Meet the Experts: Ethan Colliver, DO

Gary: For our next feature, I am excited to introduce Ethan Colliver, DO.  Ethan, for introduction, can you tell us more about what you do?

Ethan: Sure. Thanks for having me Gary.  I am a fellowship-trained physiatrist specialized in treating Sports & Spine Disorders.  I use diagnostics such as X-rays, MRIs, Ultrasounds, and a functional exam to diagnose a problem and then use a host of treatments such as medications, manipulation, injections, or exercise to alleviate the problem.  

Gary: Many people treats spine and sports conditions.  What makes your approach different?

Ethan: Physiatrists are the Function experts, so I measure the patient's success by how much function they have gained by coming to me, and not necessarily what number they say their pain score currently is.

Gary: My experience has been that some physiatrists make that claim, but in practice they function similar to other physicians.  Do you think you provide a similar experience to other PM&R physicians, or do you do specific things to make sure you legitimately prioritize function?

Ethan: Absolutely.  I have adopted functional tests from great mentors or functional exercise classes I have attended to measure a patient's function.  For example, I can quantify a patient’s ability to do a full squat and use that number to measure their improvement.  I will measure a patient's function, strength, and flexibility throughout their rehabilitation program; if their pain has improved but their function is still lacking, then I will recommend they continue the rehabilitation program.  I prefer this to questionnaires which are subjective.

There are examples where the patient's Physical Therapist has recommending discontinuing therapy, but I felt continuing it was needed to work more on functional goals. Also, one of my most useful tools is a Co-visit, where the patient, physical therapist, and I get together to go over the exercise program in detail and see how we can make it better and more efficient for those patients who are struggling.

If you ask me, the only disease modifying treatment I provide is developing a rehabilitation program to help a patient get back their function.  All other treatments just make that transition easier. 

Gary: I find that patents really have a hard time grasping what "function" means.  What do you mean?  How does that affect the patient interaction?

Ethan: We discuss with the patient multiple levels of function ranging from a very small scale such as a "dysfunctional" vertebra or one "out of alignment" that can be treated with manipulation; to a kinetic-chain level of function where lack of hip flexibility and strength is causing back pain; to a community level of function such as returning to work, sport, or exercise program.  Our interactions and goals are centered on returning function at each one of these levels.  

I use my specialized training to assess someone's kinetic chain.  I determine where their chain is restricted or not working well, and develop a rehabilitation program to restore function to the chain.  For example, this allows me to tell someone that their back hurts because they have significant hip stiffness, and that if we work on improving hip flexibility and strength then the back pain will improve.

Gary: You mean to say that doing a "pain- relieving" injection, such as an epidural steroid injection, is not enough for someone with back pain.

Ethan:  Exactly.  Almost all treatments for back pain are reactionary.  That means we wait until the patient has pain before we treat.  That treatment may help for a while but if the patient continues to have major restrictions in their kinetic chain like a stiff hip, then they will continue to move in a way that puts stress on their back.  Eventually, their back pain will return.  Improving the patient's flexibility and strength through a rehabilitation program is critical to reduce their chance of future episodes of back pain.  Again, the only disease modifying treatment I provide is developing a rehabilitation program to help a patient get back their function.  

Furthermore, patients are mistaken to think surgery on their spine will “fix” them.  It’s like putting new tires on a bent rim of a car.  You can fix the worn tires but if you continue to drive on the bent rim, then the tires will go bad again, real quick.  This is one reason why people have repeat spinal surgeries- they never fix the underlying issues leading to their back pain.

Gary: When I was contemplating making a transition from academic medicine into private practice, you were one of the first people I spoke to.  You correctly made the observation that I was really making a transition from a large system into a smaller practice model, and that you had made a similar decision successfully.  Tell me more about what you perceive as the differences between large systems and small, independent practices?

Ethan: In a large system, I found that all the clinicians were compartmentalized. I was "The Spine Specialist" and only saw back and neck pain; while this doctor over here was "The Shoulder Surgeon" and only saw shoulder pain.  This approach fails because you may have to treat someone's neck to treat their shoulder pain, or vice versa. Small independent practice allows me to treat the whole patient and not be myopic on just their neck or back pain.

Large systems are like large ships, they are hard to start moving and are slow to change direction.  For example, when I gained expertise in using ultrasound, I couldn't get access to an ultrasound machine because of the bureaucracy.  Or when I needed to add more or less time to my schedule for therapeutic injections, it took a long time to happen, which ultimately hurts patients. Now, I can more efficiently change my schedule or access to new technology or treatments because I have a small clinic.  

Gary: Do you feel you can help patients more, now that you are in physician-run small practice?

Ethan: Yes.  Like small business, small medical practice is where a lot of innovation in medicine takes place.  We can try new emerging treatments more readily.  Some may work, some may not, but our size allows us to quickly adopt changes, where it can take decades for large institutions to implement change. 

Gary: The national trend is clearly for physicians to go in the opposite direction, leaving small physician-owned practices into large systems.  My sense is that this is motivated by fear.  What's your perspective?

Ethan: I think this trend is multifactorial.  I have seen examples of physicians near retiring who think joining a large institution will take away the administrative duties of a small clinic.  I have seen examples where the doctor joins a system because they feel that the system can cover the cost of running the clinic in hopes of making the physician more productive.  The most troubling reason is for fear that if the physician does not join the big system then the physician will not get to see any patients because the big institution will only let their "own physicians" treat "their patients".  This approach is growing in many areas of the country, even though it is illegal.  The difficulty comes in proving an institution is using this approach.

  

Gary: Why do you think physicians are so risk averse?  How much of this do you attribute, for example, to student loan debt?

Ethan:  Multiple things make new physicians risk averse about starting a practice.  Student loan debt is a huge burden.  My own loans were around $250k and after 30 years of payments would be over $500k.  I have met retiring physicians who paid for medical school while working minimum wage jobs in medical school.  No wonder many earlier physicians opened their own practice - they didn't have much debt.  Nowadays, banks think twice about lending money to open a practice if the doctor already has $250k of debt. New physicians worry about how they will pay this mountain of debt, so they join large institutions that promise to pay some portion of the loan debt.

Also, most small businesses are not started by business majors, they are started by engineers, doctors, cooks, photographers, etc.  These people seldom have a background in business.  Not having this knowledge is seen as a big barrier for new doctors thinking about starting a practice.

Gary: One thing I love about private practice is the freedom to be innovative.  For example, you and I have shared ideas on novel ways to help patients, and my main "barrier to implementation" is running it by my partner Garrett.  I like running things like Garrett, because I think that adds a reasonable level of vetting to make sure something is a good idea.  What are your thoughts about innovation within private practice?

Ethan: Like I mentioned earlier, small practices are the "laboratories" of innovation.  Their size allows them to quickly measure the efficacy of emerging technologies and treatments.  Large institutions take a long time to adopt these changes only after small practices have shown these changes to be efficacious. 

Gary: I know you and I have talked off line about our concerns about how insurers are making decisions about reimbursement that are going to hurt patients.  The particular example that, to me, is the most striking is Medicare reimbursement for cervical epidural steroid injections.  Tell me more about your thoughts on this?

Ethan: Medicare and other insurers are pushing to make health insurance cheaper by trying to cut payments to providers.  A physician now gets $40 for doing a potentially dangerous cervical epidural steroid injection for someone with severe neck and arm pain.  Many physicians and institutions cannot afford to keep providing potentially dangerous treatments under such conditions.  I think two things will happen. 

First, the great institutions and physicians may choose to stop treating patients with this insurance because "it's just not worth it"; second, someone less trained and less-qualified such as a CRNA or NP may start doing these procedures at a reduced reimbursement rate.  In that case I think you will get what you pay for; fewer patients may improve and more dangerous complications may occur.

Patients trust doctors with their lives.  Already, a UPS driver can earn more than a physician over their working lifetime when you factor in the physician did not earn meaningful income for 14-15 years while training to be a doctor.  Why would you want to push away the smartest and brightest minds from going into medicine by decreasing their income incentive and replacing them with less trained, cheaper labor.  I don't think it makes sense.

Gary: I feel like a real barrier is that patients love the idea of free or government sponsored healthcare, but are not fully aware about how restrictive this is for medical decision making, and how it can adversely impact their health outcomes.  Do you think patients really understand the restrictions placed by insurance?

Ethan: Socialized medicine and Capitalistic medicine both have their pluses and minuses.  Socialism can offer some degree of basic services to everyone, but most great discoveries in medicine occur in the USA.  Capitalism encourages innovation and compensates the innovator accordingly.  The more healthcare is run by the federal government, the less innovation will occur, and the more the brightest and smartest will steer away from medicine into more rewarding careers and lead the United States away from being a leader in Medicine.  I think that is a mistake.

Gary: So, let's say that tomorrow I can appoint you as "Health Czar." What do you do?  Notice, by the way, I am deliberately not calling you "Health Insurance Czar"

Ethan: Most diseases today are due to lifestyle: obesity, high cholesterol, hypertension, diabetes, heart disease, etc. I think education and encouraging healthy lifestyle changes would be more effective and cheaper than treating a person who is already sick.  Proverbs 22:6 says "Direct your children onto the right path, and when they are older, they will not leave it."    Schools and parents can have a great impact on children by choosing healthy food options, removing junk food vending machines, promoting athletics and physical education.  The Surgeon General in 1960's has effectively decreased the smoking rate to the lowest level in 50 years and had a great impact.  Why can't we take the same approach to eating and exercise?