How “Implant Identification” Simplified a Total Hip Revision

August 27th, 2010

by Andrew Walden

Ed Note:  This is from an e-mail re how using Implant Identification helped in a total hip revision case.  We couldn’t have said it better.

I wanted to inform you of a situation in which your website helped us during a hip revision.  I’m sure you already know how valuable your x-ray registry is and it only continues to get stronger with more additions.

I was doing a case in which the surgeon was revising a prosthesis that had no op report and he couldn’t identify the components.  He was planning on revising the stem and shell and was convinced that they were loose.  However, and I think you know where I’m going with this, the stem and was solid and would have required an ETO and lots of time to bang out.  I happened to locate the stem on orthopaediclist and from there we contacted the company’s rep and got head options and liner options.  What could have been a long and very difficult revision turned out to be a head and liner exchange and most likely a better outcome for the patient.

Just to offer some feedback…what might make it easier to locate implants would be to subcategorize even further than just primary hip replacemet.  For example, pressfit vs cement, collar vs collarless, taper vs cylindrical, etc.

There used to be a site called xxxxxxxxxxxxxxxx.com that had a good number of x-rays but it appears to be gone.  Now orthopaediclist and xrayregistry.com are the only x-ray identification sites that I’m aware of and orthopaediclist has a much larger database.

Thanks for the site.  I will continue to help add more x-rays and encourage others to do so as well.

Regards,

Andrew Walden

Mr. Walden is a manufacturer’s representative based in Wilmington, NC, USA.

Posted in Orthopaedic Radiology | No Comments »

Avoid 3 Common Audit Risks Brought on By EMRs

June 10th, 2010

by Cheryl Toth

Digitizing your medical records is an effective way to improve practice workflow and reduce paper. But EMRs can also increase your risk of a documentation audit, unless you use their record keeping and automation features properly. Here are three risk areas that any orthopaedist who is evaluating, or using, EMR should be concerned with.

 

Risk #1: Poorly Designed Visit Templates

 

A critical component of successful EMR implementation is customizing the vendor’s visit templates. But many surgeons skip or abdicate this step. A large spine practice we worked with passed the task off to its non-clinical Practice Administrator. It should have been no surprise that the surgeons found the templates useless.

 

Why is customization so important? Standard visit templates create multi-page notes that don’t necessarily document what you did. The exam template for a spine surgeon bears little resemblance to what a foot and ankle surgeon needs. Templates are the most critical step toward making sure your documentation is right; bypass their customization at your own peril.

 

Vendors often aren’t much help in this area. Better to print an ICD-9 frequency report to identify the conditions you see and treat most often, and create a template for each of them in your new system.

 

Risk #2: ‘Cloning’

 

Touted as a time-saver, EMRs automatically ‘pull forward’ the History of Present Illness (HPI) documentation from each previous patient encounter. That’s ok as long as you review and update the HPI for the current encounter. But when surgeons get busy, this step can be forgotten.

 

Letting the EMR pull the previous history into an auto-generated form without reviewing it is risky because E&M documentation guidelines state that each record must stand on its own. You’ve got to pay close attention to what is being pulled forward because the patient problem could be completely different. Cloning also creates a verbose chart note that contains rote responses, which don’t necessarily call out pertinent positives.

 

How do you deal with cloning? Make sure you factor into your workflow the essential step of reviewing HPI at every visit, and making updates to the documentation that the EMR has ‘pulled forward.’

 

Risk #3: Coding Calculators

 

Don’t assume the coding calculator algorithm in your EMR is generating the correct code. Some of these put practices at risk by suggesting code levels that don’t match what was documented.

 

A seven-surgeon orthopaedic group in Minnesota noticed an increased number of high level E&M codes after their EMR go-live. The practice conducted an internal audit and realized the algorithm on the medical decision-making component was incorrect. Luckily, they had a savvy billing office that picked up on the error and overrode it with the correct, lower level E&M code.

 

Orthopaedists should be concerned about this. Medicare recently said that, in the past three years, it processed a greater percentage of 99214 and 99215 code in almost all specialties. According to Part B News, the ‘proliferation’ of EHRs ‘allows easier documentation,’ thereby justifying higher E&M levels. It’s likely Medicare may target these code levels for an audit sooner rather than later.

 

What to do? Ask the vendor to create and code few chart notes using some of your current documentation, and verify that the codes ‘calculated’ match what you billed.

 

The American Academy of Orthopaedic Surgeons’ June issue of AAOSNow features interviews with nationally-recognized auditors and coding educators discussing these documentation risks and how to deal with them. Heeding this advice can reduce your audit risk exposure and improve EMR success.

 

Cheryl Toth is a consultant with KarenZupko & Associates, Inc. and wrote this article as a guest author for OrthopaedicLIST.com.  She helps practices implement and adopt technology in order to work smarter and more efficiently.  KarenZupko & Associates, Inc. is a national leader at providing coding and documentation audits, training, and consultations. Learn more about how the firm can help you avoid documentation problems associated with EMRs by calling 312-642-5616 or visit www.karenzupko.com.  

Posted in Electronic Medical Records | No Comments »

An Issue in Need of Resolution

March 27th, 2010

 

by Augusto Sarmiento, MD

                                                             

“Reason should be the slave of passion.”     David. Hume.

 

It is inherent in our nature to believe that views we passionately hold on given issues are correct. However, much too often, eventually we find them wanting. This realization did not keep David Hume, the empiricist/pragmatist par excellence, and one of the most influential figures in the past five-hundred years, to conclude “Reason should be the slave of passion.” (Ref. 1).  The topic of this commentary is an example where I found myself wondering if my long-held conviction of the harm brought about by an inappropriate relationship between orthopaedics and Industry, now spread throughout most of the industrialized world, needed to be questioned and radically modified.

      The United States’ Justice Department investigation of serious trespasses and unethical conduct in the relationship, already in its fifth year, does not seem to have had a meaningful impact (Ref. 2). All we hear is that most of the identified culprits had “resolved” the conflicts by claiming that the receipt of moneys from Industry was justified because they represented grants devoted to legitimate educational ventures. It is very likely that this argument was valid in some instances since many educators/researchers are honest and reputable members of the orthopaedic community. On the other hand it is naïve, at best, to believe such an excuse applies to all the accused individuals, particularly in light of the fact that many of the identified parties are not in any way involved in educational or research endeavors.

          I have previously reported on episodes where I was either offered by high-industry representatives large amounts of money for the use of implants by the faculty of the department I shared at the time, or even larger funds for accepting to have a total hip prosthesis named after me even though I had nothing to do with its development. After refusing the dishonest “deals’, the response I got was, “But we do this all the time.” In the early 1970s I was invited by Industry to lecture in the capital cities of five Latin American countries. I declined on the grounds that I considered unprofessional the acceptance of the attractive offer. My reply was followed by a letter from the firm’s headquarters saying that they would not have any trouble finding someone to fill my place. I responded by saying that I was aware of the availability of others for such deeds and resentful of the fact his company seemed to consider orthopaedics a bordello, where the choice of a prostitute is simple and uncomplicated. (Ref. 3).

It is most demeaning to our profession that some of our representative organizations as well as directors of residency programs and other people occupying high positions in the hierarchy continue to perpetuate the situation. I suspect it would be very difficult to find at this time many heads of orthopaedic societies and directors of orthopaedic residency programs in America whose dependency in Industry is not significant.

A number of subterfuges are used to justify all kind of questionable activities. Sometimes funds are provided to academic programs to pay the salary of new Fellows and faculty members. Endowed chairs are accepted without hesitation in some places; in other instances the real funding source is camouflaged under the name of some “generous donor,” when the true funding source is Industry.

Would not be anything wrong with Industry’s “generosity” if it were not by the fact that Industry expects a great deal of say in the selection of topics for discussion and the choice of faculty. In addition, it economically compensates for the moneys given away by escalating the costs of their products (Ref. 4). Industry continues to win the battle. The subordination of the orthopaedic profession to Industry’s profit-driven wishes seems complete (Ref. 5).

However, throughout the land, there is a growing number of people in our discipline who are increasingly unhappy with the breakdown of the moral sphere and professionalism in our ranks, and the control of education by Industry. The increasingly large number of orthopaedists in private practice and many in the academic world are not getting sufficient support from their representative organizations, which have chosen to remain silent and comfortably continue to enjoy the status quo. 

This crisis may soon become of a serious nature. We most respond with a loud and unequivocal chorus opposing the current practices. If we continue to simply limit our efforts to increasing our financial well-being and to dwell on self-serving pocketbook issues the future our heirs will inherit from us will be an unhappy one.

 

References:

1)  Hume, David. A treatise of human nature. Oxford, 1888

2) United States Justice Department. Christopher J. Christie. Press Release September 27, 2007

3)  Sarmiento A. Bare Bones. Prometheus, 2005.

4) Sarmiento A.  Medicine Challenged. Publish America, 2009.

5)  Sarmiento A. Rise and Decline. JBJS (A) 91:2740-2,  2009.

 

 

 

 

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com.

Posted in Ethics in Medicine | No Comments »

Graduate Medical Education: Issues and Options

March 22nd, 2010

 

by Frank C. Wilson, MD

 

Graduate medical education, still in the process of being born, was not mentioned in Flexner’s 1910 landmark treatise on medical education.  The existence now of 8500 residency programs and 127 specialties and subspecialities would, a century ago, have seemed preposterous. 

 

Movement in GME prior to 1985 was largely academic and specialty specific. Curriculum, accreditation and certification, and duration of training were issues for resolution within the house of medicine.  Since the mid-1980s, influences outside of medicine, fueled by explosive population growth, technologic innovation, and social concerns have become dominant players, threatening the foundations of the educational bridge between student and practitioner.  An expanding and aging population and a panoply of therapeutic options have created overriding problems of access and expense.

 

Among the major challenges facing contemporary graduate medical education are issues related to teaching and learning, evaluation, professionalism, supervision, research training, funding, and manpower.  This book considers the issues in these areas and offers options for their resolution.

 

Following are excerpts from a few of these topics:

 

Teaching and Learning

“The search for ways to improve medical education should include a re-examination of the values underlying the profession.  Values shape the world; they should hold pride of place in the intellectual community and drive the educational enterprise.  Unfortunately the ethos that determined them in the past has been blurred by contravening trends of the present.  Propelled by the explosive escalation of knowledge and technology, too little attention has been given to the humanistic values that should determine their use.”

       

Professionalism

“Among the core competencies, professionalism is the most critical and among the most difficult to quantify. It is the competency which, possessed in full measure, gives rise to the others.  A professional possesses and maintains a unique body of medical knowledge and uses it to provide effective, safe, compassionate and ethical patient care, including the communication skills necessary to help patients navigate through a complex health care system.”

 

… “professionalism is founded on the pillars of science and service, upon possession of a specialized body of knowledge and skills, and the obligation to use that expertise to serve others before self.”  … “at the heart of this obligation is ethics, and at the heart of ethics is the welfare of the patient.”

 

“Professionalism is not just a philosophical ideal, nor can it be marginalized by the need for efficiency or productivity. It should be defined according to its characteristic traits, its cognitive base made clear, and opportunities provided to gain experience in its application to daily medical care.”

 

Manpower: Supply and Distribution

“With specialty choices determined largely by issues of income and lifestyle, fewer students are choosing careers in primary care.  High-tech specialities offer exciting opportunities for cure; but older patients having chronic conditions, are often more in need of care than cure – for someone to be there to guide them through the complex world of health care and to manage multiple diseases and depression. Despite the fact that most of the problems for which a physician is consulted can be handled by generalists, they have become an endangered species.”

“Medical care for the aged drives and will continue to drive, health care in the U.S. for the foreseeable future. By 2020, some 20% of Americans will be over 65, and people over 85 constitute the most rapidly expanding segment of the population, for which all physicians must be prepared.”

 

“Population trends must be studied, and planning for anticipated growth closely coordinated with the capacity of the U.S. health care system for expansion.  Since resources are finite, and expansion of the physician pool is very costly and time consuming, joint planning…is essential to meet short- and long- term needs for medical services.”

 

****

 

In his Foreword to the book, David C. Leach, Executive Director Emeritus of the ACGME, said: “This is an important book about this most formative time in a physician’s life, the history of graduate medical education, the key issues that consume present interests of medical educators, and the options that the profession and society have for going forward.  It is timely.  Workforce shortages, financial constraints, new knowledge and technologies, and dramatically changing demographic patterns in society pose challenges.  Changes are needed; will wisdom or reflex actions inform the changes?”

 

Dr. Wilson is Kenan Professor and  Chief Emeritus of Orthopaedics at UNC.  He is a past President of the American Orthopaedic Association, the American Board of Orthopaedic Surgery, the Association of Orthopaedic Chairmen and the Thomas Wolfe Society.  He received the Thomas Jefferson Award from UNC, and the Distinguished Clinician-Educator Award from the American Orthopaedic Association.  His book, Graduate Medical Education:  Issues and Options, can be found  on OrthopaedicLIST.com.

 

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Orthopaedic Guidelines

March 16th, 2010

 

by Augusto Sarmiento, M.D.

 

Guidelines in orthopaedics are being discussed with some frequency in America as well as in European countries. The American Academy of Orthopaedic Surgeons has officially established Guides for a number of conditions. It is a logical and noble idea since guidelines are supposed to provide information as to the most appropriate means to make decisions regarding the care of specific musculoskeletal conditions.  However, the ubiquitous “other side of the coin” lurks above the attractive concept calling for an objective analysis of their alleged benefits before they become the norm.

            We must ask ourselves if the current system of education regarding the identification of results obtained from different treatment modalities is insufficient and calls for different approaches. I submit it is not perfect, but I fail to believe that establishing guidelines for every subject is not the best way to improve it. Quite the contrary, it could result in unanticipated unhappy consequences. After all, guideless are not, regardless of contrary arguments, the product of specific scientific approach and methodology unequivocally, proven to be a true reflection of the best treatment for a defined pathological entity.  They  simply are subjective conclusions reached by a few selected people, who after reviewing segments of the literature, since a throughout and complete review of even a relatively small segment is unrealistic, who report on what appears to them to be the treatment best supported by the majority of publications.  The reviewers inevitably are influenced by the inescapable biases inherent in our human nature. Inadvertently, or otherwise, the possibility is dismissed that other treatment modalities found to have less supporting articles from recent literature may be as good if not better than the chosen one.

            Even though guidelines are, thus far, not intended to be mandates, it is within our nature to be attracted to systems that provide a sense of security and comfort. This is something that guidelines certainly do: free many from having to struggle deciding what the right answers are, since others have already determined for them.

            It is possible that one day a large number of conditions will have official endorsement of guidelines to the point of uniformity throughout. If such a scenario becomes a reality there may be a parallel stagnation in innovation and a slowing of progress, simply because the guidelines will gradually evolve from just “advice” to dogmas and Ditka not to be questioned.   

            We should learn a lesson from the conflict that arose when the American College of Chest Physicians published guidelines regarding the management of thromboembolic disease (Ref. 1). The College drew conclusions recommending a certain chemoprophylaxis but seemed to pay insufficient attention to other protocols to which a large number of orthopaedists had long-successfully adhered. However, without making it a mandate, a number of hospitals throughout the country implemented the guidelines for their respective surgical staffs.  Such action implicitly suggested that any deviation from adherence to them was a risk surgeons were unnecessarily taking.

            I use the following paragraph to indicate that despite efforts to make Guidelines simply “recommendations,” they can inadvertently become “mandates” with great power due to the prestige of the source.   In a recent article published in AAOSNow discussing the guidelines for distal radial fractures (Ref. 2), the author states, “The following recommendations have adequate evidence to support a moderately strong endorsement (italics added)………We suggest operative fixation as opposed to cast fixation for fractures with post reduction radial shortening greater than 3 mm, dorsal tilt greater than 10 degrees, or intraarticular displacement or step-off greater than 2 mm……….We suggest adjuvant treatment of distal radial fractures with vitamin C for the prevention of disproportional pain.”

No matter how we wish interpret these remarks, it is very likely that having deviated from the guidelines in a case where a patient ended with a less-than-ideal radiographic picture, someone would call it a complication and a “legitimate” cause for litigation. The guidelines did not say that anatomical/radiographic deviations or failure to prescribe vitamin C are synonymous with malpractice, but some attorneys would readily interpret them as such. A very wrong conclusion, since we know that there are circumstances dictated by reasons such as patients’ age, underlying diseases or many others, when greater degrees of radiological malalignment or shortening are acceptable. In addition, I venture to say that the overwhelming majority of orthopaedic surgeons are not aware of the “evidence” that the administration of Vitamin C reduces pain.

             The current system of education is appropriate to satisfy the needs of the practicing orthopaedist. We are not dealing with very young children who need strict behavioral guidelines, but with highly educated adults. The large number of journals and books allows the fellowship to read the experiences of surgeons and researches from different backgrounds and countries. Some journals often provide space to summarize the status of various treatment modalities, their advances, trends, and reported complications. A massive amount of information also is obtained from local, national and international meetings, the plethora of Continuing Education Courses and hands-on sessions, Grand Rounds at the local training programs, and from many others sources. Orthopaedists, based on information obtained from such multiple media, are capable of discerning the most appropriate way to deal with the various conditions with which they deal. Recommending specific, non-scientifically proven methods is not the right answer.  

            If Guidelines become popular it is logical to assume that soon there will be guidelines regarding fractures of the clavicle “strongly recommending” surgical fixation, since most articles in recent literature have dealt with the surgical treatment. Will the majority of orthopaedists anywhere in the world accept those recommendations as being creditable?

I suggest we pause before rushing into an attempt to establish guidelines for every conceivable condition. Let us look carefully at the issue at hand and decide if the current trend is a sound one, first by determining if what it is being considered by some as a “problem” is really a problem or a non-existing one. Are we, just proposing change for the sake of change, and doing something that will not be an improvement over what we already have today?

Journals, educational organizations, and subspecialty societies are not bodies created to dictate medical practices. They are simply mechanisms, avenues to disseminate knowledge, something that until now they have done in a creditable way. Let us encourage them to continue to improve their efforts.

The reservations I expressed in this Commentary are similar to those I previously discussed regarding the Joint Replacement Registry. Both topics need in-depth study before they become the law of the land (Ref. 3). 

——————————————————————————————

 

 

REFERENCES

 

1) American College of Chest Physicians. Prevention of venous Thromboembolism. Chest133-381S-453S) 2008.

2)  New AAOS guideline addresses distal radial fractures. AAOSNow December: 6-7. 2009.

            

 3) Sarmiento A. Orthopaedic Registries. Hurdles Ahead. J Bone and Joint (B) (On JBJS (B) Website) 2009.

 

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com.

 

 

 

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Lumbar Spinal Fusion Procedures: The Last 100 years

January 4th, 2010

 

by Richard J. Nasca M.D.

Spinal fusion procedures are indicated for various disorders, deformities and injuries of the lumbar spine. The Albee and Hibb’s fusions for progressive deformities due to tuberculosis were performed in the early 1900’s. The anterior and posterior Interbody fusion techniques were popularized in the 1940’s and 1950’s. The Harrington rod for correction of scoliosis was a milestone invention which was poorly received by the orthopaedic community in the 1950’s. Pedicle screw fixation popularized in Europe was introduced in the US in the early 1980’s and meet with a great deal of resistance and skepticism from both neurosurgical and orthopaedic surgeons. In addition, a great deal of litigation was generated by some poor patient outcomes and a consortium of Philadelphia based plaintiff’s attorneys. In the mid 1980’s, metallic interbody cages were developed to stabilize the spine and contain the bone grafts used for fusion. In the late 1990’s percutaneous approaches to performing spine fusions and inserting spine fixation devices were developed. Modifications in the posterior interbody approach of Paul Cloward were made by Jurgen Harms. His method referred to as a transforaminal lumbar interbody fusion (TLIF) required facet joint removal and distraction to facilitate access into the disc space for the placement of bone grafts with titanium cages.

Shortly after the turn of the century a less invasive approach to the lumbar spine called an extreme lateral interbody fusion (XLIF) was described by Ozgur, Aryan, Pimenta and Taylor. This approach allows access to the lateral spine thru a small incision in the flank for insertion of cages and spine fixation. The L5-S1 level is not accessible with the XLIF technique.

 Andrew Cragg, an interventional radiologist described an axial presacral approach to the sacrum in 2004. The AxiaLIF rod and instrumentation were developed by TranS1, Wilmington, NC. This technique provides access to the L5- S1 disc for interbody fusion by an axial portal drilled through the sacrum. After removal of the disc remnants, the end plates are prepared with Nitinal cutters. Bone grafts from the reamings and bone extenders are used to promote the interbody fusion. The AxiaLIF rod is used to stabilize the L5-S1 segment after preparing an axial tract in L5. The procedure has been used in patients with spondylolisthesis, spinal stenosis, degenerative disc disease and its variants, lumbosacral scoliosis as an anchor across L5 –S1 to enhance stability for fusion in long constructs, herniated nucleus pulposus and revision surgery. Pedicle and/or facet screws are used to supplement the fixation.

 Although the AxiaLIF approach and method of preparing the disc space for interbody fusion has generated skepticism ,the results from the procedure are  encouraging with fusion rates of 90+%, complications of less than 1%, lessened hospital stay, blood loss and operative time when compared with more traditional interbody fusion techniques.

Dr. Nasca is a retired orthopaedic surgeon who specialized in surgery of the spine and who is a Medical Advisor to TranS1 and Orthopaedic List .com

Posted in Spine Surgery | No Comments »

Ischemic Optic Neuropathy (ION)

November 26th, 2009

 

 

 

by James W. Ogilvie, MD

 

Ischemic optic neuropathy (ION) is a disorder than can occur following surgical procedures. There is partial or complete loss of vision as the result of a vascular insult. It has several possible etiologies including thrombosis of the central retinal artery most commonly associated with giant cell arteritis. Direct trauma to the orbit and cortical blindness must also be considered. ION has also been reported with acute non-surgical blood loss and the use of Viagara™. Hippocrates gives an account of someone with acute hematemesis who subsequently lost their sight, perhaps the first report of ION.

           The least common and most enigmatic cause of post-operative vision loss is an ischemic episode to the optic nerve heads which are supplied by the short posterior cilliary arteries. The diagnosis of ION is made by fundoscopic examination of the eye in someone who reports a visual field defect following surgery. Emboli in the retinal vessels (posterior ION) can be visualized while in anterior ION (That which occurs anterior to the cribriform plate.) there are no initial diagnostic findings. After several months there is visible atrophy of the optic nerve heads resulting in a pale retina.

Because there may be effective therapies for other causes, it is important to differentiate ION from other etiologies of visual loss. An ophthalmologic consultant can accurately make the diagnosis. To date there is no effective treatment for anterior ION. Many therapeutic trials have been performed including the use of steroids, osmotic agents, hyperbaric oxygen, vasodilators and surgical decompression, all without benefit. There may be some spontaneous improvement in visual fields, but recovery from no light perception is very rare.

The causes of ION are not well understood, but acute blood loss is the most constant finding. ION has been reported with surgery in the supine, sitting and prone position. Prolonged spinal surgery in the prone position is the other commonly reported factor. Long surgical procedures resulting in facial edema when accompanied by hypotension or low hematocrit is often encountered in cases of ION. While atherosclerosis or diabetes may be predisposing factors, the relationship has not been studied in a scholarly fashion and ION has been reported in adolescents undergoing scoliosis surgery.

There is speculation that with acute blood loss there is an idiosyncratic response from released endogenous vasoconstrictors which may cause vasospasm of the short posterior cilliary vessels. It is not a sympathetic nervous system response due to the fact that sympathetic nerves do not supply the short posterior cilliary arteries. There may also be a congenital predisposition to ION due to a reduced ratio of capillary vessels to optic nerve heads. Unfortunately, there are no pre-operative tests to identify those with an increased susceptibility to ION.

Prevention of ION is clearly preferable. Reducing facial edema with the use of the reverse Trendelenburg position, limiting the use of crystalloids for fluid resuscitation and avoiding hypotension or anemia may lessen the incidence of ION.

ION frequently results in a medical liability action. If there are irregularities in the anesthetic record such as prolonged anemia or hypotension, use of large amounts of crystalloid for fluid resuscitation resulting in facial edema or improper patient positioning, the surgical team is often held liable. The issue of informed consent is often raised. What responsibility for discussing visual loss lies with the surgeon and anesthesiologist? There are no absolute answers to this issue, however this question should be settled long before discovery depositions are taken, preferably prior to the surgery itself.

 

 

     The guest author of this article for OrthopaedicList.com is Dr. James Ogilvie, a board certified orthopaedic surgeon.  He is Professor, Department of Orthopaedic Surgery, at the University of Utah in Salt Lake City and Professor Emeritus, Department of Orthopaedic Surgery, at the University of Minnesota in Minneapolis, MN. He is Staff Surgeon / Attending Staff at Shriners Hospital Intermountain Unit in Salt Lake City.

 

     A more detailed article on ION by Dr. Ogilvie can be found by clicking on the following link to it in the October 2009 issue of the American Academy of Orthopaedic Surgeons newsletter “AAOS Now”.

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The Looming Total Joint Replacement Surgeon Shortage

November 17th, 2009

by Scott S. Kelley, MD

The difference between a good total joint and a great total joint replacement is initially small, but over time the difference can be significant.  A good total joint might last 10 years, but a great total joint could last 30 years.  Being a total joint surgeon is a profession with little or no room for error with every single hand movement. The procedures are demanding and the patient population is complex.  

 

Now, imagine this: The number of total joint replacement surgeons in the United States is cut by over 40 percent. The patient’s option for a surgeon is limited due to demographic or insurance restrictions.  This becomes a significant problem if the joint replacement fails because the subsequent surgery is much more complicated; therefore, fewer surgeons are willing to manage the revision.

 

Unfortunately, this could be the future of total joint replacement surgeons in America. Orthopaedic residents generally are not going into joint replacement fellowships because of this very issue.  We are 50% filled at best, during a time when we need to be increasing in size. Nationally there is a huge number of impending failures looming. Given the current state of our country, this issue is only going to get worse within the next 5-10 years.

 

The reimbursement for a single joint replacement surgery has been cut by over 65% in the last ten years.  This isn’t an issue for most surgeons currently in practice; however it does limit the amount of resources they can offer patients.  For example, try calling a doctor’s office and getting an actual person on the phone; these cuts affect everything from the number of front desk employees to the quality of care the surgeon is able to provide.

 

Cuts of over 65% in 10 years are now being followed with further cuts.  Understandably this makes doctors in training nervous.  Performing this surgery is stressful and I’m afraid it just isn’t worth it for younger doctors considering a specialty surgery career, particularly in joint replacement.

 

 While prevention and patient education remains a goal of all healthcare providers, it does not overshadow the current epidemic that is facing our society with respect to osteoarthritis and its surgical treatment options: the reality is that patients will continue to want the best in surgical care from the best providers.

 

Please click on the following to see a video entitled “Access Denied:  The Approaching Shortage of Specialist Doctors” and use it to educate your patients on the future of specialized care.  Although it’s a bit biased, it does clearly state the facts. 

 

Dr. Kelley, a third generation surgeon, is a graduate of the University of Iowa School of Medicine.  He performed his orthopaedic residency at the Upstate Medical Center in Syracuse, NY and his fellowship in Adult Hip and Knee Reconstruction at the Mayo Clinic in Rochester, MN.  He is a founder of the North Carolina Orthopaedic Clinic in Durham, NC, an affiliate of the Duke Medical Center where he is a Clinical Professor of Orthopaedic Surgery.  He has authored numerous scientific papers, serves as editor of medical journals, and is a member of a number of prestigious medical organizations.

 

 

 

 

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Stopping Healthcare-Associated Infections

November 14th, 2009

by Barbara Dunn

When someone develops an infection at a hospital or other patient care facility that they did not have prior to treatment, this is referred to as a healthcare-associated (sometimes hospital-acquired) infection (HAI).  According to the World Health Organization (WHO), at any point in time, 1.4 million people worldwide suffer from infections acquired in hospitals.

As part of an ongoing commitment to quality care and infection prevention, nationwide doctors and hospitals are partnering with Kimberly-Clark to deliver continuing education programs on healthcare-associated infection (HAI) prevention to staff and management Whether you’re a healthcare professional, patient, or visitor , the most effective way to keep HAIs down to a minimum is to wash your hands or use an alcohol-based sanitizer.

Please view the informational video at this link.

For more information please go to the Not on My Watch campaign.

Barbara Dunn was born in Jersey City, New Jersey, worked as an interior designer in Manhattan, then moved to Hawaii where she worked for a production company before moving to Arlington and reinventing herself as a PR executive.

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Marketing through Service: Double the Benefits

October 24th, 2009

by James D. Hundley, MD

            Some doctors think that “being a good doctor” is all that is needed to get patients to come see them.  That might work over a long period of time, but unless one is in an extremely underserved location, that is not likely to be enough.  Patients and referring physicians have to know of you to schedule visits or refer patients to you, so some way of getting the word out is essential to having a busy practice.  Even when one is currently busy, complacency could have negative future consequences.  Surgeons need a constant flow of new patients to maintain an optimal case load.  So, if you agree that marketing is important, how do you best go about it?  Do you do it by giving money to a marketing agency or could you do it by giving of yourself?  Neither way is cheap since giving of oneself takes time away from family, play, and work.  On the other hand, when you give of yourself in service, you’re likely to get a lot more back than you invest. 

Current wisdom seems to be that marketing one’s practice is best done through paid ads in newspapers, magazines, radio, television, yellow pages and so on.  I do not think that that is the best way to get the word out.  Anyone can say virtually anything in paid ads, so how is the potential patient supposed to know who he or she is really getting in his or her doctor?

            During my over thirty years of orthopaedic practice, I had success with marketing through service and relationships.  By this I mean giving of one’s time and talents in a variety of ways.  In every case, I tried to be more than just a member of an organization or cause.  As noted above, you don’t get much back if you don’t put much in.  Here are some examples:

 

Local Marketing

1.      I was able to become the volunteer team physician for a local university.  The work was a pleasure and much more extensive than outsiders ever imagined, but when they saw me on the bench at basketball games, many figured that I knew something about sports medicine.  The same thing works with high schools and community colleges and the need is great.

2.      The Rotary Club was a great way to meet business leaders around town.  By befriending them, they tended to call me when they or their families had orthopaedic problems.  Their employees often asked their bosses who they went to and followed suit.  The Rotary Club is but one example of many civic clubs and organization which bring you considerably more benefit than you take to them.

3.      Church is a great way to meet people.  Marketing is clearly not the reason one should join and attend a church, but doing so clearly has earthly benefits.

4.      Befriending the nurses in the operating room and on the wards can be a huge benefit.  That is not to mean that one cannot demand excellence, something that you should do.  All it takes is to treat them with respect and recognize that they bring significant knowledge to the care of your patients.  By making them partners, you get a more positive effort in behalf of your patients and the likelihood that they will both come to see you and send their friends and family, too.  Non-medical people often ask those in our profession for suggestions as who to see.  If I ever want to know if a surgeon is any good, I ask an OR nurse.  If they think you’re a good surgeon, and a good person, they are likely to send the people they care about to you.  If they dislike you, they’ll guide them elsewhere.

5.      By being appointed to the local library board (one of several), I had a fulfilling service experience and met an entirely different group of people.  It doesn’t matter what boards you serve on; it just matters that you serve.

6.      By working with the local medical society and ultimately becoming an officer, I met many local physicians whom I probably would have never met.  It makes a positive difference to physicians to refer their patients to someone they know and feel that they can trust. 

7.      Writing articles for the local newspaper makes one an instant expert in the eyes of many readers.  No matter the subject of the article, having published it makes many more people know your name and more likely to call you.  You can always pay for an ad, but news outlets are often looking for items of interest and happy to accept articles written by doctors.

8.      Word of mouth is probably the most powerful marketing tool you could possibly employ.  You can’t control it like an ad, of course, but if you consistently treat patients in their best interests and get reasonably good results, you will have unleashed a marketing force that is among the most effective.

 

Statewide Marketing

1.      Without expecting it, I found that working with our state orthopaedic society brought significant benefits to my practice.  When someone from my city was injured elsewhere and the orthopaedist who took care of them in some other city sent them to someone they knew (i.e. me) to complete their treatment or follow-up, it enhanced my reputation at home.  People talk, and this kind of talk is good.

2.      Also without any expectation of return, I learned that working (fund raising in my case) with my medical school and residency program (both within the state) enhanced my reputation at home.  When there is friendship and mutual respect between you and a professor of orthopaedics who speaks well of you to patients from your home town, they take note, and they tell their friends.

 

None of the above activities will do anything other than get more people in your door.  Once they get there, it’s up to you to properly take care of them, and that includes way more than surgical competence.  The three “A’s” (ability, affability, and availability) must be observed.  That applies to their entire experience in your office and the surgery center or hospital.

Let’s face it.  Patients generally have no good idea as to an individual surgeon’s abilities.  They have powerful perceptions, but they are not based on objective data.  If you consistently treat patients in their best interests and treat them with respect, they will keep coming back.  First, of course, you have to get them to come see you at your office.

So, if you’d like to increase your patient load without spending more money, you might just try marketing through service and relationships.  Not only is your practice likely to benefit, but the personal benefits of gratification and personal growth that incur from altruism beyond your daily medical practice may pleasantly surprise you.

 

 

 

Dr.  Hundley is a recently retired orthopaedic surgeon with forty years of experience.  He is the president and a founder of OrthopaedicList.com.

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