By ERIC NOVACK M.D.
Many in medicine view those of us in orthopedics as the ‘dumb bone doctors’ (or, according to the IV, much worse than that). Much of this stems from the basic idea that fracture care, or broken bone treatment, seems very straight-forward. Oh, but wait…
So here is a brief sense of how difficult it can be to evaluate outcomes even in the ‘simple’ area of a broken wrist. And, how it can be absurd to make the surgeon completely responsible?
The first question we need to ask is, “what outcome are we measuring”? Are
we going to look at (a) has the bone healed? (b) how ‘good’ does the
xray look- i.e. how close to ‘perfect’ are the bones lined up? (c) how
is the patient’s function, and at what point after injury do you
measure- months, years?
THCB is big on functional outcomes, so let’s just say that we care about wrist function 1 year after injury. But what kind of function? Range of motion? Return to work? Return to sports?
make it easy and say we’ll leave that to the patient and simply ask
about satisfaction with ability to return to pre-injury functioning.
with me- I know we are looking at the easy area of a broken bone. So,
we are trying to determine functional outcomes 1 year after a wrist
Here is one way to look at the factors impacting the outcome:
factors – age, motivation to get better, willingness to listen to
medical advice and follow recommendations, nutritional status, other
medical conditions, previous injuries, secondary gain issues (workers’
comp, lawsuits), body’s response to injury (i.e. inflammatory response
2. Injury factors—severity of injury force (e.g. trip
over dog vs. 60mph motorcycle crash), location of fracture (e.g.
involving joint cartilage), degree of displacement (i.e. how ‘bad’ the
xray looks), associated soft tissue injuries, associated injuries
impacting treatment and rehab decisions
factors—appropriate decision making, surgical technical skill,
doctor-patient communication (discussing injury, options, risks, and
Rhetorically (and not), I ask- how much of the outcome can the surgeon possibly control?
answer, of course, is only the ‘surgeon factors’, which I will claim
generally make up a relatively small piece of the total outcome pie.
I say again (and again)- until I can get some converts… the future of
quality improvement lies not in just trying to identify ‘best
practices’ that can be difficult to prove and identify and can change
every few years—but rather in identifying what are the WRONG approaches
for conditions (much easier to get agreement here), and emphasizing the
importance of communicating appropriate expectations to patients.
> hope this explanation helps.
It does help.
This sounds like what every UR or pre-auth clinician at an insurance company does.
Have I got it about right?
In an earlier post you asked if I agreed with you that trying to eliminate the worst practices on the right side of the bell curve is extremely important. I do. And I’d add that those worst praactices often involve “doing something” rather than failing to do something — like surgery after a few weeks of tennis elbow.
My own orthopod complains about the many patients who demand an MRI–or want knee surgery– when all they realy need is a course of physical therapy. The fact that she is a young woman and many of her patients are impatient “Wall Street types” probably adds to their distrust. But she’s very cheerful, quite charming and so manages to persuade most of them to try rehab first . .
When it comes to “best practice” at the other end of the curve, I’d suggest that when doctos disagree, it makes sense to try the easiet, least invasive, least expensive treatment first.
For eample, I don’t understand why anyone treating a patient with early stage prostate cancer would recommend either radiation treatment (with likely side effects of impotence and/or incontinnce) or surgery over “watchful waiting.” The cancer moves so slowly that if the patient continues to come in for check-ups, there will be plenty of time to catch the cancer– if it continues to develop. . .
Tom- actually, no.
Let’s be reasonable about the issue. While the list of wrong issues is technically endless, the wrong answers in many cases were never superseded since they have almost always been believed to be wrong. (The Elements of Style police will find me for that sentence…)
Here’s are some straightforward orthopedic examples-
(1) failing to check and document a neurologic exam after fractures
(2) failing to evaluate for and document same about compartment syndrome after lower extremity (especially tibia) fractures
(3) recommending surgery after only a few months of symptoms for tennis elbow
(4) fixing displaced femoral neck fractures in the very elderly vs. hip replacement (partial or full)
and the list can go on and on.
And I would wager that if you got 100 orthopedists together you could get near unanimous agreement on this kind of a list of ‘don’t dos’.
Now try to make a list of ‘best practices’ and ‘evidence based’ treatment regimens for the same conditions (plate vs. nail vs. nonop treatment of fractures, one vs. two incision fasciotomies for compartment syndrome, operative approach for tennis elbow)– and get the same 100 orthopedists together… stand by and wait for the fireworks…
hope this explanation helps.
and comment away!
Dr. Novak writes:
> identifying what are the WRONG
> approaches for conditions
Well, isn’t this list infinite?
Do you mean “identify approaches in fairly common use that are also widely agreed to have been superseded”?