JBJS is pleased to be partnering with INSIGHTS Orthopedics, featuring our online content within the new version of their app for iPad. INSIGHTS Orthopedics allows you to create your own personalized medical magazine from conveniently aggregated content, as well as follow what your peers, orthopaedic leaders, and leading Journal Clubs are reading. The newly launched Version 2.0 offers quicker access to relevant content through Featured Articles and reading recommendations.
Learn more about Insights Orthopedics, and download the free app, at http://www.insights.md/orthopedics/
Read the review on Top Ortho Apps at http://toporthoapps.com/2013/08/31/insights-orthopedics/
Thomas Thornhill, MD is the John B and Buckminster Brown Professor of Orthopaedic Surgery at Harvard Medical School and Chair of the Department of Orthopaedics at Brigham and Women’s Hospital in Boston. He recently was kind enough to answer a few questions for OrthoBuzz.
JBJS: What are some of the most significant changes in orthopaedics you have observed during your career?
Dr. Thornhill: The quality of applicants to orthopaedic residency programs seems to improve every year. I think anyone involved today in choosing new residents feels that he or she would never have been chosen by contemporary standards. Moreover, our profession has become more diverse, which is a good thing. Our residency/fellowship program has a significant number of women and underserved minorities. The most impressive thing is that there is a single set of criteria for all applicants, giving us a uniformly outstanding resident pool.
Also, the emerging use of biologics has enhanced our ability to care for some common and uncommon musculoskeletal problems. For example, the use of disease-modifying anti-rheumatic drugs (DMARDs) has revolutionized the care of the rheumatoid patient. When I began practice, 80 percent of patients undergoing total joint arthroplasty had rheumatoid arthritis, and now it is only approximately 10 percent in a center well-known for treating the rheumatoid patient.
Third, I’ve seen significant changes in the globalization of orthopaedics. The internet and social media have improved global communication. Many of the meetings in arthroplasty are global in their scope, and we are learning a tremendous amount from our orthopaedic colleagues around the world.
JBJS: Brigham and Women’s Hospital is recognized as a leader in providing patient-centered, team-based care. Why is this approach so important to orthopaedic patients?
Dr. Thornhill: Brigham and Women’s Hospital does not exist in a vacuum, and the Boston area has many fine academic and community hospitals with strong orthopaedic programs. Each subscribes to the concept of providing the right care, at the right place, and at the right time. Moreover, the changes in healthcare systems in Massachusetts and throughout the United Sates require each of us to be innovative. In the past, clinical surpluses could be used for educational and research program funding, but with the shrinking healthcare economy, there are many essential, but non-remunerative programs that are in jeopardy. Efficient, team-based care is one way to ensure we have the resources to continue these important educational and research programs. Finally, the switch from fee-for-service to episode-of-care reimbursement and population health is going to require each of us to adjust to inevitable changes in healthcare. In this environment, patient-centered, team-based care makes the most sense to ensure optimal outcomes.
JBJS: Orthopaedists are increasingly focused by subspecialty. What do you see as the benefits and risks of increased subspecialization within orthopaedics?
Dr. Thornhill: We are indeed becoming more and more subspecialized. One benefit is that it will certainly improve expertise in these areas, where patient demand is growing in an exponential fashion. It will also allow specialists to remain current in their subspecialty and prompt innovation in these different fields of orthopaedic practice.
On the other hand, intensive subspecialization may prevent us from “thinking outside the box.” Communication and idea crossover are important, and while we know many of the leaders in our own subspecialty, we don’t know many in other areas. Most of the meetings now are subspecialty-driven and fail to benefit from sharing of ideas with other subspecialties. Our graduates now virtually all take a fellowship, and 15 percent of them take two fellowships. One could argue that a trauma surgeon or musculoskeletal oncologist should have arthroplasty experience because there is a good deal of overlap within these disciplines. We should also remember that lessons learned in one specialty may benefit another. For instance, hip surgeons have long considered neck shaft angle, offset, and even material properties that have now been incorporated into the design and implantation of shoulder prostheses.
JBJS: How do you think JBJS can best address the needs of the orthopaedic community in light of this increasing subspecialization?
Dr. Thornhill: JBJS needs to maintain its preeminence as the leading orthopaedic journal. To do so, it must remain relevant, explore other mechanisms in addition to a printed version to transmit information, and the articles must remain balanced throughout the various subspecialties. I think JBJS has done an outstanding job moving into electronic media. One concern is the economics of maintaining The Journal’s viability and the concerns of some young authors about the cost of submitting a manuscript.
JBJS: Looking ahead to the next 20 years or so, what three significant advances or changes in orthopaedics do you foresee?
Dr. Thornhill: To paraphrase the book Future Shock, “If you want to see what is in the future, look around because it is happening somewhere now.” I think there will be an increased use of biologics in applications such as induction of bone formation, cartilage repair, tissue engineering, and the use of stem cells for repairing and regenerating musculoskeletal structures.
Also, we will look back several years from now and laugh at the materials we currently use for total joint replacement. One important concern in my area of interest is that 15 to 20 percent of patients undergoing total knee replacement are not completely satisfied, while many people with total hips and total shoulders forget they had an implant. I think the cause is multifactorial, but I do think that we will develop or engineer materials with characteristics that will improve the kinematics of knee prostheses, and hopefully our patients will feel that their knee replacements are more normal.
Finally, there will be an increase in technology, manufacturing, and research and development on a global scale. Global cooperation and time zone differences can allow manufacturing, design, and outcome studies to occur 24-7 in a more cost-effective fashion. If we also foster the interactions between academia and industry in a controlled fashion, we will further appreciate the tremendous advances in our specialty due to these relationships.
JBJS: What is your favorite thing about your profession?
Dr. Thornhill: The hackneyed phrase is that we get instant gratification from pain relief and restoration of function in our patients. While this is true, when I trace my training from internal medicine to orthopaedics, I recall drawing a Venn diagram showing that the three things I liked the best were surgery, rheumatology, and neurology. The only true intersection among those is orthopaedics. I would say that other than my family, I appreciate my interactions with students, residents, fellows, and colleagues, and I thoroughly enjoy treating my patients as people. Finally, I like the operating room and the technical aspects of orthopaedics.
JBJS: Thank you, Dr. Thornhill, for your time.
Kent Anderson, CEO/Publisher of the JBJS Special Report: “It Takes a Team”, sits down and talks about the 2013 Boston Marathon Bombings. Some of the topics that Kent discusses in the interview are the emphasis on teamwork in healthcare, the importance of the first responders and orthopaedic surgeons who treated the survivors and lessons learned from this horrific tragedy. Listen now: http://bit.jbjs.org/1ph87Hu
Up against an April 1 deadline that would see Medicare payments to physicians plunge by nearly 24%, a bipartisan group of Congressional negotiators introduced legislation that would repeal Medicare’s sustainable growth rate (SGR) formula and replace it with an annual 0.5% pay increase for five years. The proposed legislation contains additional provisions designed to transition Medicare from a pay-per-procedure system to one that promotes value through alternative payment methods (APMs) and rewards physicians for engaging with APMs. Those provisions include:
- A consolidation of three existing Medicare quality programs into one
- Incentives for care coordination
- Involvement by physicians in developing clinical guidelines, performance measures, and APMs
- Making provider-specific quality and utilization data more publicly accessible
Before we hail this as the epitome of bipartisan success, it should be noted that the legislation in its current form does not detail how Congress would pay for a permanent SGR repeal, which is estimated to cost between $120 billion and $150 billion. That significant detail will be debated if and when the full membership of both chambers considers the bill. Congress has been at similar SGR crossroads before and ended up passing short-term “patches” without permanently revising what everyone agrees is a failed formula.
In a study in the February Journal of Hand Surgery, nearly a third of all people who sustained a cat bite to the hand ended up hospitalized for treatment of a serious infection. Among those hospitalized, the average length of stay was 3.2 days, mostly for surgical procedures, including irrigation and debridement, and administration of appropriate antibiotics.
One major risk factor for hospitalization was a bite located over a joint/tendon sheath, rather than one located over soft tissue. Study co-author Brian Carlsen of the Mayo Clinic explained further in an interview with USA Today: “When the cat bites the hand, the joints and tendons are protected with fluid and there is no circulation, so bacteria can grow like crazy.” The most common pathogen isolated in cultures was Pasturella multocida, which the study authors described as “one of the most aggressive pathogens isolated from the saliva of 70% to 90% of cats.”
The authors conclude that “there should be a low threshold for aggressive treatment” in patients who present with a cat bite to the hand along with lymphangitis, erythema, and swelling. Or, as Dr. Carlsen told USA Today (with tongue presumably in cheek): “Rule of thumb–go see a doctor if a cat bites your hand.”
When it comes to knowing the costs of the devices they implant, orthopaedic surgeons and residents are batting only .210 and. 170, respectively. More than 500 orthopaedic surgeons surveyed at seven US academic medical centers correctly estimated the cost of common orthopaedic devices only 21% of the time. Residents at the same institutions did so only 17% of the time. Many of these respondents (36% of surgeons and 75% of residents) admitted that their knowledge of device costs was “below average” or “poor.” All respondents tended to overestimate the price of low-cost devices and to underestimate the price of high-cost devices. The implication of that tendency, say the authors of the Health Affairs study, is that “physicians may underestimate the amount that could be saved by choosing the lower-cost alternative.” The biggest barrier to physicians knowing device prices is confidentiality clauses in the contracts between device vendors and hospitals. “Widespread dissemination of device prices is not an option at many institutions,” wrote the authors. It remains to be seen whether the proliferation of accountable care organizations, with their emphasis on cost-efficient care, will alter this situation. For more about cost variation in orthopaedic devices, see the JBJS article “Variability in Costs Associated with Total Hip and Knee Replacement Implants.”