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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.

In the 1950s or early 1960s the average student was grateful to have been accepted to medical school and/or residency, was satisfied with a couple hours of sleep at night, and took primary responsibility for his education. According to some surgeons educated in that era, however, things have changed radically.

Explains Dr. Dempsey Springfield, an orthopedic oncologist at Massachusetts General Hospital, “We are now in a period in which students think they should have major input into what they are going to be taught. This shift happened over time, probably beginning in the 1960s when higher education stopped being an incredible privilege. This meant that students were no longer totally beholden to the school. Before this time, Deans could summarily dismiss you from college and medical school. We were much more passive in a way, trusting that our professors knew best about what we needed to learn. And the instructors did not think it was their job to spoon-feed us.”

The only thing that was given, says Dr. Springfield, was the opportunity. “Now medical students almost feel that it is their right to be able to demand a lot. They seem to feel like if they don’t learn something it’s not their fault, it’s the instructor’s fault. I will say that in some ways they are right. If the educational setup isn’t good and nobody learns, then it is not the students’ fault. But the fundamental issue is, ‘When do you become responsible for yourself?’ Years ago medical students and residents had an attitude of, ‘If they’re not going to teach it we had better learn it.’ These days students say, ‘You didn’t teach us such-and-such well, so that must mean we didn’t have to learn it.’”

Knowing that students are capable of more when they apply themselves fully, Dr. Springfield says, “Lately I have been thinking about piano lessons. Most people could learn piano better if someone guarantees them two hours a day with a great teacher. But thousands of people have learned without such a high level of instruction. The same is true in medicine. It, the learning, is there for the taking. Unfortunately, to a degree, students feel, ‘Yes, I was given this opportunity but I don’t really have to do all the work. It is the professors’ responsibility, too.’ And most medical schools respond by giving in to these new expectations. Life doesn’t work that way, however. I have seen that as students get closer to actually having to be responsible, it usually dawns on them that their education is ultimately their own responsibility.”

While there is no reason to believe that the IQs of today’s medical students or residents are lower than those of their counterparts 50 years ago, rumblings about what they can handle abound. Dr. Springfield: “The attitude in medical school now is, ‘Well, if we give them too much information they won’t like it.’ These are the brightest people in the country, mind you. And too often they are not applying themselves fully. For example, they frequently fail to read up on cases or to practice enough. They should understand that this is fundamental to their being a doctor and is not ephemeral. And there is not much that instructors can do about the situation. Students will criticize the instructor and that faculty member will be told that he or she overwhelmed the students. They also don’t want a lot of lectures and labs. This is akin to telling your boss, ‘I need some time to myself. My productivity will go down but you can’t change my pay.’”

A philosophical Dr. Springfield notes, “Part of the problem is that no one knows what the best method of learning is for this generation. And while there should be some level of understanding of how today’s students learn, the question is how much does the existing system have to adapt and how much, frankly, do the students just have to ‘suck it up.’ My concern is that they are going to wake up at the age of 35 or 40 and find out that the rest of the world, against whom they’re now being compared, has been working harder and is thus more independent and ahead of them in terms of personal discipline and the ability to manage themselves.”

The system is also part of the problem in that medical schools often hold medical students back from practice. Dr. Springfield, “Much of medical school is experience; and many of the elementary things you need to know are worthless if taken out of the context of practice. Therefore, lots of hands-on experiences are vital in order to develop the ability to practice medicine. The more you learn, the quicker you get to the next level. Medical schools don’t seem to understand that doing rounds and seeing what a patient looks like the first day after surgery or what a wound looks like when it is healing versus not, is critical. Students must be allowed to get in there and make some mistakes. It’s like Little League where everyone can be a winner. But if you are going to be a competitive baseball player you have got to lose sometimes; and the earlier you learn to lose, the more you progress. I don’t think it’s a coincidence that there are fewer and fewer American baseball players and more Hispanic baseball players; American elementary school children are not learning the lessons of loss.”

Turning to how this issue shows up in residency programs, Dr. Springfield says, “In my opinion many residents think that residency is just an extension of college and medical school and not the beginning of a professional career. This results in a passive attitude towards their education. They often don’t understand that most of the education that’s available to them in residency should be obtained on their own with the assistance of faculty. This is in contrast to medical school where the vast majority of education is just handed to you. I don’t think I should be telling or showing someone how to do things. The crux of the matter is that they need to learn how they will learn in the future when no one is looking over their shoulder. Most things a resident learns now will not be applicable in 15 years, so fundamentally their education should be about the process of learning.”

While medical school is more removed from the real world, the same cannot be said of residency. Dr. Springfield: “Residency takes place in real life; residents are involved in the actual management of patients, so their experience has to accommodate real life. If a resident doesn’t show up, that can affect patient care. And there is a quantum change in responsibility to others as soon as one becomes a resident—people have expectations of you and there are real consequences when those are not met.”

Dr. Charles Day, Chief of the Division of Hand and Upper Extremity Surgery in the Department of Orthopaedic Surgery at Beth Israel Deaconess Medical Center and Assistant Professor in Orthopedic Surgery at Harvard Medical School, has extensive experience in medical school education. “The surveys I have conducted on Harvard medical students indicate that while students do not understand what they need to know down the line, they are still vocal about what they should or should not be taught. And medical school administrators usually go along with their wishes. This is like asking high school students how much math they want to learn. On at least one occasion I have made up tests for an orthopedics course and been told by the students that it was excessively difficult. I subsequently altered the test so that the subjects would tie in more to what the students were learning in other courses. Then they said they didn’t have enough anatomy to understand the pathophysiology of orthopedics—so I had to review for them information that they should have already learned in previous courses. Course directors are in a catch-22 in that they have to deliver less material and spoon-feed it to the students. The students, however, don’t even show up to the lecture hall half the time because they can watch the lectures at twice the speed on video. This shows an inherent lack of respect for the field of medicine and its professors.”

Musing about how these issues will play out in the future, Dr. Day says, “I think these changes will eventually mean that we won’t have doctors whose life is medicine. Nowadays medical students are adamant about wanting time with their families. Years ago most medical students were not married during medical school or residency. This balanced life they want today benefits them but not patients. And while it makes the career of being a surgeon more attractive, we don’t know what it will do to patient care and the field as a whole. There will likely be some unforeseen consequences until society figures out how to deal with this new model of medical learning and practice.”

Also alarmed by the changes in attitudes is Dr. Mark Myerson, Director of the Institute for Foot and Ankle Reconstruction at Mercy Medical Center in Baltimore. “When I look at younger orthopedic surgeons, i.e., those who have recently finished training and those in practice for a few years, it’s astonishing how different the work ethic is today. I worked very hard for 10–15 years, during which time I was not home before 11 p.m. When I did get home I started writing, and I would often continue until 1 a.m. or 2 a.m. There is a sense of entitlement today that wasn’t present a few decades ago. I sometimes wonder nowadays what I myself am doing incorrectly that might contribute to this problem. Perhaps I am giving the fellows too much information rather than stimulating and encouraging them to discover things on their own.”

Dr. Myerson continues, “During their formative years in medical school and residency, I believe that they are educated to think and perform in a way which encourages ‘test taking’ and following surgical techniques according to the ‘written word.’ In doing so, they lack initiative, intuition and the ability to think and discover information independently. So, currently, when fellows begin their year of training, I regularly use an expression which certainly did not apply a decade ago…that they need to lose their ‘GPS.’ While never at the expense of patient care, I want them to get lost, lose their bearings, and struggle a little. They need to discover not so much how we do things, but why. And, more importantly, they need to be able to put it in a historical perspective rather than just learning to treat and perform by rote. The practice of medicine has evolved significantly, and if students of medicine are not aware of the past, they will never understand the present. Perhaps in the end, residents and fellows in training should recognize that you don’t get anywhere without hard work.”