Other Articles

Elegance in Spine: Extracavitary Approaches
The delicate task of dealing with spinal problems is getting a bit less complex, says Dr. Francis Shen. Orthopedists can now remove a section of rib and approach the front of the vertebrae from the back in an oblique direction.

Endotec Beats FDA, Strikes Blow for Innovation
Endotec has struck a blow for every orthopedic surgeon who wants to develop a better device. See how the company’s founders took on the FDA and got a federal judge to charge the agency with “stymieing progress and technological advancement.” How did they do it? Read on.

From Obesity to Osteoarthritis, the Carpal Tunnel Connection
It’s certainly no surprise that Carpal Tunnel Syndrome (CTS) is an exceedingly common orthopedic malady. But, as PearlDiver’s data show, the linkage between obesity, osteoarthritis and other conditions to CTS is most surprising. Check it out.

Using DNA to Predict Scoliosis
Six million people (estimate from the National Scoliosis Foundation) have scoliosis in one form or another. The primary age for onset of idiopathic scoliosis is 10-15 years old. Finally, there is a test which can reliably predict scoliosis. Fewer X-rays. Lower cost. Better outcomes.

New Capital, New Science for Cartilage Repair
$36 million invested in the last couple of months. TiGenix has more than that in the bank to fund market penetration. Then a new paper last week finds molecular cause of OA. Cartilage repair momentum is building.

Should I Become a Physician-Employee?
Large healthcare institutions are increasingly purchasing orthopedic practices. What does this mean for patient referrals? How beneficial can it be for orthopedists? The upside is more stability, among other things…and one of the downsides is loss of freedom.

Outrageous Whistleblower Lawsuit Challenged
Spine surgeons sued by whistleblowers in Boston are fighting back. Their lawyer is outraged and says the claimants are just shopping an old and settled case to another judge. Is this the proverbial lipstick on a pig? Find out.

Medical Education Under the Microscope – Is It Up to Today’s Challenges?
Where is the line drawn between what medical schools, residencies, and professors should provide to students and what doctors-in-training should reach for themselves? Here are the results of interviews with three senior surgeons, who opine on things such as attitudes, how people learn, and the possible effects on the field.

The Underlying Meaning of Zimmer’s Purchase of Abbott Spine
From the price paid to the timing, this transaction held an underlying meaning for the entire spinal implant industry. Zimmer, the $4.2 billion (revenue) diversified orthopedic company is now #5 in spine. More to come?

Resurging Lumbar and Cervical Total Disc Replacement Markets! New PearlDiver Estimates
Rumors of the TDA market’s demise were premature. Increasingly positive long term patient data is at the core of a resurging lumbar and cervical TDR market. Senior analyst Matt Menze tackles the TDA market and interviews one of the fathers of TDR, Dr. Scott Blumenthal from the Texas Back Institute. Where is this market actually heading? We think to the $2 billion range by 2015. All details here.

Six Days in June – Biomet and Zimmer Battle for Distributors in Kentucky
Documents filed recently in a Kentucky lawsuit pull the curtain back on an epic battle between Biomet and Zimmer. For six fevered days in June 2007, Biomet CEO Jeff Binder and founder Dane Miller went into the trenches to save one of their own. For all the details, read on.

Multicenter Clinical Trials: Do They Get the Respect They Deserve?
They’re not fast or sexy, but they are critical…large trials, that is. With multiple sites and principal investigators who donate their time, large trials are more complex—and normally yield more actionable data—than smaller, quicker studies. But large trials don’t always get the respect they deserve. And, says at least one physician-researcher, this could affect the future of the field.

Patent Wars: Medtronic Attacks NuVasive
MSD’s lawsuit came amid a period of declining spinal implant market share – from a peak of 60% in late 1998 (just prior to being acquired by Medtronic) to, we estimate, 36% currently – and a growing sense that MSD’s reign as the king of spine was coming to a close. What’s really behind Medtronic’s attack on its former senior exec? Read on.

For orthopedic surgeons in training, there is an aura of angst surrounding post graduate year two (PGY2)…the time when you have your orthopedic training wheels ripped out from under you. Explains Dr. Nick Pappas, soon to be a third-year resident at the University of Pennsylvania in Philadelphia, “Those who have done an orthopedic residency can relate to the huge transition that occurs in your second year when you go from being a general surgery intern to an orthopedic consult resident and start covering nights in the ER. You spend the first year of residency putting in orders and getting a feel for how the hospital works. You write prescriptions and give discharge plans, but there is little operative learning and it’s not a time of significant independence. While independent thought is acceptable to the senior surgeons, independent action is not. You basically spend the first year trying not to create any problems for people and making sure all the patients go home in decent shape. Then you are thrust into the second year when you automatically have a lot more responsibility and are expected to be able to come up with solid treatment plans. Residents go quite abruptly from being robots to decision makers. This is particularly challenging because there is insufficient orthopedic instruction in medical school.”

Despite the sink or swim milieu, residents are often energized by the obstacles that lay before them. Dr. Pappas: “Most people are excited to move to the second year because this is when you really have your ‘coming of age’ as an orthopedic resident. Even the oldest attendings will likely remember their first times taking primary ER call. You’re finally doing more of what you’ll be doing the rest of your life and you want to try to do your best and impress those around you. And it’s interesting to interact with different departments on consults, although it can take awhile to learn how to triage cases. Triage and time management become particularly important in the summer months when we get a large volume of patients. And there are always things you’ve never even heard of before, so that’s when you call a senior resident. While most of these people understand that you are just learning, there is still a lot of pressure, particularly in the ER where you are expected to be really ‘on.’ And then there is the issue of communication, or lack thereof. It often happens that, say, five different people may have called you for one patient.”

But back to time management. Part of the reason that this is such an issue involves basic human emotions such as fear, control, and excitement. Explains Dr. Pappas, “You start off knowing nothing about orthopedics your first day as a consult resident and are scared of what orthopedic trauma might suddenly show up in your ER. Each consult is approached meticulously and you agree to see every patient you are called about so as to ensure you don't miss anything. And you don't want to let your senior residents and attendings down, all of whom are judging you.”

Continues Dr. Pappas, “Things vary depending upon the institution. At a big university hospital you will likely be accompanied by an upper-level resident. This is helpful as many times you have only read about something and never seen it or been through the workup of it. When a resident is at a tertiary referral center he or she is getting cases transferred from the general community where the population tends to have more acute or more complicated problems. In this situation, every time you take call you will see incredible things you have never seen before, be it gunshot wounds, pit bull maulings, falls from trampolines, or falls from the top of the cheerleader pyramid.”

Citing an early experience in PGY2, Dr. Pappas notes, “The first consult I saw in the ER was a non-displaced, transverse metatarsal shaft fracture, which is hardly a challenging case. However, there are multiple options for treating this fracture, such as a hard-soled shoe, a removable boot called a CAM walker, a posterior splint and crutches, or even a short leg cast. The question is, ‘Which is the best treatment option?’ Frankly, I had no clue. I ended up calling both my senior-level resident and the attending on call for advice. Luckily, each was receptive to the call and both advised a hard-soled shoe. In general, I found that upper-level residents and attendings were very receptive to these types of calls early in the year because they remember what it was like starting out when the orthopedic world was new.”

With 206 bones and numerous muscles and joints, it’s difficult to understate the importance of musculoskeletal health. Yet, says Dr. Pappas, students emerge from medical school unprepared to contend with the related issues. “Medical schools aim to give students a broad medical education such that we spend a lot of time learning things we will likely never use. When you get to your intern year you’re on almost every service, but it doesn’t help much with orthopedics. Whereas medical school does a solid job of preparing someone for cardiology or pulmonology, orthopedics is not emphasized. This is despite the fact that one-third of visits to a primary care doctor are orthopedic in nature. I suppose that orthopedics is left out because generally speaking, it is not life-saving.”

Dr. Ryan Garcia, soon to be a third-year resident at Case Western Reserve University in Cleveland, also feels as though he leapt into the lions’ den without a whip. “Going into PGY2 we are all bringing different medical school experiences so there are differences in the amount of knowledge any one of us brings to the table. Without much experience, we PGY2s are often taking call by ourselves in level 1 to 3 trauma centers. While we may have resident backup, the challenge is to try to stay independent. It is a bit intimidating to think that on any given night in the ER, you’re ‘it’ as far as orthopedics is concerned.”

And while they didn’t sign up for the circus, residents must learn the art of juggling. “The other challenge,” states Dr. Garcia, “is that you have lots of responsibilities to a number of different people and issues—peers, attendings, patients, the administration, etc. And while in PGY2 we are mainly responsible for patient care on the floors, as we move through residency we try to shift away from that and toward a more operative concentration. Learning how to balance all of this with the vast amount of reading we are expected to do, as well as the research, makes time management a huge issue.”

Specifying his own experience, Dr. Garcia notes, “As a young resident the thinking is often, ‘OK, if I do more conservative measures I am less likely to be wrong.’ And while this was often the case for me, throughout my second year I felt it was better to attempt things myself instead of calling an upper-level resident. That way I learned and experienced more.”

But from case to case there is usually the thought, “Should I call for help or not?” It’s a thought that might not occur as frequently if residents were better prepared. Dr. Garcia: “Take ankle fractures, something that is very common. Knowing the anatomy or what specifically is operative versus nonoperative is something that could be better facilitated with more medical school training. Let’s say there is a patient with a lateral malleolus fracture who has some tenderness on the medial side but no widening at the medial mortis. You can follow a conservative approach or operate, but it takes training and experience to know what course of treatment to take.”

Of finding his way through the web of information and personalities, Dr. Garcia notes, “It seems that residents are constantly trying to figure out what the senior surgeons are thinking. The reality is that we often try and protect the senior surgeons by not asking them ‘nitpicky’ things of how to manage patients day to day, and by doing this we end up guessing how they want their patients managed. You do what you think is best, and sometimes it’s not what they wanted. For example, take total joint replacement. There could conceivably be three attendings in the same hospital who manage their patients in completely different ways. So the PGY2 comes along and tries to learn the ins and outs of the case without bothering the attending with the minute details. If it’s the middle of the night, we typically feel more comfortable calling the younger attendings who are closer to their own residencies. It's the more senior attendings who we, as PGY2 residents, try and protect from the minutia. The way that we are trained to do this is to go to the more senior resident first and then on up the chain of command. And the culture is such that you protect the people above you by, for example, not calling them in the middle of the night if it can be avoided.”

Empathy is not sympathy…and understanding doesn’t have to create an excuse for someone who doesn’t do the work. Dr. Garcia concludes, “It would be helpful if the older, more senior residents or attendings could remember what it was like to be in PGY2 where you are responsible for the majority of the unexciting workload. Perhaps then they would understand a number of things, including how frustrating it is to work hard on some of the more trivial issues that may not even be necessary. In the end, we’re going to do what is expected of us.”