Risk Insider: Phil McClure

Therapy: Not Surgery

By: | May 16, 2017 • 2 min read
Dr. Philip McClure is an internationally recognized educator and expert in physical medicine and vice president of MedRisk’s ECB. He is a professor and chair of the Doctor of Physical Therapy Program at Arcadia University in Pennsylvania. He can be reached at [email protected]

The medical community is changing its approach to low back pain, forgoing MRIs and aggressive surgeries in favor of first trying physical therapy.  A 2015 Fritz et al study showed that patients first sent for MRIs were more likely to receive surgery or injections, require specialty care or visit an emergency room. Their low back pain-related charges averaged $6,193, which was $4,793 higher than patients who received physical therapy before imaging.

The traditional biomedical model suggests that pain reflects a structural problem and fixing the problem will eliminate or reduce the pain. When physicians saw a herniated disk on an MRI. for example, they assumed it was causing the pain.

However, surgery does not always alleviate pain. Many people have herniated disks with no symptoms.

There may always be some residual weakness, but unless the patient is a major-league pitcher or lifting roof shingles overhead every day, 80 percent capacity is usually enough.

Newer findings indicate that low back pain cannot easily be explained by simple pathological anatomy and imaging. Many causes of pain, such as inflammatory cascades, changes in neurotransmitters or psychosocial issues, cannot be imaged.

Similarly, rotator cuff surgery does not always reduce pain, and many people who have tears have no pain at all. Over 50 percent of patients improve significantly without surgery, and this rate is higher when examining only non-traumatic injuries.

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While traumatic or acute tears may require surgery, one study by Kuhn showed that six weeks after first participating in an exercise-based physical therapy program, only 25 percent of patients with non-traumatic rotator cuff injuries opted for surgery.

Conservative care can involve multiple treatment paths that work together, including exercise. Most researchers and physicians now believe that appropriate physical training can strengthen the muscles around the shoulder to compensate for deficiencies in the injured or degenerative rotator cuff and preserve functionality.

There may always be some residual weakness, but unless the patient is a major-league pitcher or lifting roof shingles overhead every day, 80 percent capacity is usually enough.

Conservative care of shoulder pain can lead to savings for payers by eliminating the cost of the surgery and related medication and rehabilitation. However, surgeons struggle with deciding which patients need surgery and which will respond to non-operative therapy because there is no consensus in the medical community or clear diagnostic guidelines.

While a conservative surgeon might recommend physical therapy as initial treatment, a more aggressive surgeon may feel the issue needs to be fixed before it gets worse.

These challenges mirror those seen several years ago with low back pain. Today conservative care is clearly indicated for low back pain and used as the initial treatment path for many patients.

Patient expectations, job satisfaction, social support at home and work, how patients think about disability, and how much diagnostic imaging they’ve received also impact pain and recovery.  All of these factors seem to hold true, whether the injury is in the back or shoulder.

More from Risk & Insurance

More from Risk & Insurance

Risk Management

The Profession

Pinnacle Entertainment’s VP of enterprise risk management says he’s inspired by Disney’s approach to risk management.
By: | November 1, 2017 • 4 min read

R&I: What was your first job?

Bus boy at a fine dining restaurant.

R&I: How did you come to work in this industry?

I sent a résumé to Harrah’s Entertainment on a whim. It took over 30 hours of interviewing to get that job, but it was well worth it.

R&I: If the world has a modern hero, who is it and why?

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The Chinese citizen (never positively identified) who stood in front of a column of tanks in Tiananmen Square on June 5, 1989. That kind of courage is undeniable, and that image is unforgettable. I hope we can all be that passionate about something at least once in our lives.

R&I: What emerging commercial risk most concerns you?

Cyber risk, but more narrowly, cyber-extortion. I think state sponsored bad actors are getting more and more sophisticated, and the risk is that they find a way to control entire systems.

R&I: What is the riskiest activity you ever engaged in?

Training and breaking horses. When I was in high school, I worked on a lot of farms. I did everything from building fences to putting up hay. It was during this time that I found I had a knack for horses. They would tolerate me getting real close, so it was natural I started working more and more with them.

Eventually, I was putting a saddle on a few and before I knew it I was in that saddle riding a horse that had never been ridden before.

I admit I had some nervous moments, but I was never thrown off. It taught me that developing genuine trust early is very important and is needed by all involved. Nothing of any real value happens without it.

R&I: What about this work do you find the most fulfilling or rewarding?

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Setting very aggressive goals and then meeting and exceeding those goals with a team. Sharing team victories is the ultimate reward.

R&I: What is the most unusual/interesting place you have ever visited?

Disney World. The sheer size of the place is awe inspiring. And everything works like a finely tuned clock.

There is a reason that hospitality companies send their people there to be trained on guest service. Disney World does it better than anyone else.

As a hospitality executive, I always learn something new whenever I am there.

James Cunningham, vice president, enterprise risk management, Pinnacle Entertainment, Inc.

The risks that Disney World faces are very similar to mine — on a much larger scale. They are complex and across the board. From liability for the millions of people they host as their guests each year, to the physical location of the park, to their vendor partnerships; their approach to risk management has been and continues to be innovative and a model that I learn from and I think there are lessons there for everybody.

R&I: What is the risk management community doing right?

We are doing a much better job of getting involved in a meaningful way in our daily operations and demonstrating genuine value to our organizations.

R&I: What could the risk management community be doing a better job of?

Educating and promoting the career with young people.

R&I: What have you accomplished that you are proudest of?

Being able to tell the Pinnacle story. It’s a great one and it wasn’t being told. I believe that the insurance markets now understand who we are and what we stand for.

R&I: Who is your mentor and why?

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John Matthews, who is now retired, formerly with Aon and Caesar’s Palace. John is an exceptional leader who demonstrated the value of putting a top-shelf team together and then letting them do their best work. I model my management style after him.

R&I: What is your favorite book or movie?

I read mostly biographies and autobiographies. I like to read how successful people became successful by overcoming their own obstacles. Jay Leno, Jack Welch, Bill Harrah, etc. I also enjoyed the book and movie “Money Ball.”

R&I: What is your favorite drink?

Ice water when it’s hot, coffee when it’s cold, and an adult beverage when it’s called for.

R&I: What does your family think you do?

In my family, I’m the “Safety Geek.”

R&I:  What’s your favorite restaurant?

Vegas is a world-class restaurant town. No matter what you are hungry for, you can find it here. I have a few favorites that are my “go-to’s,” depending on the mood and who I am with.

If you’re in town, you should try to have at least one meal off the strip. For that, I would suggest you get reservations (you’ll need them) at Herbs and Rye. It’s a great little restaurant that is always lively. The food is tremendous, and the service is always on point. They make hand-crafted cocktails that are amazing.

My favorite Mexican restaurant is Lindo Michoacan. There are three in town, and I prefer the one in Henderson as it has the best view of the valley. For seafood, you can never go wrong with Joe’s in Caesar’s Palace.




Katie Dwyer is an associate editor at Risk & Insurance®. She can be reached at [email protected]