During the last two decades, we have made tremendous progress in orthopaedic surgery in terms of limiting the negative impact of surgical dissection on patient functional outcomes. The expanding use of the arthroscope has been at the forefront of these advances. Limiting the breadth, depth, and imprecision of surgical dissection has obvious benefits that have been well documented in hundreds of musculoskeletal procedures.
In the August 3, 2016 issue of The Journal, Kim et al. demonstrate arthroscopic repair of elbow instability following elbow dislocations with injury to the lateral ulnar collateral ligament. Despite the notable success reported by the authors in 13 patients, arthroscopic elbow ligament repair is obviously a technique that requires careful preparation, and patients should be advised to work with a surgeon who is experienced in this specific application of arthroscopy.
This study does not address the question of whether or not surgery is indicated for an individual patient with post-dislocation elbow instability. Comparing outcomes among surgically managed and non-surgically managed patients would be the mode of addressing that important question. Nevertheless, we should continue efforts to advance “limited surgical damage” approaches by applying appropriate clinical research designs to clarify the reward /risk tradeoffs related to patient outcomes.
Marc Swiontkowski, MD
There are currently no standards or regulations governing when it’s safe to drive after a knee replacement. But researchers reporting in the American Journal of Physical Medicine & Rehabilitation found that patients with right-knee replacements using an automatic-transmission driving simulator had 30% slower braking times eight days after surgery compared with presurgery measurements.
Braking times were significantly reduced in the right-knee group for six weeks and reached preoperative levels at 12 weeks postsurgery. Braking time was only 2% slower after left-knee replacements, but braking force, a crucial factor in emergency stopping, decreased by 25% to 35% in both groups during the week after surgery.
The authors conclude that, while “categorical statements cannot be provided,” these automatic-transmission findings suggest that “right TKA patients may resume driving six weeks postoperatively.” However, even the presurgery measures of braking time and force that these researchers used may not represent “normal” values because severe osteoarthritis can impair driving skills. And the findings have no bearing on TKA patients who drive manual-transmission cars with clutch pedals.
If you’re a physician in private practice, there may be very few doctors following in your footsteps, according to results from athenahealth’s 9th annual Epocrates Future Physicians of America Survey.
Among medical students who responded to the survey, 73% said they plan to seek employment through a hospital or large group practice; a mere 10% said they hope to join a private practice, down from 17% the previous year. One reason for the employed practice-setting preference: med students feel their training doesn’t prepare them for the challenges of running a business. Fifty-seven percent expressed dissatisfaction with their education in practice management, and 65% reported feeling unprepared for the exigencies of billing and coding.
When asked about their “top concerns,” 60% of respondents cited a desire for work-life balance as number one. That, along with an apparent aversion to the administrative hassles of private practice, helps explain this year’s findings.
However, when OrthoBuzz asked members of the JBJS Resident Advisory Board to comment on these findings, another side of the story emerged. Daniel Hatch, MD, a fifth-year resident at Penn State Hershey Orthopaedics, said, “I am a huge proponent of private-practice medicine and hope to join a private-practice group when I am done with training, but I too feel the pull toward employed positions with guaranteed high salaries for the first few years and large signing bonuses. But I am looking for more autonomy and control in the decision-making related to my practice.”
Orrin Franko, MD, a chief resident at UC San Diego, concurred: “Personally, I desire the independence of private practice and do not fear the inevitable challenges I will face by running a business—but I am in the small minority,” he said. “I have seen first-hand the personal satisfaction, financial success, and independence of private-practice surgeons, and I desire that for myself. I hope that more of my colleagues feel the same way. Otherwise, I feel we are at risk of losing control over our specialty to large hospital systems and payors.”
For Benjamin Service, MD, a resident at Orlando Health, the choice is “not simply academic versus private practice versus hospital employed…due to the variation in orthopedic practices.” Dr. Service agrees with the survey’s findings about subpar private-practice preparedness. “US medical schools are severely lacking in educating their students on debt management, finance, asset protection, and practice management,” he said. “It is obvious that many students would not initially consider private practice due to this gap in our education.”
What do you think? Please let us know by clicking the “Leave a comment” button.