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Sell those residency spots
Value is not always appreciated (fully)

In his recent AAOS Now article, “Change without confrontation is unlikely”, Dr Edward J Collins stated “if one did a cost benefit analysis on what orthopaedists provide society, I believe our reimbursement [$440,000] would be quite modest compared to those benefits.”

As much as I (selfishly) like that line of reasoning, the only valid argument is the converse: that if our benefits exceeded our pay, that pay should be cut. There are many cases in which one does not necessarily get paid for the full benefits of what one provides. (And in some of those settings where that does happen, customers are often irate!).  T

For example, The New York Times costs me about $2 per day. I would willingly pay $3 or more if I had to---just as I do on vacation. The difference between what I pay ($2) and what I received (benefits that are worth at least $3) is called “consumer surplus”  . Consumers like their consumer surplus, and they are worse off when they lose it. 

Thus, while if one did a cost benefit analysis on my relationship with The New York Times and found that the costs “would be quite modest compared to those benefits”, I would be worse off (and sad) if the NY Times were to raise its prices to the limit of what I would pay.

Similarly, if orthopaedic surgeons provide more than $440,000 of benefits to society each year (and I assume they do!)  it is far from clear that they should receive the full measure of their productivity. More to the point, society would be unhappy to cede to us every penny of the benefits we generate.  Indeed, the only thing one can say is that we should not receive more than the value of our work---but anything between zero and that sum is up for grabs.

The salaries of policemen and school teachers, to name two, are also quite modest compared to the benefits they provide, and while I would like them to get paid what they (seemingly) deserve, I would be unhappy to see my taxes raised even for that purpose. Likewise, we should not expect a sympathetic ear from society when we ask for more money---especially when our pay is an order of magnitude greater than the average working person.  

Flying is safe. Takeoff and landing are dangerous.

Sleep is an essential human function - right up there with eating, drinking, and breathing. If you don't sleep, you die. Even after being kept awake for just 24 hours, cognitive (and emotional) changes are noted. It is for that reason, primarily, that the ACGME mandated restrictions on resident work hours. After all, who wants to be taken care of by a cognitively (and emotionally) impaired physician?

Despite the obvious and overwhelming evidence that sleep deprivation is deleterious to the very functions that we'd expect from our physicians, there are those who suggest that the 80 hour work week has not been helpful. (See the JBJS paper cited below, for example)

The perhaps glib retort to those complaining about restrictions is that they are being willfully ignorant of the salubrious effects of sleep. But of course there is a more nuanced answer, namely, that while there are benefits of a well rested house staff, the benefits accrued are offset by the added harm of more frequent "changings of the guard".The transfer of patients between house staff is, this argument goes, an invitation to omit vital information. Bereft of these key data, the covering house officer may make a mistake (despite being well rested) that his more fatigued colleague would not have made, even in the 25th or 30th duty hour.

If that's so -or even if it's just possibly true - we should take steps to minimize the dangers of sign-out.

One important change is that, at a fundamental level, medical education has to stress more teamwork. One gets into medical school and top residency programs, it can't be disputed, by out-competing one's peers. (Earning an A in a course which is graded on a curve is simply a form of winning a tournament.) Although programs may say they prefer candidates those with a pleasant mien and a certain measure of bonhomie, those attributes only come into play at the margin (ie, among two tournament winners, the nicer one gets the job--but only winners are considered!) Unless and until cooperation skills are taught and stressed, graded and rewarded, it is unlikely that sign-out and other "team sports" are going to be played optimally. (Better cooperation can also help in the day-time management of complex patients too.)

Of course, changing attitudes can take a generation or more. In parallel, and perhaps with greater speed and to greater effect, we can employ technology to minimize the dangers of sign-out. In the not too distant future, I can imagine, we'd have computer programs imbued with some artificial intelligence that will serve as the Sign-Out Oracle. The doctor leaving will give report to this computer, and the receiving physician will accept report from it. The special utility of this computer intermediary is that it will know what to ask the sign-out doctor, it will have access to the hospital's information systems (lab values, etc) to shape its "understanding" of the patient, and of course, it will neither tire nor forget. (And again, this Oracle can facilitate the integration of sub-specialists' efforts in the management of complex patients as well.)

At the other technology extreme, one can imagine a system in which the signing out physician leaves a voice mail message regarding each patient that would be fetched only in the event that the covering physician were called about the patient in question. This approach can be effective because for many patients (at least on a surgical floor) the expectation is that they will sleep quietly through the night and need care only in the event of a change in their status. Should that call occur, the covering physician can listen to this voice mail and get a perhaps more informative sign-out than what would be otherwise possible. (If the signing out physician were to give 30 such messages to the signing in physician, there would be a vast signal to noise ratio problem. Most of these messages would be irrelevant (as almost all the patients would tend to be quiet through the night). Using this voice mail system also would save considerable slabs of both doctors' time.

I offer these two suggestions as just that: suggestions. I'm not sure which will work best. Indeed, it's likely that something else will work better than both. My hope, therefore, is that some organization (professional, philanthropic, or trade) might consider sponsoring a high stakes competition for the best "sign-out machine" (or system). These would be developed locally and tested empirically. If I were running this competition, I would offer a substantial prize (on the order of $100,000 or more) and promise to heavily promote the winner. The goal would be to have an excellent program for widespread use. It can be done.

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Selecting Residents (part II)

Within a few days, we'll know if Larry Summers will be appointed to be Secretary of the Treasury (again). If he gets the post, it's because he's a brilliant economist who knows how to solve problems. If he is passed over, it's because he was an impolitic president of Harvard who put his foot in his mouth while discussing gender

The issues of gender may be too hot to handle. Still, no discussion of the selection of orthopedic residents is complete without noting the paucity of women who opt for a career in orthopedics.

Note the choice of phrase: "women who opt for a career in orthopedics". The fundamental problem is likely not that the applicant selection process is biased (Susan Scherl and colleagues have shown that it probably isn't) but that few women decide to apply.

Why is this a problem?

I see three facets: First, the orthopedic surgery community is denied the benefits of diversity (in its true sense); second, the orthopedic surgery community is not availing itself of the complete top talent pool; and, last, the lack of women applicants may reflect the presence of some toxic element which dissuades women from considering this profession.

I don't suspect easy answers to the problem will be forthcoming. Yet there is one step that can be implemented empirically and justified on its own merits: namely, a greater involvement by departments of orthopedic surgery in the medical school curriculum My work has shown that there is a higher proportion of female applicants from schools that have courses in musculoskeletal medicine -and however hard to believe this may be, not all schools have these courses! At least part of the problem, then, is a lack of awareness and exposure, and that's more easily fixed.

Selecting Residents (part I)

'Tis the season for residency applications (come to think of it, it's always the season for residency applications, except for perhaps the Thursday after the match) and pretty soon we'll be hearing from some disgruntled students.   

Why are they unhappy? Because the residency selection process stinks (so they think). Without necessarily agreeing or disagreeing with the proposition, all I can say (having read David Friedman's Hidden Order: The Economics of Everyday Life) is that if a system stinks, look no further than the incentives built in to see why.
If one were to consider the rewards and incentives arrayed before the faculty who are charged with selecting next year's residents, it's a miracle they ever get it right. To start, the task itself is very hard.  Even if the selectors thought only about the long term -who will be a great orthopedic surgeon for 30 years post training?-there is no easy method at hand. Past may be prologue, but we don't know what metrics of current performance - if any - are good predictors for future performance. But it's unlikely that the selectors have their eyes only on the long term. Consider the following:

  • Faculty members want good worker bees taking care of  their patients now.  (You look like you have drone potential.  Great! Welcome aboard.)   
  • They want residents who can take standardized tests: too many failures on the boards reflects badly on the residency program.  (Let's see them USMLE scores - however irrelevant to orthopedics  they may be!)   
  • They want residents who are pleasant company.  (I like myself,  so I'll be looking for residents who look just like me.)   
  • Faculty are justifiably risk averse. (You may be the genius who one day  finds the cure for arthritis, but in my small program a little too much genius may upset the local  ecology...Let somebody else take a chance on you)
  • And of course they don't want to be blamed should they select one who turns out to be a complete loser. (High grades from a name brand school  -again, possibly irrelevant- will inoculate me against criticism.)   

Oh, one more thing: Aristotle was right; man is a political animal.  (I think I'll pick students recommended to me by my friends, so they'll do me a favor when I need it. )
Let's be clear: these are not the only incentives at work. Faculty members spend a lot of time and fire many neurons in hopes of detecting excellence. Most are scrupulously fair. Many work hard to fight the biases endemic to the process. They take their jobs as stewards of the profession very seriously. Nonetheless, selecting the best orthopedic surgeons for tomorrow, all the while finding folks who will work well today, is a nearly impossible task, and one warped by the some perverse incentives.  

Knowing that, maybe some of the disgruntled students will be a little more gruntled now.

The Dull Hypothesis

There was another article in the New England Journal of Medicine pointing out the relative ineffectiveness of arthroscopy for arthritis of the knee. (They'll keep running them every couple of years til the word gets out.) Writing in the same issue, an esteemed colleague offered some insightful observations about the study.

One of his comments, though, is hard to support: namely, "...the lack of efficacy of arthroscopic surgery in this trial does not imply that it has no role in the treatment of patients who may have osteoarthritis and also another knee condition, such as a symptomatic meniscal tear".

The study under discussion certainly did not disprove the effectiveness of arthroscopy for meniscal tears in the setting of arthritis. In Popperian terms, the null hypothesis "Arthroscopy for meniscal tears in the setting of arthritis is helpful" was not falsified. But that's the wrong null hypothesis to consider.

A null hypothesis represents what's assumed to be true until there's evidence to reject it. It's hardly appropriate to start from the premise that therapies are efficacious until proven otherwise.

The obvious effectiveness of so many orthopedic procedures - the internal fixation of femur fractures, say —should not lull us into a state of intellectual complacency in which all our treatments, by default, are assumed to work. It's just not so.

Frugal Profligacy

The other day, one of the senior residents told me about his fellowship plans.  A program in New York City intrigued him, he said, but he was not going to apply- he simply did not think he could live in the Big Apple on a fellow's salary.   

Of course, one's sense of what one can afford is a matter of taste; and about taste there is no argument---de gustibus something or other. But this resident was wrong.  

Classical economics teaches that there is diminishing marginal utility of wealth.  That is to say, when one has a lot of money, the value of any one particular dollar is lower than the value of that single dollar in times of relative scarcity.  For a person earning $50,000 a year, the value of one more dollar is undoubtedly higher than the marginal value of a dollar for someone earning $250,000. 

Now, if that's true -and it is!- it is highly advisable that this resident should borrow as much as necessary to live well in New York City during the fellowship year.  Put it on plastic if need be. That's because this resident's salary is apt to jump five-fold or more as soon as he begins practice. Thus all dollars borrowed during fellowship will be paid back with dollars that are worth far less (owing to the diminishing marginal utility of wealth).   

This borrow-and-spend approach is conservative and prudent. If you were informed that inflation was going to be 50% over the next year, it should be clear what you should do:  borrow and spend as much as you can---at least enough to buy everything that you'd refuse to buy at its current price, but would buy at a 50% discount.  

That's what we have here. The resident is going to experience a marked (yet personal) devaluation in the currency and the right response to this coming phenomenon is (seemingly) excessive spending.  Just as it is sometimes conservative and prudent to recommend operative treatment -draining an infection, say- there are times it may be conservative and prudent to borrow and spend.  The last year of residency is one such time. 

(PS I didn't share this opinion with the resident. It's not because I am any good at minding my own business - I am not - but it would have been futile. The underlying modus operandi of all residents, workers of long hours at  low wages, is deferred gratification. This "living for tomorrow" approach is so ingrained in the resident's mindset I don't think I could have convinced him to borrow and spend--even when it is conservative and prudent.)

Burn out and leisure

I came across an interesting paper from The Annals of Internal Medicine on burnout among medical students. I did not quite identify with the students discussed in the article -back when I was a burnt out resident, I was probably more tempted to harm my tormentors than myself-but the story still resonated. My training was far from pleasant and it took its toll on me.

I'll leave it to others to say whether I have recovered from that burn out, but to the extent that I have gotten well, it is because I have the opportunity for leisure. Case in point: I didn't read this paper in The Annals itself. Rather, I ran across a reference to it in an article I found surfing the NY Times website

Leisure is not a casual issue; we have a serious need for play. If orthopedic faculty members are going to prevent burnout among our students and residents, allowing for, and even promoting, leisure for our trainees will be essential. (A great discussion of leisure can be found in this article in The Atlantic It's more than 8,000 words long-you may have to wait for your residency to end before you tackle it. I favor leisure but with limits.)

Leisure has its critics. I've heard more than one discussion about the 80-hour work week that included an argument that residents are not taking advantage of the reduced workload to sleep and study, but simply to have fun. Horrors!

Allowing residents to have fun - dating, exercise, and yes, skimming the New York Times - is essential to their mental health. And a mentally healthy house-staff is a necessary condition for protecting patients and delivering good care.

Resident work hours should be limited to allow them to sleep, of course. If you are sufficiently sleep-deprived, you are as impaired as if you were drunk. But merely satisfying that particular biological need no more guarantees the overall wellbeing of a resident than allowing him or her to drink adequate fluids or eat a sufficient number of calories.

When I am in need of medical care, I want the residents taking care of me to have slept enough to pass a sobriety test, but I also want them to have had enough leisure to pass a personality test too.

There may be valid arguments against the 80-hour work week, but that the residents are having too much fun is not one of them.

The grapes really are sour...

Philadelphia Magazine just published its list of local Top Doctors, and of course I read the recent issue with great avidity. Having moved my practice from the main university hospital a few years ago, I did not expect to find myself back on the list, but of course I was fascinated to see which of my friends (and enemies) had made the cut.   

That list is all good for gossip. As for actually detecting pure excellence, it's not the place to look.  Forget that some of my favorites are off the list or that some quack is on it; rather, the process itself is warped.   

The problem with the concept of Top Doctortude is that it favors action over inaction---even when the latter is better medicine.  For instance, the list contains doctors who will inject  the  spine; it has surgeons who will fuse the spine. It does not have the heroic doctors, who, contrary to their own financial interests, are willing to tell patients  'so your back hurts; welcome to terrestrial human life. Let me help you cope, but don't make me over-treat you'.  

(This phenomenon is not limited to orthopedics: The magazine lists doctors who will radiate the prostate,  it has others who will remove it.   it omits the doctor who reminds patients 'Most men die with prostate cancer, not of it. Maybe you should just do nothing and avoid the risk of incontinence and impotence'? The list has surgeons to bypass arterial blockages and doctors to stent them-again, eliding the default option of reassuring patients but ignoring the "lesions", even though blockages outside of the left main coronary artery might well be left alone.  )

I would imagine that a national top doctor's list 100 years ago would have been headed by Halstead at Hopkins, yet he caused maybe millions of breasts to be radically removed, perhaps needlessly...Who on today's list will be remembered similarly?

As House of God put it (in jest but in truth): "The delivery of good medical care is to do as much nothing as possible".

(If any this resonates with you, or especially if it doesn't, I strongly advise reading Dr Nortin Hadler's recent book or his classic on the diminishing returns of expansive medicine.)

The Monty Hall Paradox

That my residents today did not know of the Monty Hall Paradox was not particularly disappointing or surprising; Game Theory is a small and quirky field. But that they never even heard of Monty Hall, thereby reminding me that I am of a previous generation, was a real downer.

The Monty Hall Paradox came up in a discussion of shoulder pain and arthroscopy. I will get to that in a second. Here's the paradox (as recounted by Parade magazine):

Suppose you're on a game show, and you're given the choice of three doors: Behind one door is a car; behind the others, goats. You pick a door, say No. 1, and the host, who knows what's behind the doors, opens another door, say No. 3, which has a goat. He then says to you, "Do you want to pick door No. 2?" Is it to your advantage to switch your choice?

The "paradox" is that it is to your advantage to switch even though this is a one-for-one swap.

The whole key to understanding why the switch is valuable is to understand that the host (Monty Hall) always can open a door with a goat behind it (he knows where the goats are, after all) and as such, has not given you any new information about his hand in general (door #2 plus door #3) by opening door #3 alone and showing you a goat-except to show that his 2/3 probability of holding the car collapses, Schrödinger style, on door #2. Thus, the trade, ostensibly door #1 for door #2, is really door #1 for (door #2 PLUS door #3); his TWO doors for your ONE. His two doors have an a priori have a 2/3 chance of a winner, and still do even after he opens one of them deliberately. Certainly, you'd trade his 2 doors for your lone selection before he opens one, and that is what you are doing here-even after he opens one of them.

So what's this got to do with shoulders? Maybe nothing. (As my residents implied, I am getting old. Tirades are to be expected and excused.) The similarity I see is that one can assume a priori that a 60 yead old man has some anatomic abnormality in the shoulder. "Discovering" some fraying here or there at the time of arthroscopy is not edifying. It's like finding a goat behind door #3. No new general information was obtained. The fraying may not be the source of the pain, and finding something "abnormal" does not, in retrospect, prove that your surgery was indicated.

Information, as defined by Shannon, is a measure of what a medium conveys above the base probability. When you "learn" something you already knew -be it that a goat lies behind one of the host's doors or that a 60 year old shoulder harbors some structural abnormality-you did not acquire new information.

In America, every dog can grow up to be the president's dog

I read the sports pages as an orthopedic surgeon - one trained in sports medicine to boot. That is, I skip the feature stories, gloss over the box scores, and go right to those little articles describing the injuries. Who broke what? Which doctor was consulted? What information is being withheld? In my crazy world, sports exist as an adjunct to sports medicine, not the other way around.

When I was a kid in New York City in the 70's I was more familiar with the names Dr. James Parkes and Dr. James Nicholas than I was with the names of some of the players they took care of... it wasn't until I got frostbite at a Penn/Cornell football game one late November that I started to think rationally about the dream of growing up to be the president's dog.... I think that was my last game on the sidelines as a team physcian. I miss some of it, but not the tundra that is Ithaca in November.

AAOS Orthopaedic Surgeons' Disclosure Program

I just received a notice from the AAOS asking me to once again complete my disclosure form. Of course I did so, but not without rolling my eyes. For one thing, this program simply asks if you get any money at all and ignores the magnitude of the payments one might be receiving. For the average orthopedic surgeon (whose income is by definition average, that is, about $465,000 a year) the payment of a few hundred dollars really is not material. On the other hand, as the Department of Justice Deferred Prosecution Agreement has shown us, some orthopedic surgeons receive in excess of $5 million a year from industry. To me, there is a qualitative difference between 5 hundred and 5 million dollars. The second thing is that this program ignores potential conflicts: it only considers whether you got the money already, and not whether you are doing things in anticipation thereof. Said cynically, one might divide the orthopedic community into two groups – those who get $5 million a year, and those who do not get $5 million a year, but want to.

Making Orthopaedia safe for bloggers

Actually, we did not have to do much (indeed anything) to bring blogging to Orthopaedia. As you see, this is simply the NEWS section of the personal space.

It would be great if our community members take to blogging. I see two obstacles, both psychological: first, users are going to have to get used to the idea that their own personal pages cannot be edited by anyone else. That is, the blog entry looks like a wiki page, but it isn't. (Maybe we should change the layout for blog pages just to keep that distinction sharp.) The second obstacle is the reluctance to actually speak one's mind in a professional ambit where dissent has not been rewarded. (We could "correct" that problem by allowing anonymous sock puppet posting, but in that case the cure would be worse than the disease.)

Overall, these are not insurmountable obstacles; and the exchange of opinions can be a boon to writer and reader alike.

Hip impingement is bogus

That got your attention. I have no idea (yet) whether impingement will turn out to be bogus, but as of today, at least, hip impingement is a hypothesis, not a fact.

And I am at a loss regarding the utility of this hypothesis. What do you do with the information--prophylactic osteotomies?

I recently discovered that the "Double Crush Phenomenon", the process in which proximal yet subclinical compression of a nerve is said to place distal segments of that nerve at risk of damage from compression that would otherwise be noninjurious, was introduced into the medical literature as the "Double Crush Hypothesis". At no point was this hypothesis proven; nonetheless, simply by enduring for years, the concept lost its question mark.

The "shoulder impingement" hypothesis never had a question mark in the first place – surgeons are nothing if not confident – and 35 years later sub-acromial decompression is among the most popular operations in our field, even after it was said in the JBJS that the hypothesis did not withstand the test of time. Hmm...

I propose that the community of orthopedic surgeons adopt the convention whereby all podium speakers who wish to utter the phrase "hip impingement" (and not "hypothetical hip impingement" or "purported hip impingement") must make little quote marks with their fingers when they say the words.