Friday, July 18, 2014

Rating Doctors Different Rating Hotels or Restaurants or Movies -Because We Have to Tell You Things You Do Not Want to Hear

It is normal for Patients to be Unhappy
Like you I use online ratings to guide my decision making for hotels, restaurants and movies and other products.  I have mostly been pleased with the usefulness of the information. The same can not be said of online doctor ratings.  Your Doctor often times has to tell you facts you might not want to hear.

In fact, one study has shown that the more satisfied the patient is with their doctor the more likely they are to suffer a serious complication or even death.  This is because unnecessary tests or treatments that please the patient result in unneeded medical care that turns out to harm patients.

A recent spoof on The Onion web site tells of a physician that just writes a few more unnecessary prescriptions for Adderall and his online rating gets back up in no time !

Vitals and Healthgrades estimate that a good physician will at best have 80 % of their patients "satisfied".  Often times doctors tell patients things they do not want to hear like your eating habits are unhealthy or you smoke or drink too much or you can not have any more opioid pain pills or you are recovered from the treatment and you have to go back to work, all events that make some people unhappy with their doctor. However, best practice directs the doctor to make decision that follow accepted guidelines, whether the patient likes it or not.

The Daily Beast posted an article entitled "You Can Not Yelp Your Doctor".  Quoting from the article -- "In fact, the most satisfied patients are 12 percent more likely to be hospitalized and 26 percent more likely to die, according to researchers at UC Davis. “Overtreatment is a silent killer,” wrote Dr. William Sonnenberg in his recent Medscape article, Patient Satisfaction is Overrated. “We can over-treat and over-prescribe. The patients will be happy, give us good ratings, yet be worse off.  
It’s Economics 101. If we ask drug-addicted patients to grade their physicians on how satisfied they are with the “service,” then a high score will likely indicate they got the opposite of good medical care. It doesn’t take a genius to figure out how putting addicts in charge of the patient encounter contributes to the $24 billion in excess medical costs caused by prescription opiate abuse. Nevertheless, some emergency rooms are even offering Vicodin “goody bags” to improve their ratings.
Thanks to patient satisfaction scoring, unnecessary antibiotic prescriptions are also on the rise, adding to the deadly menace of drug-resistant bacteria. A patient demanding unnecessary antibiotics is one of the things that doctors hate most, yet nearly half of physicians surveyed said they’ve had to “improperly [prescribe] antibiotics and opioid pain medication in direct response to patient satisfaction surveys,” as reported in Forbes.
Why is this happening? - Easy - it's about the money.  Quoting the Daily Beast again, "by 2017, Obamacare’s “pay for performance” program mandates that hospitals will lose 2 percent of their Medicare payments if they perform poorly on quality measures—some 30 percent of which will be based on patient satisfaction scores. Hospitals are investing in capital upgrades like escalators to improve the “customer” experience.  Meanwhile, doctors are under even more pressure to “please the customers”—even if it means unnecessarily scoping them, irradiating them, or plying them with toxic and addictive pills.

Friday, July 11, 2014

ACL Reconstruction - Proper Tunnel Position Key to Success

Proper tunnel angle - blue pen/green arrows
Improper Vertical Tunnel -green pen/red arrows
ACL reconstruction is a common procedure that allows injured athletes to return to sporting activities.  The surgical technique has evolved and I am pleased to report that 75% of Orthopedic Surgeons perform this operation using the proper, modern technique recommended by all the leaders in our field, termed Anatomic ACL reconstruction.  This method requires the femoral bone tunnel to be created at the perfect angle using an Accessory Inferior Medial Portal. {side note-single bundle technique is equally successful as double bundle technique - Most surgeons use single bundle technique}

Be sure to confirm that your surgeon is current with Anatomic ACL reconstruction technique.  A vertical femoral bone tunnel (also known as trans tibial technique) is more likely to result in an unstable knee, limited knee motion,  or even worse, early graft failure.

The above Xray case shows an unfortunate 40 year old male that had vertical ACL reconstruction in late 2012.  The graft failed at 74 days and the surgeon repeated the "error" and redid the operation using vertical tunnels (look carefully on the left xray and see two metal endobuttons in the femur-upper red arrow-one from each of the failed procedures).  As expected, the graft failed again with no new trauma.  Dr. Tarlow revised the ACL using the Anatomic ACL Reconstruction technique and now the patient has a stable knee and is able to perform normal activities (look carefully at the right xray and see the proper endobutton position on the side of the femur-upper green arrow).

Sunday, June 1, 2014

ACL Reconstruction Surgery Patients - Some Go On To Have Knee Replacement in Their 50's

May 21, 2014 JBJS article Total Knee Arthroplasty After Previous Knee Surgery from Department of Orthopedic Surgery, Washington University.

ACL Tear MRI - Yellow Arrow
The authors found average age for Knee Replacement Surgery in general population without previous knee surgery occurs mid to late 60's. However if patient has had previous menisectomy Knee Replacement occurs late 50's.  Youngest group at time of Knee Replacement is previous knee ligament reconstruction (most common is ACL reconstruction) around age 50.

This study does not predict the incident of knee replacement in patients with previous ACL or meniscus surgery.  The study is an overview of a group of patients that did have knee replacement surgery. 29 % of these patients had had previous knee surgery.

Dr. Tarlow take home:  Knee ligament injuries occur because of high energy trauma.  The immediate consequence (ACL tear) can be fixed.
There are late consequences to these serious injuries as well, sometimes leading to knee joint replacement surgery at a young age. The opportunity exists to understand why this occurs despite successful ligament surgery and treating the "why" to prevent premature joint demise is one of our next goals in helping our patients.

Friday, May 30, 2014

Custom Cutting Blocks for Total Knee Replacement Not Recommended

From JBJS March, 2014.

Surgeons from the Palo Alto VA investigated the claim that custom cutting blocks based off CT or MRI for Total Knee Replacement surgery improved component position.

The conclusion from their study is that these devices do not improve implant position and in fact in a third of the cases the blocks were abandoned in favor of traditional instruments due to fears of inaccurate bone cuts. 
Patient Specific Blocks - from

These devices add $1000 to the cost of the procedure.

Dr. Tarlow concurs with this report.  Routine use can not be supported in uncomplicated knee replacement. Patients should not be influenced by marketing efforts suggesting widespread adoption of these products.   

Friday, May 23, 2014

Prevent the Spread of Disease: Ban Handshaking Between Doctors and Patients

Dr. Tarlow's thoughts:
The best ideas are often simple, common sense based, and for some reason no one has ever thought of implementing the idea.  I agree with this proposal - The benefit of preventing transmission/spread of disease far outweighs the "negative" social connotation.

from UniversityIowa Healthworks bulletin Dec2013

From JAMA May, 2014

The handshake represents a deeply established social custom. In recent years, however, there has been increasing recognition of the importance of hands as vectors for infection, leading to formal recommendations and policies regarding hand hygiene in hospitals and other health care facilities.

Nevertheless, the hands of health care workers and patients often serve as vectors for transmission of organisms and disease. Health care workers’ hands become contaminated with pathogens from their patients, and, despite efforts to limit the spread of disease, cross-contamination of health care workers’ hands commonly occurs through routine patient and environmental 

Despite knowledge of best practice compliance of health care personnel with hand hygiene programs averages 40%, and patients and visitors to the health care setting generally also have low compliance with hand hygiene policies.  Additionally, handwashing does not kill all bacteria and viruses, so transmission occurs even when best practice is followed.  

Given the pervasive social/cultural role of the handshake, any effort to restrict the handshake from the health care setting should consider practical and infection-conscious alternatives, along with extensive educational programs and appropriate signage, such as: “Handshake-free zone: to protect your health and the health of those around you, please refrain from shaking hands while on these premises.”