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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.

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

Empathic Orthopaedists: Worth Waiting For

When I was a waiter during high school and college, I quickly learned the value of connecting with my customers. If I could fulfill whatever role they were looking me to fill (i.e., being fun and interactive, serious, acting invisible, or anything in between), I would usually be rewarded with a sizable tip or a compliment. I realized that I was not there primarily to help customers make food choices, but rather to make each customer feel as though I existed only to care for them. There is a big difference between those two roles, and I found myself thinking about those experiences while reading the article by Kortlever et al. in the February 20, 2019 issue of JBJS.

The authors aimed to determine whether an association existed between a patient’s wait time and the amount of time he or she spent with a surgeon and the patient’s perception of the surgeon’s empathy. Considering the well-established connection between the perceived empathy coming from a physician and patient satisfaction, this is an important question to examine. Interestingly, Kortlever et al. found that neither time-related variable was associated with perceived physician empathy, suggesting that decreasing wait times or spending more time with individual patients may not increase their satisfaction with the visit. However, the authors did find a direct, inverse association between surgeon stress levels and patient-perceived empathy. Specifically, for every 1-point increase in a surgeon’s self-reported stress (as measured with the Perceived Stress Scale short form), there was a 0.87 decrease in perceived empathy (as measured with the Jefferson Scale of Patient’s Perceptions of Physician Empathy).

Like most humans, patients value the quality of an interaction more than its duration. Similarly, patients are more concerned with what happens during their medical appointment than with the wait time that transpires before it. It probably does not take very long for a patient to feel that you are fully engaged with his or her concerns—or not—and increasing the length of a “bad” interaction usually will not increase its quality. Patients may not always know whether your medical advice is on target, but almost all of them can tell how much you care and whether you are “present” during their appointment.

I agree with the authors’ conclusion that the present findings indicate “that the patient-physician relationship is more built on actions and communications than on time spent.” I suspect that future studies will continue to show how powerful the perceptions of caring and empathy are when it comes to patient care.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

Editor’s Note: Kortlever et al. cite a 2005 Instructional Course Lecture by Tongue et al. that describes easy-to-learn skills for effective and empathic patient-centered interviews. Click here for full text of that article.

Surgeon-as-Patient: Tech Data May Cloud Clinical Judgment

The 24th installment of our “What’s Important” series in the JBJS Orthopaedic Forum comes from orthopaedic surgeon Jack W. Crosland. In detailing his recent experience as a patient at a prestigious university teaching hospital, Dr. Crosland declares that what’s important for physicians is “listening and reasoning.”

His thesis is that in the current health care system,  the “technology component” of clinical decision making—lab results and imaging data, for example—has become overemphasized, while reliance on information obtained from patients is underemphasized.

In his essay, Dr. Crosland says that his dual perspective as patient and surgeon further convinced him that “physicians can get more pertinent and valuable information from a thorough patient interview than from any other source.”

Dr. Crosland is not radically antitechnology, but he does conclude that “technology should be used to confirm a diagnosis or narrow the list in a differential diagnosis, but it should not be the primary resource to diagnose disease or to determine treatment modalities.”

If you would like JBJS to consider a “What’s Important” story for publication, please submit a manuscript via Editorial Manager. When asked to select an article type, please choose Orthopaedic Forum and include“What’s Important:” at the beginning of the title.

Guest Posts: Two Views on Gawande’s New Yorker Article about EMRs

OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent New Yorker article by Atul Gawande, the following two commentaries come from Matthew Christian, MD, and Paul Matuszewski, MD, respectively.

In his November 12, 2018 article in The New Yorker, Dr. Atul Gawande notes that more than 90% of American hospitals have been computerized in the past decade. In theory, that should make documentation easier, but Gawande cites a 2016 study revealing that most physicians now spend 2 hours documenting for every 1 hour of face-to-face patient interaction. That hit home to me when I joined a group practice that uses an electronic medical record (EMR) system for clinical documentation. One of my senior partners informed me that he spends 2 hours per day at home finishing clinic notes and dictations.

The downside of digitization seems clear. Dr. Gawande cites a study noting that primary care physicians screen positive for depression at a rate double that of the general population. A Mayo clinic study discovered that the amount of computer documentation was a strong predictor of physician burnout.

Gawande further describes medicine as a “complex adaptive system” that is “meant to evolve with time and changing conditions.” EMRs, conversely, seek to universalize and mandate best practices—often to a fault—with little or no flexibility. In Gawande’s adaptive model, computerization is “all selection and no mutation.”

What makes medicine so engaging and satisfying for me is treating each patient in a unique and personalized manner. It seems that the last bastion of the happy physician is the proceduralist, of which the orthopaedic surgeon is an example. We spend 2 or 3 fewer days a week documenting clinical visits and instead solve unique and intellectually challenging musculoskeletal problems. This break from a computer screen frees us to do the thing we have spent our whole adult lives training for—practicing medicine. That is, until the procedure is complete and we must log in to complete the operative notes, postop orders, attending attestation, and other seemingly endless tasks.

Matthew Christian, MD is an orthopaedic surgeon at OSS Health in York, Pennsylvania and a member of the JBJS Social Media Advisory Board.

*  *  *  *

The electronic medical record—a marvelous marriage of modern technology and medicine to improve care for patients. At least, that was the promise.  How it has played out over the past decade, however, leaves much to be desired from the perspective of physicians. Patient care has not been streamlined, and mounting evidence suggests that EMRs have increased the workload for physicians, adversely altered the physician-patient relationship, and increased the degree of physician burnout.1  Atul Gawande’s New Yorker article outlines his and other physician experiences with EMRs, concluding that many physicians—especially nonsurgeons bound to an office or clinic—now hate their computers.

But why? Gawande describes the evolution of EMRs from simple “cool” programs into complex, “very uncool” systems, eventually culminating in what former IBM software engineer Frederick Brooks described as the “Tar Pit.” That’s when a system becomes so complex and universalized for so many different people and functions (clinical and administrative in the case of EMRs) that it becomes the electronic equivalent of miles of bureaucratic red tape. For physicians, the “Tar Pit” means more clicks, more steps, more checks, more alerts and notifications—with little or no improvement for patients and less work/life balance for doctors.

Gawande relates the experience of a primary-care physician who once effectively maintained her own problem list for each of her patients. But the list has become in her words “utterly useless,” because now anyone across the organization can modify it, often inserting duplication and inaccuracies.  Computerized complexity that adds more work but little to no value discourages physicians from engaging with the system, compounding the problem.

Gawande’s article doesn’t go into detail about how we can solve this problem, but it presents several ways that physicians and hospital systems have coped. Some have resorted to medical scribes (often aspiring med students) or more highly trained overseas physicians who transcribe physician encounters. Some tech-savvy physicians expend effort to bend the software to their will – customizing components of the EMR despite pushback from vendors. This has led to various home-grown apps designed to help improve workflow and reduce hassles.

Time will tell whether these or other workarounds will actually help. One thing is certain, however. Unless physicians take charge and guide the design (and redesign) of EMR technology, the system will fail to serve the physician, and the current reality of the physician serving the system will persist.

Paul E. Matuszewski, MD is an assistant professor of orthopaedic traumatology and Director of Orthopaedic Trauma Research at the University of Kentucky School of Medicine and a member of the JBJS Social Media Advisory Board.

Reference

  1. Arndt et al. Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations. Ann Fam Med. 2017 (15) 5, 419-426
    Editor’s Note:
    The US Department of Health and Human Services has unveiled a draft plan to ease the burden of using EMR software. The draft strategy is open for public comments through January 28, 2019. Also, see this related OrthoBuzz Editor’s Choice post from JBJS Editor-in-Chief Dr. Marc Swiontkowski.

 

November 2018 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 November 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Does Health Care Utilization Before Hip Arthroscopy Predict Health Care Utilization After Surgery in the US Military Health System? An Investigation Into Health-Seeking Behavior.

This observational cohort study found that patients who used more health care prior to hip arthroscopy also used more health care after surgery. The findings lead the authors to conclude that clinicians “should consider prior patterns of health care utilization…when determining care plans and prognosis.”

October 2018 Article Exchange with JOSPT

jospt_article_exchange_logo1In 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 October 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Validity of Clinical Small-Fiber Sensory Testing to Detect Small–Nerve Fiber Degeneration.

This prospective, cross-sectional, diagnostic-accuracy study found that pinprick testing, followed by warm and cold tests if pinprick is normal, is a valid and cost-effective method to detect small-fiber degeneration in a carpal tunnel syndrome model of neuropathy.

Team Physicians Finally Get Federal Licensing and Liability Protection

Capitol Dome for OBuzzWhen it comes to passing federal legislation on Capitol Hill, common-sense solutions for relatively straightforward problems are often not easy to come by. There always seems to be something holding up every piece of legislation, no matter how great the benefits and how minimal the risks/costs.

That is why I was happy to hear that Congress passed the Sports Medicine Licensure Clarity Act  earlier this month.  The legislation clarifies that health care services provided by a licensed provider in a state other than the one in which he/she is licensed (a scenario commonly encountered by physicians and athletic trainers who travel with collegiate or professional athletic teams) will be considered in-state services and will be covered by the provider’s liability insurance.

The American Association of Orthopaedic Surgeons (AAOS) and several other provider groups—including the American Orthopaedic Society for Sports Medicine (AOSSM)—have long recognized that previous laws exposed many team physicians to medical liability if they provided care in states in which they did not have a medical license. The Clarity Act protects orthopaedic surgeons, athletic trainers, and other health care professionals who serve as traveling care providers from licensure hassles and potential liability so they can focus on caring for their athlete-patients.

As someone who has been engaged in orthopaedic advocacy efforts for my entire, albeit short, orthopaedic career, I am proud of this accomplishment. Advocacy is not for the faint of heart, and the amount of work that goes on behind the scenes to get legislation like this enacted is astounding. Arguably, such efforts have never been more important than they are in today’s health care environment.  If we, as orthopaedic surgeons, do not advocate on behalf of our patients and ourselves, no one else will.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media