There are many stories journalists could report on about conflicts of interest and questions about evidence in the treatment of low back pain, perhaps especially with spinal fusion. We talked about many of these with journalists from the American Society of News Editors in a workshop at the Foundation for Informed Medical Decision Making in Boston in May.
John Fauber of the Milwaukee Journal-Sentinel hammers one of these issues, looking at how Medtronic’s Infuse product “went from revolutionary advance to public health alert.”
With the prospect of 32 million new patients clamoring for care comes sorting out who will see them all. New medical schools are opening and students say they relish the idea of entering a market that will demand their services. American College of Physicians member Manoj Jain, M.D., offers a more tempered view of how the fallout might affect primary care. (AP, American Medical News, Fort Worth Star-Telegram, Memphis Commercial Appeal)
Even Hawaii has a shortage, especially in primary care, but also cardiology and orthopedic surgery. It’s hard to believe recruiters couldn’t sell Hawaii as a destination. (Honolulu Advertiser)
*This blog post was originally published at ACP Internist*
Pain management is a hot topic in medicine in general and certainly in medicine for the outdoors. Injuries in particular, and many illnesses, cause pain, which in turn causes the victim to suffer. To a great extent, pain is subjective, but regardless of whether your pain is a “1″ or a “10,” it can be disabling and even dangerous, particularly if it causes you to be distracted in a situation of risk (e.g., climbing, swimming, walking along a ridgeline).
Broken bones usually hurt a great deal. It’s commonly believed that the pain is always of a severity to require the administration of “strong” pain medicine, notably, something containing a narcotic compound. This may not be true. Read more »
It has been proven than there is tremendous variation in the practice of medicine across the United States. The Dartmouth data (Wennberg et al) has documented the differences in how medical resources are used and how different physicians practice medicine, depending upon where they live. The Dartmouth studies are mainly focused on cost and outcomes and make the case that improved quality is often inversely related to the cost of care. More (expensive) care is not necessarily better care.
Now that I am recovering from a total joint replacement, I am amazed to see the differences in how physicians, doing the same surgery, treat the patient. Total knee replacement (TKA) is one of the most common orthopedic procedures done today. Despite this, the patient cannot expect the same post op care. Read more »
A close relative recently underwent hip replacement at the Texas Orthopedic Hospital in Houston’s Texas Medical Center. She raved about her surgeon, Dr Richard Kearns. I had the opportunity to sit by her bed while he made his evening rounds (he didn’t know I was a physician until we were introduced at the end of his visit).
These are the qualities seem to make him successful:
Approachable.
He bridged the technical gap that often separates patient and surgeon. He used carefully chosen language
and examples the average person can understand.
……have demonstrated a practical way to embed a patient’s own adult stem cells in the surgical thread that doctors use to repair serious orthopedic injuries such as ruptured tendons. The goal, the students said, is to enhance healing and reduce the likelihood of re-injury without changing the surgical procedure itself.
The project team of 10 undergraduates focused on Achilles tendon injuries which require repair in approximately 46,000 people in the United States every year. The surgery may fail in as many as 20%. Recovery can take up to a year even with successful surgery. If this new suture speeds healing and lowers failure rates – what potential!
At the site of the injury, the stem cells are expected to reduce inflammation and release growth factor proteins that speed up the healing, enhancing the prospects for a full recovery and reducing the likelihood of re-injury. The team’s preliminary experiments in an animal model have yielded promising results, indicating that the stem cells attached to the sutures can survive the surgical process and retain the ability to turn into replacement tissue, such as tendon or cartilage……………
As envisioned by the company and the students, a doctor would withdraw bone marrow containing stem cells from a patient’s hip while the patient was under anesthesia. The stem cells would then be embedded in the novel suture through a quick and easily performed proprietary process. The surgeon would then stitch together the ruptured Achilles tendon or other injury in the conventional manner but using the sutures embedded with stem cells.
[Dr. Jim Herndon is a past president of the American Academy of Orthopaedic Surgeons, and chair emeritus of the department of orthopaedic surgery at Partners Healthcare]
***
The challenges of health care reform are enormous. To expect that the vast array of problems that exist today will be corrected or solved in a couple of months is totally unrealistic. Witness the moving target of announced changes and options occurring daily in the press and media in general. And add to the confusion…these changes are being developed at the top (Congress and the White House)…not from the bottom up (from doctors, nurses and other health care providers, and importantly, patients). In their place are the powerful lobbyists…the health insurance industry, the hospital industry, the drug industry and even organized medicine (AMA)…who wield their influence over our policy makers by all sorts of tangible (financial donations) and intangible (spouses of leaders on corporate boards) pressures.
I must admit, although occasionally said without real meaning…I don’t hear an outburst of support for the essential mission/purpose of health care…the health of our citizens…”the patient comes first”. Where is the patient…who is supposed to come first…in this national debate?
Everyone knows that health care is expensive. In 1970 health care spending consumed 7% of the Gross Domestic Product. In 2009 health care spending is consuming 16% or more of our Gross Domestic Product. It is increasing more rapidly than inflation. Yet, as a nation, we have not…in all these years…had a serious conversation about Americans’ health. Where is it in our list of priorities? I don’t think we know. From recent events we do know it is lower than the need to remove Saddam Hussein from power…it is lower than bailing out investment companies and banks…it is lower than stabilizing the mortgage market…and it is lower than bailing out two automobile manufacturers. I am not knowledgeable enough to question the priority of the bailouts of banks and financial institutions or the mortgage companies…but I do question the priority of removing another country’s dictator or bailing out two automobile manufacturers instead of allowing them to proceed through bankruptcy in our court system…over health care reform.
Too often in my lifetime I have seen the importance of health care reform pushed down the list of priorities over other needed programs…to wait for another day. How important is the patient, the health of Americans today? How far are we going to push the profession of medicine from “a calling”…a profession, as President Obama states to “a business”. It is known that patients trust their doctors, but not our health care system. When will patients begin to trust their own doctors less? It will happen if and when they believe doctors are more “concerned with the pulse of commerce” rather than the “pulse of their patients”. I submit we are getting very close to this tipping point…in losing the trust of our patients and society in general.
There is no unanimity of opinion regarding the health care reform debate…amongst Democrats, amongst Republication…amongst the public…amongst physicians in general…and orthopaedic surgeons specifically. I asked a few young physicians in an orthopaedic residency program their opinions about the health care reform debate. All believed that every American should have basic health care insurance coverage. Obvious to them, it would include coverage for care of patients with acute fractures or patients with severe pain or loss of function. They admit not knowing much about the “public option” and the swirling politics going on. They also were not comfortable with defining what situations or problems would not be covered by insurance…although they agreed that some restrictions above “basic care” would have to be implemented.
Their responses reminded me that in 1990, when I was in graduate school for an MBA…we had a class debate about whether health care was a right or not of all citizens? Although the discussion was lively and some felt health care was a privilege, the class conceded that health care was a right of all citizens…admitting historically it was considered a privilege for the few who could afford it, but then (1990 or earlier?) health care had become a right for all in the US. I then asked a few of my colleagues who enjoy leadership positions in the field of orthopaedic surgery their opinions regarding health care reform. They also could not agree on the issues of this debate.
One area where they did agree was that academic medical centers are not well positioned for the future…especially those that depend on state funding. We have already witnessed this in Massachusetts where apparently the state has decreased funding to some teaching hospitals that traditionally have cared for a large number of uninsured. Now that most citizens have insurance, they are seeking their care in other hospital emergency departments. My colleagues also agree that physicians will receive lower payments for specific treatments or participate in “bundled” payments to the entire healthcare team/facility for comprehensive care of the patient.
Otherwise my colleagues disagreed. On the one side some support the public option and universal coverage…although “the devil is in the details”. For this group they have become tired…like so many American physicians…with the convoluted way we finance health care and the associated paper trail/documentation overload. The system has made some patient conditions profitable and others not profitable…described by one as “perverted incentives”. These physicians (me included) are angry at the loss of our professionalism as hospitals and physicians chase dollars and not the health needs of each patient and the public. On the other side (against public option), my colleagues have some agreements…most orthopaedic surgeons are supportive of care of the uninsured and underinsured, especially for patients presenting with acute problems to hospitals’ emergency departments. Most also agree that there needs to be a serious realignment of incentives and improved collaboration of hospitals and doctors.
But they have many disagreements…including the provision of elective care. They argue…with good reasons…that with continued rising costs to practice medicine (rent, electronic records, employee wages and benefits, malpractice insurance, increased personnel requirements for the administration/paperwork overload) and continued reductions in reimbursement (Medicare, for example, pays an orthopaedic surgeon today approximately 50% of the reimbursement it paid for a total hip replacement in 1990)…it is becoming increasingly problematic to provide elective care for the underinsured and uninsured. They commonly ask…”How can you provide care that costs more than any receipts”?
Other disagreements include: the single payor system…they don’t believe it will work; although well-intended, they believe these reforms will result in overall lower quality of care for patients; that emergency departments will still be used by those with insurance because patients can see a physician at the patients’ convenience and avoid long delays to see a doctor in his/her office…for example there is a 40-day wait to see an orthopaedist in his/her office in Boston; the continued tremendous demands by American patients to have the latest technology, the latest treatment…even if evidence for its use is unknown; skepticism about the prevention of disorders that have a genetic basis, i.e. osteoarthritis…in the foreseeable future; the simple fact that to reduce errors and overuse/misuse of tests by an electronic medical record and computer physician-order system will cost enormous amounts of increased spending in the short term…before cost savings are eventually realized… and to draw attention to one specific unsolved problem area…Workers’ Compensation…where orthopaedists, daily, see ineffective treatments being used and large numbers of patients on disability.
Briefly, the follow are factors that have led to increased and inefficient health care in the US: high administrative costs; overuse of services and new technology; an increased prevalence of chronic disease; tremendous geographic variations in care; increased payments not resulting in improved quality; a continually high number of medical errors and complications; a broken professional liability system; a shift in costs from the uninsured to the insured; a predominant third-party payer system; overuse and misuse of care; focus changing from the patient to the pocketbook; insurance company abuses (cherry-picking healthy patients, denying care of patients with chronic disease, deliberately lowering the normal of “usual and customary” fees…to name a few); and continued issues of fraud and abuse, especially in the Medicare and Medicaid programs.
Finally I would like to close with the official position of the American Academy of Orthopaedic Surgeons (AAOS) on health care reform: “Any changes to the health care financing and delivery system…the well-being of the patient must be the highest priority. The AAOS strongly supports reform measures…that provide individuals with patient-centered, timely, unencumbered, affordable and appropriate health care and universal coverage while maintaining physicians as an integral component to providing the highest quality treatment”.
The AAOS is opposed to a single-payer health system or even a federal health care authority. The AAOS suggests “a number of tax initiatives…that will level the playing field and make health care coverage more affordable”. There should be “adoption of policies that restore equity and enhance market competition”. The AAOS also “strongly believes that patient empowerment and individual responsibility are necessary components of health care reform. Health choices should be recognized and preventive care should be promoted”.
Wooden legs sure have come a long way since they were first used as artificial prostheses. In the latest issue of Journal of Materials Chemistry, there is a report on the recent developments at the Institute of Science and Technology for Ceramics in Italy in which scientists have turned wood into something similar to bone, a material that may one day be used to create custom replacement parts.
Researchers heated the wood to decompose organic material to leave only the carbon template. Then, they reacted the template with calcium, oxygen, and carbon dioxide to form calcium carbonate that was then converted to hydroxyapatite. This hydroxyapatite scaffold mimics the structure of bone. The advantage of this process is the architectural make-up of the wood’s structure that affords the ability of cells and blood vessels to grow through it, much like real bone.
‘Current [hydroxyapatite] production processes do not generate an organised hierarchical structure,’ says Anna Tampieri. ‘Materials able to maintain adequate properties at extremely high temperatures and mechanical stress are highly sought after for use in several different applications, such as space vehicles. An intriguing possibility is that of simultaneously achieving high values of strength and toughness, for which ordinarily there is a trade-off. In addition, new materials with extreme physical properties, such as thermal expansion or piezoelectricity, can be obtained.’
Yes, it’s time for another installment of my series on the physical exam. The goals of this series are:
To educate my readers on the intricacies of the physical exam.
To teach the anatomy and physiology as it relates to different parts of the human body.
To delight my readers with my wit and fine prose.
World peace.
So you see, through my hard work and persistence (writing almost 30,000 words about the physical exam so far), I have come nowhere near any of these goals. In fact, I have made absolutely no progress toward world peace. I think I’ve been banned in Iran for using the word “Shuttlecraft” too many times.
Maybe I just need some new goals. How about these:
To irritate my high school English teachers.
To cause at least 200 people to waste time that they could have spent watching Oprah.
To make sure Canada stays north of us and does not sneak to Florida.
To put those pesky French people in their place.
Yes, I think those are much better goals.
Extremely Upper
Our journey over the human body has now led us to the long things that stick out of the top of your torso that have those grabby things on the ends. We doctors call these things arms. There are some hoity-toity doctors who call them the upper extremities. These are the doctors you don’t want to invite to dinner, as they will probably tell you disgusting scientific facts about the food you are eating. Consider yourself warned.
The exam of the arms is usually only referred to vaguely during routine exams. Most docs don’t deal with the arms unless they pick up subtle clues that are discovered only by trained professionals, like when the patient says “I’m having problem with my arms”. We doctors are proud of our mad skills.
What I am driving at is that the arm exam is a problem-oriented exam. If you have a boo-boo, the doctor looks at it and sees if a kiss will make it better. If a kiss doesn’t work, usually an anti-inflammatory will (but we’ll get to that later). And boo-boo problems with the arm are usually specific to the longitude and latitude on the body. So today we will discuss the shoulder.
The Shoulder
The shoulder is a joint – meaning, it is a place where your body bends. Without joints, your arms would be unwieldy and you’d whack everyone who came near to you. Not only that; it would also make it impossible to put on deodorant. So between whacking people and offending them with your odor, a jointless existence would truly be a hard one. We all should thank our joints more often.
There is not a more complex joint in your body than your shoulder. Here are some amazing facts about the shoulder:
There are three bones that are involved in different types of movement: the collarbone (clavicle), shoulder blade (scapula), and humerus (not humorous).
There are at least 18 muscles that are involved in shoulder movement. Two of them have the word “rhomboid” in them. I like the word “rhomboid.”
When people say the word “shoulder,” they may be referring to the joint, and they could be referring to the top part of their torso – between their neck and shoulder joints. This is a sad testimony to the English language and just serves to make the jobs of medical professional all the harder.
The word “shoulder” rhymes with a lot of of words and so is very useful in poetry. For instance:
You shouldn’t have told her that she’s looking older
She wants you to hold her with arm on her shoulder
And go get the folder that llamas once sold her
But there on the boulder the weather is colder.
A fine Jell-O mould or perhaps something bolder
Has rocked her and rolled her but never controlled her
So anger may smolder at cellular slime mold or
Other thingies, sort of.
See? Pretty amazing, isn’t it? Try doing that with “elbow!” Perhaps Dino could write a haiku about it.
So it should not be seen as a coincidence that the shoulder has by far the largest range of motion of any of the joints in the body. This makes things very confusing for medical students when they have to describe the motion, as the joint doesn’t follow any of the rules the other joints have agreed upon. Most joints can be bent (flexed) and straightened (extended). Some joints (like the wrist) can be hyperextended and rotated as well. All the other joints are content with these motions. Is this good enough for the shoulder? Not even close.
Here are the basic movements of the shoulder:
1. Flexion – moving the arm forward toward the chest.
2. Extension – moving the arm toward your back.
3. Abduction – Being picked up by aliens and brought to their mother ship. (This also refers to lifting your arms up from your sides).
4. Adduction – Bringing your arms down back to your sides
5. Rotation – Turning the arm around the axis of the humerus bone.
I have suggested a few more motions that may be added to the roster:
6. Subflaxion – What you have to do to your shoulder to get your elbow in your ear.
7. Soufflétion – When your shoulder is mixed with eggs and baked at 400 degrees.
8. Mallardduction – When your shoulder gets down.
So far the shoulder committee hasn’t answered my mail. I’m not sure why.
But really, the shoulder is very confusing to many medical professionals. The range of motion is so great that it blurs the lines between the typical movements. For instance, adduction is supposed to be when the limb is moved toward the body’s midline. The shoulder makes this difficult. When you put your arm by your side and when you raise it over your head, you move it toward midline. Both could be considered adduction. The same is true with flexion and extension – when is the shoulder joint opened up and when is it closed?
Really, in this modern time we should give up this archaic nomenclature and instead use a GPS device to determine shoulder position.
Wow. 1000 words already and I haven’t gotten to the actual exam. I’ll give it a rest now and let you ruminate on words that rhyme with “elbow.”
This is the funniest public service announcement I’ve seen in as long as I can remember. Congratulations to the creative communications team at the American Academy of Orthopaedic Surgeons for putting this together!
Back story: I met Sandra Gordon, Director of Public Relations, at the AMA Medical Communications Conference (where I was faculty) and where she presented this video. After the show I approached her to say how surprised many of us were that Orthopaedic Surgery was leading the way in creative PR - and that it was quite unexpected. The PSA had almost a hint of Monty Python humor to it.
She responded with out batting an eye: “Nobody expects the Spanish inquisition!”
Update From Haiti: Despair Sets In And Women Consider Suicide
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I was lucky enough to be asked by one of the local TV stations to talk about some back-to-school issues when it comes to health. I don t know about where you re at but most of the local schools around here started yesterday August rd Keeping up-to-date on immunizations…
Next in our series of posts about our founder Doc Tom. Previous time capsules and Come ye economics buffs and algebra fans Get out your pencils and solve for x n and XX Whatever else the year XX is remembered for it will without a doubt go down in history…
Book review by Dan Buckland Dan Buckland is an editor at Medgadget and an MD PhD student at Harvard Med MIT whose thesis deals with diagnosing back injury in spaceflight using ultrasound. Mary Roach author of previous entertaining books Bonk a history of sex research and Stiff a history of…
I really didn t expect to like Eat Pray Love. In fact since its publication in I’d been avoiding it like the plague. Typical new-agey Oprah-y girly-book I thought. Nothing in it to speak to me. Then I saw the trailer for the movie and I was hooked probably because…
Wouldn’t it be great if we could find a way to prolong our lives and to keep us healthy right up to the end Ponce de León never found that Fountain of Youth but science is still looking. What are the chances science will succeed How’s it doing so far…
With the prospect of 32 million new patients clamoring for care comes sorting out 
Wooden legs sure have come a long way since they were first used as artificial prostheses. In the latest issue of Journal of Materials Chemistry, there is a report on the recent developments at the Institute of Science and Technology for Ceramics in Italy in which scientists have turned wood into something similar to bone, a material that may one day be used to create custom replacement parts.
So you see, through my hard work and persistence (writing almost 30,000 words about the physical exam so far), I have come nowhere near any of these goals. In fact, I have made absolutely no progress toward world peace. I think I’ve been banned in Iran for using the word “Shuttlecraft” too many times.
The shoulder is a joint – meaning, it is a place where your body bends. Without joints, your arms would be unwieldy and you’d whack everyone who came near to you. Not only that; it would also make it impossible to put on deodorant. So between whacking people and offending them with your odor, a jointless existence would truly be a hard one. We all should thank our joints more often.
