Changing Workplace Culture to Avoid Physician Burnout
In the February 6, 2019 issue of JBJS, David A. Rothenberger, MD contributed a thoughtful and practical “What’s Important” article about how to foster well-being among physicians and thus reduce the risk of physician burnout.
Since the article’s publication, Dr. Rothenberger has received many comments from readers. Here are several, de-identified to protect privacy, along with some responses from Dr. Rothenberger:
In my opinion, the internal culture of medicine, and specifically surgery, is to blame for poor mental health, burnout, and depression… [Surgeons are] trying to make up declining reimbursement by working harder. .. I too lived in that culture and relished being the busiest surgeon in the system, knocking out 10 to 12 operations a day,… but after the age of 50, I began noticing age catching up and increasing negativity within the profession. That is about when I decided to bail out. I have never looked back, although I miss my patients. Our profession… rewards self-punishment. Like you, I am hopeful that this will change for future physicians… My hope is that the welcome influx of women physicians will teach us misguided men a thing or two about taking care of oneself, one’s family, and understanding the limits of what we can do.
I believe burnout, in my case, was caused by, among other things, the destruction of our fee schedules… My brightest child wanted to follow in my footsteps, and I talked him out of it… I feel society has forsaken us. I plan to quit this November, and it’s not soon enough.
To which Dr. Rothenberger replied as follows:
“I understand your decision to leave medicine,… but my advice is ‘do not go it alone.’ Get some support from someone you trust who understands this predicament… Plan for your future after medicine. Re-imagine your life.”
I know a lot of physicians here who have problems in their practice, including a lot of my partners. I think the concept of a Chief Wellness Officer [CWO] is a great idea. I plan on forwarding [your “What’s Important” article] to our administration.
To which Dr. Rothenberger replied as follows:
“A CWO will help only if the other leaders of your system are committed to changing the culture of the workplace. It is not an easy undertaking, but I think the return on investment justifies the multiyear approach we are taking here [at the University of Minnesota].”
It is really meaningful that you have emphasized that this is a bigger issue than the individual. I believe you are absolutely correct in highlighting a culture shift that prioritizes giving…factors [such as autonomy] back to physicians. [That] is probably the single most effective way to turn this around.
I am finishing my orthopedic residency… Our hospital system occasionally holds “wellness activities” that typically include massage and similar events, but these often don’t work with a busy surgeon’s schedule. I’m interested in making burnout prevention a more recognized issue within our department and want to help bring in resources to help our residents and staff, but I am struggling with how best to practically bring this about. Do you have any advice for integrating wellness resources and burnout prevention into a busy orthopaedic department?
To which Dr. Rothenberger replied as follows:
“Wellness activities” like massage, yoga, and exercise classes are often put together by Human Resources for the workforce at large. They are useful to individuals but do little to change the workplace culture… Our effort here at the University of Minnesota is to build a Well-Being Alliance of health care professionals who are working together as a coalition of the willing to restore well-being and joy to the practice of medicine. We will do this by changing our workplace culture—a multiyear effort. Features of our Alliance are that it is
- Interprofessional (i.e., it involves MDs, nurses, pharmacists, etc.)
- Longitudinal (i.e., it includes students; residents and fellows; early, mid and late-career physicians; and retired members of our community)
- Evidence-based as much as possible, and
- Financially and operationally sustainable.”
These issues of physician wellness and burnout prevention need to be highlighted locally, and local resources need to be brought to bear to address the challenge. I’m grateful to be at the University of Minnesota, where Dr. Rothenberger and the Well-Being Alliance are tackling the problem in meaningful ways.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Preventing VTE in Below-the-Knee Surgery
Venous thromboembolism (VTE) following hip fractures and hip/knee arthroplasty—both deep vein thrombosis (DVT) and pulmonary embolism (PE)—has been relatively well studied. We therefore have a fairly clear understanding what the risks for DVT and PE are with no treatment as well as with modern preventive chemotherapeutic agents. However, such clarity on the need for and effectiveness of VTE prophylaxis is lacking for below-the-knee (BTK) orthopaedic procedures. This is largely due to the fact that such procedures have been deemed “low risk”—despite a dearth of supporting evidence for that assumption. In the March 20, 2019 issue of The Journal, Heijboer et al. used a sophisticated propensity score matching methodology to evaluate the rate of VTE in >10,000 BTK surgery patients at their tertiary care referral center.
The authors evaluated patients who underwent orthopaedic surgery distal to the proximal tibial articular surface, including foot/ankle procedures, open reduction of lower-leg fractures, and BTK amputations. They performed propensity score matching to compare 5,286 patients who received any type of chemotherapeutic prophylaxis with the same number who did not, across several key risk categories. The good news is that VTE prophylaxis effectively lowered the risk of symptomatic DVT or PE from 1.9% to 0.7% (odds ratio of 0.38, p <0.001).
Unfortunately (but not surprisingly), this effectiveness came at the price of increased systemic or local bleeding among patients using chemical VTE prophylaxis, with an incidence of 1.0% in the no-prophylaxis group and 2.2% in the prophylaxis group (odds ratio of 2.18, p <0.001). The authors did not assess the incidence of deep infection or hematoma formation, which often accompany increased local bleeding. The low overall incidence of VTE and bleeding did not allow for subgroup analysis according to location of surgery, and aspirin use was not controlled for in their study. In addition, Heijboer et al. used hospital coding data, and the accuracy of the database was not assessed.
The authors recommend that “anticoagulant prophylaxis be reserved only for patient groups who are deemed to be at high risk for VTE,” but we still don’t know precisely who is at high risk among BTK surgery patients. It is my hope that these findings will prompt large, prospective multicenter trials in the foot and ankle community to better determine which types of patients should be exposed to an increased risk of postoperative bleeding complications in order to achieve a clinically important decreased risk of VTE with chemical prophylaxis.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
In My Hands, There’s a Dog Leash
As a journalist covering symposia at the 2019 AAOS Annual Meeting last week, I repeatedly heard the phrase “in my hands…,” referring to a surgeon’s individual experience with this or that technique. That got me to thinking about a research letter published in the March 6, 2019 issue of JAMA Surgery. This retrospective cross-sectional analysis of emergency department data revealed that the annual number of patients ≥65 years old presenting to US emergency departments with fractures associated with walking leashed dogs more than doubled during 2004 to 2017. Women sustained more than three-quarters of those fractures, and while the hip was the most frequently fractured body part, collectively, the upper extremity was the most frequently fractured region. Slightly more than one-quarter of those patients were admitted to the hospital.
The authors rightly pinpoint the “gravity of this burden”; the hip-fracture data alone are worrisome. And in a related online article by hand and wrist surgeons from Rush University Medical Center (titled “Doggy Danger”), the focus is on the many injuries that the human leash-holding apparatus can sustain. The authors of the JAMA Surgery research letter and the Rush authors offer common-sense advice for all us older dog walkers out there, including:
- Dog obedience training that teaches Bowser not to pull or lunge while on leash
- Selection of smaller dogs for older people contemplating acquiring a canine companion
- Holding the leash in your palm, not wrapping it around your hand
- Paying attention to where you walk, and being situationally aware (That means not texting while your dog is momentarily sniffing to see who peed on that post.)
- Selecting footwear that is appropriate for the terrain and environmental conditions during your walk
To these tidbits I would add finding a safe area where your dog can “be a dog” off-leash, preferably with other dogs and people. Socializing is good for both species, and most dog trainers and owners agree that “a tired dog is a good dog.”
The research letter states that a “risk-benefit analysis with respect to dog walking as an exercise alternative is essential,” and the authors do a concise job of quantifying fracture risk and suggesting risk-reduction strategies. The list of benefits from dog walking is too long to itemize here; suffice to say that the advantages run the gamut from physical to mental to spiritual. But let’s be safe and sensible out there. We owe it to our families (dogs included, of course) and to all those overworked orthopaedic trauma surgeons to stay on the sidewalks and in the forests and fields–and out of the ER.
Lloyd Resnick
JBJS Developmental Editor
In THA, Less Blood Loss with Multidose Postop Oral TXA
The recent orthopaedic literature, including a 2017 JBJS study, provides substantial evidence that oral and intravenous tranexamic acid (TXA) are equivalent in their effectiveness at reducing blood loss after total hip arthroplasty (THA)—with oral administration being less expensive and more convenient. But what are the optimal doses and timing of oral TXA in the setting of THA?
The findings of a randomized controlled trial by Wang et al. in the March 6, 2019 issue of JBJS go a long way toward answering that question. The authors randomized 200 patients undergoing primary THA to 1 of 4 groups, with all patients receiving an intraoperative topical dose of 1.0 g of TXA and a single dose of 2.0 g of TXA orally at 2 hours postoperatively. In addition,:
- Group A received 1.0 g of oral placebo at 3, 9, and 15 hours postoperatively
- Group B received 1.0 g of oral TXA at 3 hours postoperatively and 1.0 g of placebo at 9 and 15 hours postoperatively
- Group C received 1.0 g of oral TXA at 3 and 9 hours postoperatively and 1.0 g of placebo at 15 hours postoperatively
- Group D received 1.0 g of TXA at 3, 9, and 15 hours postoperatively
The mean total blood loss during hospitalization was significantly less in Groups B, C, and D (792, 631, and 553 mL, respectively) than in Group A (984 mL). Groups C and D had lower mean reductions in hemoglobin than did Groups A and B. No significant between-group differences were observed regarding 90-day thromboembolic complications (there were none) or transfusions (there was only 1, in Group A), but the authors said “this study was likely underpowered for establishing meaningful comparisons concerning [those 2] outcomes.”
Although this study documented significantly lower total blood losses in patients who were managed with multiple doses of oral TXA postoperatively, additional studies are required to determine whether the 3-dose regimen is superior to the 2-dose regimen.
March 2019 Article Exchange with JOSPT
In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of March 2019, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “The Impact of Decreased Scapulothoracic Upward Rotation on Subacromial Proximities.”
In this shoulder kinematics study of 40 people classified as having high or low scapulothoracic upward rotation, contact between the coracoacromial arch and rotator cuff tendon occurred in 45% of participants. The relatively low prevalence of contact suggests that subacromial rotator cuff compression may be less common than traditionally presumed.
Patellar Resurfacing in TKA: Is There a ‘Right’ Answer?
Based on available data, it appears that most arthroplasty surgeons in the United States (myself included) usually resurface the patella during total knee arthroplasties (TKAs). This strategy is supported by much of the orthopaedic literature, but there is no universal consensus on which approach is best. Internationally, surgeons in some countries resurface the patella <20% of the time.
Amid this debate, the March 6, 2019 JBJS study by Maney et al. utilizes the New Zealand Joint Registry to shine a little more light on the issue. After analyzing close to 60,000 primary TKAs performed by 203 surgeons, the authors found that patients who underwent knee arthroplasty by surgeons who “usually” (>90% of the time) resurfaced the patella had significantly higher patient-reported Oxford Knee Scores at both 6 months and 5 years postoperatively, compared to those who had their knee replacements performed by surgeons who “selectively” (≥10% to ≤90% of the time) or “rarely” (<10% of the time) resurfaced the patella. However, only 7% of the surgeons in the study fell into the usually-resurface category. That fact, along with the authors’ inability to account for possible confounding patient or surgeon factors, imparts some fragility to the study’s data. Just as (or even more) importantly, the authors did not find any differences in revision rates per 100 component years between the three resurfacing strategies, with >92% survival for all implants at 15 years postoperatively.
This study seems to support previously published data suggesting that resurfacing the patella yields functional outcomes that are at least as good as, if not slightly better than, those with not resurfacing the patella. Still, added costs and potential complications are associated with patellar resurfacing, and these results could also be used to support the strategy of surgeons who do not routinely perform that part of a total knee arthroplasty.
While we still don’t know the “best” strategy, this study adds further credence to the notion that there is not a “wrong” technique when it comes to resurfacing the patella, and surgeons should continue to use whichever technique they feel is best for individual patients.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
A Four-Legged Step Toward Preventing Elbow Contractures
Up to 50% of patients who sustain an elbow injury subsequently develop some type of contracture, making elbow contracture following trauma a common and vexing clinical scenario. While we do not completely understand the molecular basis or structural mechanisms underlying these contractures, we do know that active range-of-motion (ROM) exercises and gentle stretching are often helpful, whereas prolonged immobilization and forceful passive ROM exercises are often, if not always, detrimental.
In the March 6, 2019 issue of The Journal, Dunham and colleagues document with a rat model a better understanding about which specific tissues around the elbow account for this condition. They performed a surgical procedure on rat elbows to simulate a dislocation and then immobilized the injured extremity for 6 weeks. After the authors obtained ROM measurements at that point, some of the rats were allowed an additional 3 or 6 weeks of free active motion before a postmortem surgical dissection was performed to determine which soft tissues were most responsible for the subsequent contracture.
While the authors hypothesized that all soft tissues (muscles/tendons, anterior capsule, and ligaments/cartilage) would play a significant role in posttraumatic stiffness, they found in fact that the ligaments and cartilage caused 52% of the lost motion after 21 days of free motion and 74% of the contracture after 42 days of free motion. With this information, clinical therapies such as pharmacologic infiltrations or biophysical energy delivered to the ligaments or cartilage could be investigated. In addition, refined surgical techniques focused on these structures could be proposed and analyzed. This study represents a small preclinical step in further understanding the mechanisms of joint contracture, but it provides a foundation on which further investigations can be built.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
2018 EST Awards: And the Winners Are…
JBJS Essential Surgical Techniques (EST) and The Journal of Bone and Joint Surgery (JBJS) give out two annual awards–one for the best Subspecialty Procedure (SP) article, and the other for the best Key Procedures (KP) video published during each calendar year.
We are pleased to announce the winners for 2018:
- Editor’s Choice Technique Award:
The Pararectus Approach to Acetabular Fractures: A New Concept
by Marius J.B. Keel, MD, Klaus-Arno Siebenrock, MD, Moritz Tannast, MD, and Johannes D. Bastian, MD - Editor’s Choice Video Award:
Use of Suture Button in the Treatment of Syndesmosis Injuries
by Mette Renate Andersen, MD and Wender Figved, MD, PhD
Full open access to both articles is available for a limited time.
Submissions for the 2019 EST Awards are currently being accepted.
Rabbit Study Suggests Antibiotic-Releasing Implant Coating Could Cut Infection Risk
A study by Miller et al. in the February 20, 2019 issue of JBJS provides preclinical proof of concept that antibiotic-loaded coatings on orthopaedic implants could eventually reduce the incidence of implant-associated infection.
The researchers used in vivo bioluminescence imaging (BLI) and ex vivo analysis of colony-forming units (CFUs) to show the efficacy of an implant coating that released linezolid-rifampin over a 7-day period. Through a parapatellar arthrotomy, researchers reamed the femoral canal of 12 rabbits and inoculated the canals with a bioluminescent strain of MRSA. They then inserted a surgical grade titanium peg into each canal. All of the pegs were coated with a nanofiber coating; 6 of the pegs were loaded with the antibiotic coating and 6 were not.
Implants coated without antibiotics were associated with significantly increased in vivo BLI signals and significantly increased knee width, relative to implants with the antibiotic-releasing coatings. The animals were killed on day 7, and ex vivo analysis of CFUs isolated from soft tissue, bone, and implant specimens showed significantly increased CFUs in the specimens without the antibiotic-releasing coating, while CFUs were undetectable in the implants with antibiotics.
This larger-animal model to assess bacterial burden employed a clinically used orthopaedic implant and replicated a medial parapatellar arthrotomy in humans. According to the authors, the coating used is “highly versatile, and the polymers or drug concentrations could be modified for more rapid or longer release.” This rabbit model should be amenable to studying additional antibiotic-releasing strategies for possible translation to clinical research in humans.
Residual Pain after Joint Replacement
This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.
In the absence of infection and aseptic loosening, significant postoperative pain persists in up to 20% of joint-replacement patients. In one study related to this predicament, investigators studied 3 groups of individuals: 1) those without a total joint replacement (TJR) and no self-reported pain, 2) patients with a well-functioning TJR and no self-reported pain (mean implant time of 1.5 years), and 3) patients with a painful TJR (self-reported pain of >8 on a 0 to10 VAS scale; mean implant time of 1.76 years)1.
Peripheral blood mononuclear cells were collected for use in a lymphocyte reactivity assay to detect anti-inflammatory (IL-1ra, IL-10, IL-13 and IL-11) and inflammatory cytokines or receptors (IL-1rII and TNFR1). In general, anti-inflammatory cytokine markers in patients with post-TJR pain were decreased compared to controls and to individuals with no pain following TJR, with IL-10 and IL-13 significantly decreased among painful TJR patients. TNFR1 was significantly elevated in those with painful TJRs, and IL-1rII was modestly elevated. The authors note that treating this “1-2 punch” of elevated proinflammatory cytokines and decreased anti-inflammatory cytokines may require “a complex pattern” of both inhibition of proinflammatory mechanisms as well as anti-inflammatory medications.
In a separate study, investigators used scanning electron microscopy (SEM) to try to determine whether implant corrosion was secondary to inflammatory cellular reactions or to the effects of electrocautery used in near proximity to metallic surfaces2. Twelve knee prostheses taken at necropsy were compared to an off-the-shelf cobalt-chromium knee implant intentionally exposed to Bovie and Aquamantys electrocautery sources. SEM data was collected using an identical method to that of the retrieved implants. Five of the 12 necropsy retrievals showed signs of inflammatory cell-induced corrosion. Compared to the necropsy-retrieved implants, the iron/carbon ratio of the Bovie electrocautery-damaged implant was significantly higher, suggesting that the mechanism by which immune cells corrode implants is different than the mechanism of electrocautery damage.
In a third study, which compared results of lymphocyte transformation testing (LTT) for metal sensitivity with histological and clinical findings in 27 cases of primary total knee arthroplasty (TKA), researchers found that LTT results alone were insufficient for the diagnosis of TKA pain-relief failure due to an immune reaction3. A positive LTT might not indicate that an immune reaction is the cause of pain and stiffness post-TKA.
It will take more research to determine whether there is a connection between surface pitting and chronic knee pain in metal-sensitive persons, whether the elevated macrophage response is an associated risk factor, and whether that is associated with metallic material response.
References
- Lauryn S, Caicedo M, Jacobs J, Hallab NJ. Do TJR Patients with High Self-Reported Pain Levels Exhibit Decreased Serum Anti-inflammatory Cytokine Markers? Abstract 0135 Orthopaedic Research Society 2019
- Sorrels JA, Heise G, Morrow B, Arnholt C, Kurtz S, Mihalko WM. Inflammatory Cell- Induced Corrosion and Electrocautery Damaged TKA Implants. Abstract 0131 Orthopaedic Research Society 2019
- Yang S, Dipane M, Lu CH, Schmalzried TP, McPherson EJ. Lymphocyte Transformation Testing (LTT) in Cases of Pain Following Total Knee Arthroplasty: Little Relationship to Histopathologic Findings and Revision Outcomes. J Bone Joint Surg Am. 2019 Feb 6;101(3):257-264. doi: 10.2106/JBJS.18.00134. PMID: 30730485
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