Reporter's Notebook

Dear OTW Reader:

Dr. Stephen Hochschuler’s take on why orthopedists are the weakest link; new life for old stem cells; and, are we soon going to need bake sales for residency funding?

A Stryker Goes -Selling.  

There are a few descendants of Dr. Homer Stryker, founder of the eponymous company, who own a large percentage of the company’s stock…but at least one is getting rid of portions of said stock. Ronda E. Stryker, a company director and Homer’s granddaughter, according to an August 12, 2011 article on marketbrief.com, this director—the only member of the family to serve on the Stryker board—sold 1, 465, 000 shares of company stock for a total of $84, 547, 826. Why? We do not know. But this 57-year-old is according to Forbes.com, believed to be among the anonymous donors to the Kalamazoo Promise, a scholarship program that provides college tuition to all Kalamazoo Public School students.

Egos Harming the Field?  

Stephen Hochschuler, M.D., famed founder of the Texas Back Institute, says that despite the “squeeze” on orthopedics, he would do it all again. “But it’s tougher now, ” Dr. Hochschuler tells OTW. “To come out of residency with $250, 000 in debt and no sign of paying it off anytime soon is less than optimal. But we orthopedists are the weakest link. Why? Because we never organized ourselves. Physicians are more concerned about how another doctor is doing than how their field is doing. And residents don’t get involved in things that affect them overall…they are more concerned about why the other guy made chief resident.”

Residents Driven Around the Bend?  

Giving a behind-the-scenes look at the duty hour melee, a resident tells OTW, “It’s really causing havoc with how much residents can learn. Interns in particular are very limited in what they can do. We rely on them to take call at night with us—both for us and so they can learn…but that is really restricted now. You have a situation where they are on call but it’s 10pm and they come in to do an ankle reduction, but then learn that they have exceeded their hours. I haven’t seen people flout the rules, but it has been talked about as a possibility. One of the ideas behind these regulations was that residents would go home and read. Instead, we are spending time putting our schedules into a computer in order to maintain compliance. Overall, the situation is ridiculous…someone may not have worked all afternoon, but because it’s after midnight they can’t come in. In several years the orthopedic universe will realize that residents are lacking in skills and that it is unsafe for the general populace.”

Fully Trained Isn’t Fully Trained.  

Other parties involved with residency aren’t so happy either…one tells OTW, “Several weeks ago the Residency Review Committee released what it considers to be the ‘minimum’ number of surgeries for certain procedures. When I look around—and take into consideration these new ‘minimums, ’ there is no way that residents coming out of programs are fully trained. You know, in Europe the duty hours are down to about 50 hours a week. If the trend continues in our country then we will just have to extend residencies. When someone finishes residency the program signs off on the person being a qualified independent practitioner of orthopedic surgery. That is really a stretch nowadays. And it doesn’t do much good to police duty hours…if a person is going to fudge his or her time, then they will find a way to do that.”

Car Wash, Bake Sales for Residency Education?  

Brian Parsley, M.D. tells OTW, “There is a firestorm of concern about graduate medical education funding. The severe budget cuts in federal and state funding mean that we have to either get organized and fight for the restoration of those funds—or, we have to find alternative funds. Some people are predicting that in ten years there will be no funding for residents and fellows. Although the ACGME, residency programs, and the specialty societies have this issue on their radar, so far no one has come up with an effective idea. At Baylor they recently sent a note around saying that if you have a fellowship or residency slot that was not filled that you can’t fill it without the administration’s approval. That is a huge change. In the past if you had an open slot after match day you could continue to search for applicants and had complete freedom to fill that slot. And we think we have ‘manpower’ problems now!”

Feds Overlooking the Obvious? 

A Ph.D. involved in orthopedic education tells OTW, “The Obama plan to cut 30% of the budget for graduate medical education is top on everyone’s mind. The American Association of Medical Colleges has recently done a survey about how this would affect the financing of graduate programs. One of the things all institutions must ask these days is, ‘How could we do this with less money and at the same level of quality?’ At a time when we need to be training more orthopedic surgeons (because of baby boomers needing joint replacements, for example) we are going to have to make do with fewer doctors. It’s too bad that the powers that be aren’t thinking about the big economic picture…if we were able to keep older people functioning well then their medical care would be less of an economic burden.”

New Life for Old Stem Cells.  

Evan Flatow, M.D., Chair of Orthopaedics at the Mount Sinai Medical Center, tells OTW, “In my lab we have recently found out that stem cells age as we do. This is one of the reasons that older people with tendon injuries don’t heal as well—they have fewer stem cells and they don’t reproduce as well. BUT, there are certain genes that you can turn on that make old stem cells act like young stem cells. If you just dump stem cells into tendon injuries it doesn’t do much; you have to turn them on and give them the right biologic signals. We are now working on it with a broader group of patients, and are applying for a federal grant that will enable us to manipulate the stem cells.”

Doors Opening for Younger Shoulder Surgeons.  

In a major shift, says a shoulder and elbow surgeon, the American Shoulder and Elbow Surgeons (ASES) is on the verge of opening up its membership. He tells OTW, “The ASES has traditionally been a closed society, i.e., meetings have been restricted to members. We realized that we were one of the few societies in all of orthopedics to remain closed…there is a new initiative to open our society and make it more inclusive. That way younger, less established people can participate and become involved in the growth of our society. We didn’t want to be perceived as elitist. Also, inclusion of more members would allow us to extend our educational mission.”

Cutthroat Orthopedics? 

John Kelly, M.D., Associate Professor of Clinical Orthopaedic Surgery at the University of Pennsylvania, is seeing an ugly side to the field these days. He tells OTW, “I’ve seen several instances of people driven off staff at different institutions because of increased competition in the field. In one instance I was trying to counsel a peer who had been reported to the medical board. It was a competitor group that did the reporting—and he was exonerated. Resources ‘out there’ are dwindling…and this is bringing out the worst in people.”

Quick, Learn a New Implant! 

An orthopedist in academic medicine tells OTW, “A fundamental question is, ‘How are hospitals going to align with doctors to cut costs?’ I already see hospitals putting pressure on providers, saying, ‘We need to cut costs.’ Hospitals are saying, ‘Help us renegotiate contracts with the vendors’—or, ‘Use less expensive implants.’ One of the biggest healthcare consortiums in my city owns several hospitals. They are telling the physicians, ‘Here are the three acceptable vendors for total joints.’ I have some colleagues at these institutions whose ‘normal’ implants were not selected and so they had just one month to learn new implant systems.”

HSS? No Germs Allowed!  

Hospital for Special Surgery (HSS) is reporting that it is the only hospital in New York State with an infection rate that is significantly lower than the state average for hip replacement or revision surgeries. Surgeons at HSS performed the most hip replacement surgeries in New York State. During each of those surgeries there was an infection prevention nurse who oversees the operating room. As indicated by HSS, also helping matters is that each room is standardized, improving efficiency and lowering surgical time by having surgical tools laid out and organized in the same order. Additionally, HSS minimizes patients’ exposure to contaminants by isolating them from the environment by a specially designed Plexiglas enclosure (helping to improve airflow and to restrict excess personnel at the surgical field).