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.
Events like the 2013 Boston Marathon bombing can have a tremendous emotional impact on any care provider—physicians, nurses, imaging techs, registration and administrative personnel, transporters, and housekeeping staff. “The solution is not to tell people to ‘suck it up,’” insisted Ron Walls, MD, chair of the Department of Emergency Medicine at Brigham and Women’s Hospital.
Many of the stories in It Takes a Team—The 2013 Boston Marathon, a new Special Report jointly published by JBJS and JOSPT, emphasize the importance of caring for the caregivers–making sure the basic physical and emotional needs of clinicians are met so they can do their jobs of caring for others.
It Takes a Team provides a behind-the-scenes look at how the level 1 trauma centers involved that day (Tufts Medical Center, Beth Israel Deaconess Medical Center, Brigham and Women’s, Boston Medical Center, and Mass General) ensured that their staffs had the emotional backing, resources, and systems in place so they could focus on their seriously injured patients.
Not a single bombing victim who reached a hospital alive on April 15, 2013 died, a stunning result of years of preparation and teamwork. But the lives that were given back to the survivors had changed forever—along with the lives of the clinicians who cared for them. Everyone directly exposed to the Marathon trauma will have emotional ups and downs, and those who seemed unaffected early on may develop problems later. So caring for the caregivers will be an ongoing obligation.
It Takes a Team—The 2013 Boston Marathon: Preparing for and Recovering From a Mass-Casualty Event is divided into three parts:
Part 1: Readiness—Fortune Favors Prepared Teams
Part 2: Response and Recovery—April 15 Through December 31
Part 3: The Road Ahead—A Long Haul for Each and All
After reading our item about Google Glass in the January OrthoBuzz, Dr. Ran Schwarzkopf, assistant clinical professor of orthopaedics at the University of California, Irvine (UCI), wrote us to explain briefly how teams of surgeons, nurses, and anesthesiologists use the technology at UCI. Dr. Schwarzkopf kindly responded to our follow-up questions in the following interview.
JBJS: Thank you, Dr. Schwarzkopf, for sharing your experiences with OrthoBuzz. First, can you tell us a bit about yourself?
Dr. Ran Schwarzkopf: I am an assistant professor in the Department of Orthopaedic Surgery at UCI, where I head the Adult Reconstruction Joint Replacement Service. I trained at NYU Hospital for Joint Diseases and completed a fellowship in adult reconstruction at Brigham and Women’s Hospital in Boston. I am part of the UCI Joint Replacement Surgical Home, which is a perioperative clinical care model jointly run by orthopaedics and anesthesiology.
JBJS: We understand that you’ve been using Google Glass in some interesting ways. How did the program get started?
Dr. Schwarzkopf: UCI has always been a pioneer in incorporating new technology into medical care. We have a long tradition of innovation and entrepreneurship. Due to the orthopaedic department’s close relationship with our anesthesia department and our successful Joint Replacement Surgical Home, we were approached by Pristine, a company that develops platforms for integrated medical systems. Together we decided to explore the use of different interactive glasses for operative applications. We started working with Google Glass as our first glass prototype, but we have also examined similar products from other companies. Together with the developers at Pristine, we designed different clinical pathways for optimizing the use of the Glass to enhance our clinical work from both the orthopaedic and anesthesiology perspectives.
JBJS: Was there a particular challenge you hoped Google Glass would help you address?
Dr. Schwarzkopf: In today’s orthopaedic operative environment, efficiency, cost reduction, and successful outcomes need to go hand in hand. We were looking to increase team interactivity and real-time communication while decreasing waste and unnecessary traffic in the operating room. We also wanted to enhance our resident learning options. Our anesthesia colleagues were looking to improve communication between their team members with real-time visuals.
JBJS: Please describe some of the things you and your colleagues have done using Google Glass?
Dr. Schwarzkopf: The orthopaedic team was able to broadcast surgery live to team members who were not inside the operating room, giving residents and visitors the ability to observe the procedure from the “surgeon’s point of view” without increasing traffic in the operating room. The surgeon was also able to view both check-lists and images on his glass view screen during the procedure. The nursing team inside the OR was able to communicate with our nurse manager without needing to exit the room or use the phone through a tablet screen outside the OR. Our anesthesia team includes an attending anesthesiologist and two residents or nurse anesthetists in two separate rooms. The anesthesiologist can observe both rooms from his tablet and can communicate with the physician/nurse inside. He can see both the monitors and the patient and help with decision making and problem solving without the need for constant paging and phone calls.
JBJS: What is the greatest benefit from this technology?
Dr. Schwarzkopf: I think the greatest benefit is the increased integration of the operating team and the streamlined processes that the technology affords us. We are able to communicate and provide oversight in a whole new way. It decreases traffic in the operating room and increases the speed of communication and care given to the patient.
JBJS: What surprised you the most about your experience with Google Glass?
Dr. Schwarzkopf: The ability to build a complex control tree, which enables one supervising physician to oversee others in a completely new way. We can now see through other peoples’ eyes and we can help and communicate in real time, without old-fashioned back-and-forth information transfer.
JBJS: By using several pairs of Google Glass simultaneously, you have been able to link surgeons, nurses, and anesthesiologists. What are the most important benefits of that type of teamwork? What barriers remain to greater collaboration?
Dr. Schwarzkopf: The ability to pair several glasses together is one of the main advantages of this new technology. We observed greater and more efficient teamwork on all sides—surgical, nursing, and anesthesia. The benefits include decreased OR traffic and cost reduction through reduced procedure times. The ability of a supervisor to see through his trainees’ eyes is priceless. We can now directly control actions beyond our immediate line of sight and we can do it without time-consuming back-and-forth communications. When you can see what your resident sees, the phrase “lost in translation” will no longer be relevant. The main barriers that remain are mostly technical, such as the hands-free or voice-activated ability to control the camera angle and “wink” control of the Glass activity. That’s being worked on as we speak.
JBJS: In honor of the 125th anniversary of JBJS this year, we are interested in what orthopaedists think might be important trends in the future. Looking ahead to the next 20 years or so, what do you think might be three significant advances or changes in orthopaedics?
Dr. Schwarzkopf: We will see significant changes in the way health care is managed and provided, mostly due to changes in regulation and federal guidelines. Resident education will incorporate more advanced methods to allow residents to improve their proficiency while still abiding by increasingly restrictive work-hour regulations. On the technological side I think we will see much more influence from the “gaming” world, like enhanced/augmented reality technology.
JBJS: Thank you very much, Dr. Schwarzkopf. We wish you continued success with all the innovations taking place at UCI.