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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

  1. Interprofessional (i.e., it involves MDs, nurses, pharmacists, etc.)
  2. Longitudinal (i.e., it includes students; residents and fellows; early, mid and late-career physicians; and retired members of our community)
  3. Evidence-based as much as possible, and
  4. 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

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:

Full open access to both articles is available for a limited time.

Submissions for the 2019 EST Awards are currently being accepted.

Benchmark Data on Aseptic Revision after Knee Replacement

The main advantage of joint registries is their large number of recorded procedures, ideally with very few patient “types” not represented in the database. This is the case with the Australian Orthopaedic Association National Joint Replacement Registry, which includes data on almost 100% of all joint replacements performed in Australia since 2002. In the February 20, 2019 issue of The Journal, Jorgenson et al. analyze almost 6,000 major aseptic total knee arthroplasty (TKA) revisions from a cohort of 478,000 primary TKAs registered between 1999 and 2015. This analysis provides robust benchmark data for patients and surgeons, although it comes too late for the 3% of patients who required such a revision surgery within the 15-year study period.

The authors found that fixed bearings were revised for aseptic reasons at a significantly lower rate than mobile bearings (2.7% vs 4.1%, respectively) and that patients <55 years old had an almost 8-fold higher revision rate compared to patients ≥75 years old ( 7.8% versus 1.0%, respectively). The study also found lower aseptic revision rates with minimally stabilized total knee prostheses compared to posterior-stabilized prostheses, and higher aseptic revision rates with completely cementless fixation relative to either hybrid or fully cemented fixation. These are valuable data for arthroplasty surgeons in terms of selecting implants and surgical techniques and for preoperative counseling of patients—especially younger ones. While many of these findings have been previously reported, these registry-based results add significant strength to published data.

Ideally, data such as these would be controlled for confounding variables such as surgeon experience and additional patient-specific variables such as activity demands and medical comorbidities. Still, these data provide useful prosthesis-specific factors for shared decision making with patients. We look forward to more helpful information from this and other national joint registries and encourage the continued growth of similar registries in other subspecialties.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Smoking, Depression Adversely Affect Outcomes after TAA

After some relatively poor results in the 1980s, there was a “reboot” with total ankle arthroplasty (TAA) in the late 1990s to improve outcomes so that TAA would provide a reliable treatment for patients with end-stage ankle arthritis. Advances in the understanding of the biomechanical requirements for ankle prostheses and which patients might benefit from them the most—plus the realization  that TAA is a technically demanding surgical procedure that requires advanced education—have vastly improved the outcomes of these procedures. In fact, TAA has become reliable enough that we can now begin to tease out the patient variables that seem to affect outcomes.

In the February 6, 2019 issue of The Journal, Cunningham et al. use an extensive clinical TAA registry to identify patient characteristics that impact TAA outcomes. The good news is that, 30-plus years after the inauspicious outcomes of first-generation TAA, overall pain and function significantly improved among the patients in this study. However, current smoking was associated with poorer patient outcomes at the 5-year follow-up, as it seems to be with the vast majority of orthopaedic procedures. Also, at a mean 1- to 2-year follow-up,  a previous surgical procedure on the ankle was associated with significantly smaller improvements in at least 1 patient-reported outcome. This makes sense because prior surgery leads to scarring and its attendant risk of infection and increased difficulty with exposure and the ideal placement of TAA components. Cunningham et al. also identified depression as being associated with worse TAA outcomes at all follow-up points, adding to our already ample body of evidence that patient psychological factors play a major role in orthopaedic surgical results.

Interestingly, these authors found that patients undergoing staged bilateral ankle arthroplasty did not do as well as those undergoing simultaneous bilateral TAAs. And somewhat surprisingly, the authors found obesity to be associated with better outcomes at the 5-year follow-up. This may be related to increased bone density and greater soft-tissue coverage, but this finding is still seemingly counterintuitive based on everything else we know about the negative associations between obesity and outcomes of other joint replacements.

As more surgeons and orthopaedic centers make use of TAA, it will be important for us to follow the lead of the total knee and total hip communities in providing large datasets to further clarify which factors—patient-related and surgical—lead to the best and worst patient outcomes. This study by Cunningham et al. provides a starting point upon which other research will hopefully build.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Ankle Surgery: Who Should Do It?

The relationship between orthopaedic foot and ankle surgeons and podiatric surgeons has been checkered. Many have advocated that the orthopaedic community should isolate itself from interaction with the podiatric community. Conversely, a smaller group of orthopaedic foot and ankle surgeons have recommended sharing CME endeavors with podiatric surgeons, and combining clinical services with them. As long as individual states continue to legislate surgeon scope-of-practice matters (38 states currently allow podiatric surgeons to perform ankle surgery), it seems to me that shared learning, combined clinical services, and collaborative research make the most sense for advancing foot and ankle care for as many patients as possible. We should all be willing to work with our surgical colleagues to improve everyone’s decision making and skill.

In the January 16, 2019  issue of The Journal, Chan et al. probe an administrative database to evaluate several outcomes after total ankle arthroplasty (TAA) and ankle arthrodesis performed by both types of surgeon. Probably because many podiatrists self-limit their practices to forefoot surgery, podiatric surgeons provided the treatment for only 18% of the patients in both ankle-surgery groups. When podiatrists were the primary surgeon, the authors found increased lengths of stay for both procedures and increased hospital costs for arthrodesis patients. The authors did not investigate the reasons for these increases, but they should be investigated in the future. Chan et al. did find that, in general, podiatric surgeons operated on sicker patients and tended to work in smaller, non-teaching hospitals.

The authors also found an increasing percentage of these procedures being performed by podiatrists over the period from 2011 to 2016. This is likely related to multiple factors, including variable availability of orthopaedic foot and ankle surgeons relative to podiatric surgeons in many communities, and an increased number of podiatry training programs that specialize in hindfoot surgery.

It seems to me that data like these from Chan et al. should be shared with both communities to foster discussions regarding how to optimize length of stay, costs, and patient outcomes across the board. The goal should always be to raise every surgeon’s level of care for the benefit of all patients.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Unexplained Pain After TKA? Duloxetine Might Help

Somewhere between 10% and 15% of patients are unsatisfied with their outcome after primary total knee arthroplasty (TKA). In some cases, dissatisfaction is related to poor range of motion, but more often it is related to residual—or even intensified—pain in the knee several weeks after surgery.

In the January 2, 2019 issue of The Journal, Koh et al. report the results of a prospective randomized trial assessing the effects of duloxetine (Cymbalta) in TKA patients who were screened preoperatively for “central sensitization.” In central sensitization, a hyperexcitable central nervous system becomes hypersensitive to stimuli, noxious and otherwise.

Koh et al. randomized 80 centrally sensitized patients (mean age of 69 years), 40 of whom received a multimodal perioperative pain management protocol plus duloxetine, and 40 of whom received the multimodal protocol without duloxetine. During postoperative weeks 2 through 12, patients taking duloxetine reported better results in terms of pain and functional and emotional outcome measures than those not receiving the drug. Patients in the duloxetine group expressed greater satisfaction with pain control (77% vs 29%) and daily activity (83% vs 52%) at postoperative week 12, compared with those in the control group.

This research represents an important advance in identifying and treating patients who are prone to poor outcomes after TKA. The concept of central sensitization is relatively new to the orthopaedic community, and this pharmacologic intervention is likely to be just the first among many that will help these patients. I think it is probable that other, nonpharmacological interventions will eventually be as or even more successful in helping TKA patients with central sensitization. Koh et al. make a valuable  contribution in this article by educating us as to the neurophysiologic basis of this condition, and their work should pave the way for more important research in this area.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

What We Owe our Patients—Continuous Improvement

It has been said that a surgeon’s skill and judgment account for between 80% and 90% of a patient’s outcome. (I believe this is true for both surgical and nonsurgical treatments.) Throw in a physician’s ability to listen and clearly communicate with patients, and I am sure we are approaching that 90% mark. That means that when we conduct randomized trials comparing two types of knee prostheses or fracture-fixation constructs, we are, in essence, scrutinizing only about 10% of the patient-outcome equation. 

So how do we best evaluate the 90% of the outcome equation that is physician-dependent? With the advent of “bundled” episodes of care, the orthopaedic community has emphasized the need for risk-adjustment in evaluating surgeon performance. Clearly, there are certain patients who are at higher risk for worse outcomes than others, such as those with diabetes, nicotine abuse, advanced age, and less social support.

In the December 19. 2018 issue of The Journal, Thigpen et al. report on patient outcomes 6 months after arthroscopic rotator cuff repair in 995 patients treated by 34 surgeons. The authors evaluated patient-reported outcomes from all surgeons using both unadjusted and adjusted ASES change scores. The adjusted scores took into account about a dozen baseline patient characteristics, including symptom severity, functional and mental scores, medical comorbidities, and Workers’ Compensation status. Relative to performance rankings based on unadjusted data, risk adjustment significantly altered the rankings for 91% of the surgeons.  According to the authors, these findings “underpin the importance of risk-adjustment approaches to accurately report surgeon performance.”

But what is of even greater interest to me is that risk adjustment led to positive increases in patient outcomes for some surgeons, while decreasing outcomes for other surgeons. Some of these outcome differences likely reflect each surgeon’s patient-selection biases, but in the words of the authors, the numbers strongly suggest “that there is a meaningful, distinguishable difference in patient outcomes between surgeons.”

What should we do with this data? In my opinion, surgeons in the lower 80%  of the list, at least, ought to be engaging with the surgeons who demonstrated the highest adjusted performance scores to understand what is helping them obtain outcomes that are superior to everyone else’s. We owe it to our patients to understand what our personal outcomes are for at least the most common conditions we treat. I believe it borders on unethical behavior to quote patients outcome data of a procedure from the peer-reviewed literature when we have no idea how our personal results compare. Orthopaedic surgeons need to be more active in lobbying our groups and health systems to support best practices for clinical outcome data collection and reporting so we can, in turn, improve our care by adopting the best practices of the surgeons with the best outcomes.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Using CT Data to Diagnose Osteoporosis

Osteoporosis is a “silent” disease, often becoming apparent only after a patient older than 50 sustains a low-energy fracture of the wrist, proximal humerus, or hip. Monitoring serum vitamin D levels and DEXA testing represent ideal screening methods to prevent these sentinel fragility fractures. In addition, through programs such as the AOA’s “Own the Bone” initiative, the orthopaedic community has taken a leadership role in diagnosing and treating osteoporosis after the disease presents as a fragility fracture. Own the Bone is active in all 50 states and, through local physician leadership, is identifying individuals who present with a fragility fracture so they can receive follow-up care that helps mitigate bone loss and prevent secondary fractures.

We still have a long way to go, however. Recent analyses show that only 30% of candidate patients (albeit up from 20%) are receiving this type of evidence-based care. The best-case scenario would be to identify at-risk men and women (osteoporosis does not affect women exclusively) before a potentially serious injury.

In the December 5, 2018 issue of The Journal, Anderson et al. present strong evidence that computed tomography (CT) can provide accurate data for diagnosing osteoporosis. CT is increasingly used (perhaps overused in some settings) across a spectrum of diagnostic investigations. The osseous-related data from these scans can be used to glean accurate information regarding a patient’s bone quality by analyzing the Hounsfield unit (HU) values of bone captured opportunistically by CT.  HU data are routinely ignored, but the values correlate strongly with bone mineral density, and they could help us recommend preventive care to our patients before a fragility fracture occurs. (For example, a threshold of <135 HU for the L1 vertebral body indicates a risk for osteoporosis.)

Orthopaedists should discuss the possibility of asking their radiologist colleagues who read CT scans of older patients to routinely share that data. When indicated, we could promptly refer patients back to their primary care provider for discussion of pharmacological treatment and lifestyle changes proven to help prevent primary fragility fractures. There is little doubt that our patients are getting older. Reviewing CT data  could help us dramatically improve preventive care and decrease the risk of first-time fragility fractures.

Click here for additional OrthoBuzz posts about fragility fractures.

Marc Swiontkowski, MD
JBJS Editor-in-Chief