speaking, and I enjoyed that. Now I'm thinking what I'd like to do is maybe get behind the scenes for medical management for workers' compensation insurance carriers. Because not only can by helping them develop the right policies, you can stop those cases from running off the rails. So you can cast that case. Hey, wait a second, yeah, they were in a car accident, but those pre-existing findings are not clinically related. So we don't need to be doing a fusion on this patient. We need to be doing something different based on the exam, the clinical presentation findings, so you can set policies and procedures that might slant care going in the right direction. So it's a sweet system when you can improve clinical outcomes, decrease the cost of care, and help shield from unnecessary liability, right? Because all of a sudden, and because we didn't talk about this little aspect too, but when you tell a patient you have a discarniation, they own that. So if they think that it happened as a result of the employer, it creates a whole psychological thing that they've been hurt by the employer. But here's an interesting concept, too. So I worked the booth for a medical device company in 2019 at CES. And I was the doc in the booth, so everybody wanted to talk to them to find out if this little device which is used for pain management would actually work for them. So by the time I was done, I had no voice after two days of that. But the one thing I noticed was that patient or person after person that came up when I asked what their problem is, they would not tell me where their pain is or what caused their pain or what the characteristics of the pain. They read to me what they thought was their MRI results. Oh, I have three disc coronations, I have a bulging disc, you know, I have a pinched nerve. It's like, I got that, but tell me about you. Because the truth is, I mean, because that disconnect, so you can fix the disconnect on radiology by if the primary care or the ordering physician would simply write on the on the order instead of MRI low back, rule out back pain or rule out disc herniation, to write, hey, onset back pain with radiation along the posterior aspect of the thigh going to the knee immediately following an MBA two weeks ago. Okay, that little information to the radiologist would help them focus in. It's like, yeah, you have all this degenerative disc disease, multiple levels, but you're asymptomatic before that, so maybe what else on here could account for that? So you get a more focused, patient-centered interpretation that might change the outcome of treatment. So we can fix that disconnect, that would be nice. But if you can take that and force that into the workers' comp model where the interpretation now could say, hey, comment on the timeline. Are there modic changes? When do you think these pathologies occurred? Is it significant or consistent with the mechanism of injury at the time of the injury that would make sense? Because that might stop these cases from going off the rails. So I think that there's a potential to impact the quality of care on a larger basis. The question is, can you get these workers' comp carriers to listen to you? Because it's not going to be a third-party administrator. Because the reality is third-party administrators want those procedures to go and happen because they make money on the procedure happening if they can reduce the fee and get a percentage of that. So it's going to have to be to the employer, it's going to have to be to the UPS or the Amazon, you know, the people who are employing these patients where you can show they can save money, improve care, and reduce liability all in one shot. What's it worth to you? So that's where I'd like to be. So I've been spending a lot of time knocking on doors trying to get someone to talk with me.

Dr Andrew Greenland 54:17

Amazing. I'd like to thank you so much for joining us today. It's been such an exciting conversation. But interestingly about your model, and really, I think you've illustrated the value of being able to spend that chunk of time with patients because you know you mentioned four hours, which is kind of unheard of.

David Glick 54:32

Oh, the fact you could have a record takes four hours to compile.

Dr Andrew Greenland 54:35

Yeah. And then you could have a telemedicine conversation where you could reduce those symptoms just by the virtue of your approach. I think it's a really, really powerful thing. And I completely advocate for this because working in functional medicine, I spend a lot of time with my patients as well and can really see the value of it. But thank you very much for sharing. Thank you so much for sharing. It's been a really great conversation, and I'm very grateful for your time.