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When in doubt about lab tests …
Last week I saw a 35-year-old man for follow-up on a positive rapid plasma reagin (RPR). He thought he had syphilis, but he had never had any syphilis symptoms, so I suspected the RPR was a false positive. Because I seldom encounter this situation, it was time for some “point of care” research. I checked an online reference and found that the fluorescent treponemal antibody absorption (FTA-ABS) test is highly sensitive and would be sufficient to rule out syphilis. The good news: His subsequent FTA-ABS was negative. But the situation left me wondering why the FTA-ABS had not been done automatically after the positive RPR.
The question, “What is the best test to rule in or rule out X?” comes up frequently for family physicians (FPs), and sometimes we are uncertain about ordering the best test and interpreting the results correctly. According to a recent national survey sponsored by the Centers for Disease Control and Prevention1—for which I was privileged to be the principal investigator—1768 FPs and general internists reported ordering diagnostic laboratory tests for an average of 31.4% of their patients per week. They were uncertain about the right test to order for 14.7% of these patients and uncertain about interpreting the results for 8.3%. That might not seem like a lot, but with more than 500 million primary care patient visits per year in the United States, this potentially affects 23 million patients each year.
We asked about problems with test ordering, too. I don’t think you will be surprised that physicians reported insurance company restrictions and costs to patients were the main barriers. They also reported difficulty with the variety of names for the same tests, which I certainly noticed when I moved from Cleveland Clinic to University of Illinois at Chicago. Not getting test results in a timely manner was a big problem, too, as was confusing report formats. In our electronic medical record, 90% of the lab report details things I don’t need to know and to get to the 10% I do need, I have to scroll or click.
In this issue, Tessier et al illustrate ways to avoid common lab testing pitfalls. I would argue that in addition to helpful articles like this one, we also need better electronic tools to help guide us when uncertain. Then again, the phone is still good technology; when in doubt, pick it up and call your lab.
REFERENCE
1. Hickner J, Thompson PJ, Wilkinson T, et al. Primary care physicians’ challenges in ordering clinical laboratory tests and interpreting results. J Am Board Fam Med. 2014;27:268-274.
Last week I saw a 35-year-old man for follow-up on a positive rapid plasma reagin (RPR). He thought he had syphilis, but he had never had any syphilis symptoms, so I suspected the RPR was a false positive. Because I seldom encounter this situation, it was time for some “point of care” research. I checked an online reference and found that the fluorescent treponemal antibody absorption (FTA-ABS) test is highly sensitive and would be sufficient to rule out syphilis. The good news: His subsequent FTA-ABS was negative. But the situation left me wondering why the FTA-ABS had not been done automatically after the positive RPR.
The question, “What is the best test to rule in or rule out X?” comes up frequently for family physicians (FPs), and sometimes we are uncertain about ordering the best test and interpreting the results correctly. According to a recent national survey sponsored by the Centers for Disease Control and Prevention1—for which I was privileged to be the principal investigator—1768 FPs and general internists reported ordering diagnostic laboratory tests for an average of 31.4% of their patients per week. They were uncertain about the right test to order for 14.7% of these patients and uncertain about interpreting the results for 8.3%. That might not seem like a lot, but with more than 500 million primary care patient visits per year in the United States, this potentially affects 23 million patients each year.
We asked about problems with test ordering, too. I don’t think you will be surprised that physicians reported insurance company restrictions and costs to patients were the main barriers. They also reported difficulty with the variety of names for the same tests, which I certainly noticed when I moved from Cleveland Clinic to University of Illinois at Chicago. Not getting test results in a timely manner was a big problem, too, as was confusing report formats. In our electronic medical record, 90% of the lab report details things I don’t need to know and to get to the 10% I do need, I have to scroll or click.
In this issue, Tessier et al illustrate ways to avoid common lab testing pitfalls. I would argue that in addition to helpful articles like this one, we also need better electronic tools to help guide us when uncertain. Then again, the phone is still good technology; when in doubt, pick it up and call your lab.
Last week I saw a 35-year-old man for follow-up on a positive rapid plasma reagin (RPR). He thought he had syphilis, but he had never had any syphilis symptoms, so I suspected the RPR was a false positive. Because I seldom encounter this situation, it was time for some “point of care” research. I checked an online reference and found that the fluorescent treponemal antibody absorption (FTA-ABS) test is highly sensitive and would be sufficient to rule out syphilis. The good news: His subsequent FTA-ABS was negative. But the situation left me wondering why the FTA-ABS had not been done automatically after the positive RPR.
The question, “What is the best test to rule in or rule out X?” comes up frequently for family physicians (FPs), and sometimes we are uncertain about ordering the best test and interpreting the results correctly. According to a recent national survey sponsored by the Centers for Disease Control and Prevention1—for which I was privileged to be the principal investigator—1768 FPs and general internists reported ordering diagnostic laboratory tests for an average of 31.4% of their patients per week. They were uncertain about the right test to order for 14.7% of these patients and uncertain about interpreting the results for 8.3%. That might not seem like a lot, but with more than 500 million primary care patient visits per year in the United States, this potentially affects 23 million patients each year.
We asked about problems with test ordering, too. I don’t think you will be surprised that physicians reported insurance company restrictions and costs to patients were the main barriers. They also reported difficulty with the variety of names for the same tests, which I certainly noticed when I moved from Cleveland Clinic to University of Illinois at Chicago. Not getting test results in a timely manner was a big problem, too, as was confusing report formats. In our electronic medical record, 90% of the lab report details things I don’t need to know and to get to the 10% I do need, I have to scroll or click.
In this issue, Tessier et al illustrate ways to avoid common lab testing pitfalls. I would argue that in addition to helpful articles like this one, we also need better electronic tools to help guide us when uncertain. Then again, the phone is still good technology; when in doubt, pick it up and call your lab.
REFERENCE
1. Hickner J, Thompson PJ, Wilkinson T, et al. Primary care physicians’ challenges in ordering clinical laboratory tests and interpreting results. J Am Board Fam Med. 2014;27:268-274.
REFERENCE
1. Hickner J, Thompson PJ, Wilkinson T, et al. Primary care physicians’ challenges in ordering clinical laboratory tests and interpreting results. J Am Board Fam Med. 2014;27:268-274.
Intimate partner violence: Screen others, besides heterosexual women
We were happy to learn in “Time to routinely screen for intimate partner violence?” (PURLs. J Fam Pract. 2013;62:90-92) that the US Preventive Services Task Force (USPSTF) agrees with the Institute of Medicine (IOM) that all women of childbearing age should be screened for intimate partner violence (IPV).1 Although the USPSTF recommendation comes 2 years after that of the IOM, it is truly better late than never.
Two populations with known IPV issues require special consideration: lesbian, gay, bisexual, transgender (LGBT) patients and heterosexual men. The rate of IPV is higher in the LGBT population than in heterosexual men and women cohabitating with their partners.2 Despite high rates of IPV within the LGBT population, women in this group frequently are overlooked for IPV screening.2
We must remember to screen men in heterosexual relationships, as well. In 2000, the National Violence Against Women survey found that 7% of men reported having experienced IPV in their lifetime.2 Given this data, we believe that all patients ages 14 years and older—regardless of gender or sexual orientation—should be screened for IPV. This would be a much-needed step towards addressing a major public health problem.
Barbara McMillan-Persaud, MD
Kyra P. Clark, MD
Riba Kelsey-Harris, MD
Folashade Omole, MD, FAAFP
Atlanta, Ga
1. Screening for intimate partner violence and abuse of elderly and vulnerable adults. US Preventive Services Task Force Web site. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsipv.htm. Accessed September 16, 2013.
2. Artd KL, Makadon HJ. Addressing intimate partner violence in lesbian, gay, bisexual, and transgender patients. J Gen Intern Med. 2011;26:930-933.
We were happy to learn in “Time to routinely screen for intimate partner violence?” (PURLs. J Fam Pract. 2013;62:90-92) that the US Preventive Services Task Force (USPSTF) agrees with the Institute of Medicine (IOM) that all women of childbearing age should be screened for intimate partner violence (IPV).1 Although the USPSTF recommendation comes 2 years after that of the IOM, it is truly better late than never.
Two populations with known IPV issues require special consideration: lesbian, gay, bisexual, transgender (LGBT) patients and heterosexual men. The rate of IPV is higher in the LGBT population than in heterosexual men and women cohabitating with their partners.2 Despite high rates of IPV within the LGBT population, women in this group frequently are overlooked for IPV screening.2
We must remember to screen men in heterosexual relationships, as well. In 2000, the National Violence Against Women survey found that 7% of men reported having experienced IPV in their lifetime.2 Given this data, we believe that all patients ages 14 years and older—regardless of gender or sexual orientation—should be screened for IPV. This would be a much-needed step towards addressing a major public health problem.
Barbara McMillan-Persaud, MD
Kyra P. Clark, MD
Riba Kelsey-Harris, MD
Folashade Omole, MD, FAAFP
Atlanta, Ga
We were happy to learn in “Time to routinely screen for intimate partner violence?” (PURLs. J Fam Pract. 2013;62:90-92) that the US Preventive Services Task Force (USPSTF) agrees with the Institute of Medicine (IOM) that all women of childbearing age should be screened for intimate partner violence (IPV).1 Although the USPSTF recommendation comes 2 years after that of the IOM, it is truly better late than never.
Two populations with known IPV issues require special consideration: lesbian, gay, bisexual, transgender (LGBT) patients and heterosexual men. The rate of IPV is higher in the LGBT population than in heterosexual men and women cohabitating with their partners.2 Despite high rates of IPV within the LGBT population, women in this group frequently are overlooked for IPV screening.2
We must remember to screen men in heterosexual relationships, as well. In 2000, the National Violence Against Women survey found that 7% of men reported having experienced IPV in their lifetime.2 Given this data, we believe that all patients ages 14 years and older—regardless of gender or sexual orientation—should be screened for IPV. This would be a much-needed step towards addressing a major public health problem.
Barbara McMillan-Persaud, MD
Kyra P. Clark, MD
Riba Kelsey-Harris, MD
Folashade Omole, MD, FAAFP
Atlanta, Ga
1. Screening for intimate partner violence and abuse of elderly and vulnerable adults. US Preventive Services Task Force Web site. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsipv.htm. Accessed September 16, 2013.
2. Artd KL, Makadon HJ. Addressing intimate partner violence in lesbian, gay, bisexual, and transgender patients. J Gen Intern Med. 2011;26:930-933.
1. Screening for intimate partner violence and abuse of elderly and vulnerable adults. US Preventive Services Task Force Web site. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsipv.htm. Accessed September 16, 2013.
2. Artd KL, Makadon HJ. Addressing intimate partner violence in lesbian, gay, bisexual, and transgender patients. J Gen Intern Med. 2011;26:930-933.
Impacted cerumen or something else?
During my preceptorship, I (PK) encountered a 67-yearold cattle rancher with a month-long history of right ear pain, right-sided headaches, hearing loss, and occasional dizziness. He’d seen 2 other physicians on separate occasions who had prescribed antibiotics and ear drops for cerumen removal, yet his symptoms persisted. A computed tomography (CT) scan was normal.
When I examined the patient, his right inner ear canal showed a white, crusting exudate condensed in the tympanic membrane area. I inserted the otoscope farther into the canal and observed a single insect leg sticking out from the grey mass. A resident used the otoscope and forceps to extract the live specimen intact. It was identified as an Otobius tick.
Despite having a tick in his ear canal for more than a month, the patient was doing well at his 2-week follow-up appointment and showed no signs of tick-borne illness. The appearance of the tick had closely resembled impacted cerumen, which had led to delayed diagnosis and an unnecessary CT scan.
A careful otic exam was paramount, because directly viewing the insect’s extremity was the key to diagnosis.
Petra Kelsey, 2nd year medical student
Marfa, Texas
Adrian Billings, MD, PhD
Galveston, Texas
During my preceptorship, I (PK) encountered a 67-yearold cattle rancher with a month-long history of right ear pain, right-sided headaches, hearing loss, and occasional dizziness. He’d seen 2 other physicians on separate occasions who had prescribed antibiotics and ear drops for cerumen removal, yet his symptoms persisted. A computed tomography (CT) scan was normal.
When I examined the patient, his right inner ear canal showed a white, crusting exudate condensed in the tympanic membrane area. I inserted the otoscope farther into the canal and observed a single insect leg sticking out from the grey mass. A resident used the otoscope and forceps to extract the live specimen intact. It was identified as an Otobius tick.
Despite having a tick in his ear canal for more than a month, the patient was doing well at his 2-week follow-up appointment and showed no signs of tick-borne illness. The appearance of the tick had closely resembled impacted cerumen, which had led to delayed diagnosis and an unnecessary CT scan.
A careful otic exam was paramount, because directly viewing the insect’s extremity was the key to diagnosis.
Petra Kelsey, 2nd year medical student
Marfa, Texas
Adrian Billings, MD, PhD
Galveston, Texas
During my preceptorship, I (PK) encountered a 67-yearold cattle rancher with a month-long history of right ear pain, right-sided headaches, hearing loss, and occasional dizziness. He’d seen 2 other physicians on separate occasions who had prescribed antibiotics and ear drops for cerumen removal, yet his symptoms persisted. A computed tomography (CT) scan was normal.
When I examined the patient, his right inner ear canal showed a white, crusting exudate condensed in the tympanic membrane area. I inserted the otoscope farther into the canal and observed a single insect leg sticking out from the grey mass. A resident used the otoscope and forceps to extract the live specimen intact. It was identified as an Otobius tick.
Despite having a tick in his ear canal for more than a month, the patient was doing well at his 2-week follow-up appointment and showed no signs of tick-borne illness. The appearance of the tick had closely resembled impacted cerumen, which had led to delayed diagnosis and an unnecessary CT scan.
A careful otic exam was paramount, because directly viewing the insect’s extremity was the key to diagnosis.
Petra Kelsey, 2nd year medical student
Marfa, Texas
Adrian Billings, MD, PhD
Galveston, Texas
Authors’ Response
I thank Dr. Strauss for his comments regarding our article—“Chronic Exertional Compartment Syndrome in a Collegiate Soccer Player: A Case Report and Literature Review” (Am J Orthop. 2008;37(7):374-377).
The history in most cases alone is not sufficient to justify compartment pressure measurements as the first diagnostic test. Many athletes with leg pain have the more common diagnosis of tibial periostitis or stress fracture, and certainly radiographs and an MRI scan may not only be diagnostic but also noninvasive. However, as Dr. Strauss suggests, in some patients, the history alone, if more classic for chronic exertional compartment syndrome, may make it reasonable to
proceed with compartment pressure measurements initially. I also agree that if the diagnosis of chronic exertional compartment syndrome can be made from the resting compartment pressure measurements alone, additional needlesticks post-exercise may not be necessary. I still believe that the standard diagnostic protocol, as described by Pedowitz and colleagues,1 should be used to set the diagnostic criteria for chronic exertional compartment syndrome. Even in the runner who required 45 minutes before the chronic exertional compartment symptoms manifested themselves, it is possible that, with the standard protocol, elevation of compartment pressures may have existed prior to, immediately after,
or 5 minutes after exercise as well.
Once again, I greatly appreciate Dr. Strauss’s insight. I do agree that further research in the diagnosis of chronic exertional compartment syndrome is needed. I hope that our article demonstrating a representative case of this entity with
an encompassing literature review was a help to readers.
Harlan Selesnick, MD
Coral Gables, FL
Reference
1. Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990;18(1):35-40.
I thank Dr. Strauss for his comments regarding our article—“Chronic Exertional Compartment Syndrome in a Collegiate Soccer Player: A Case Report and Literature Review” (Am J Orthop. 2008;37(7):374-377).
The history in most cases alone is not sufficient to justify compartment pressure measurements as the first diagnostic test. Many athletes with leg pain have the more common diagnosis of tibial periostitis or stress fracture, and certainly radiographs and an MRI scan may not only be diagnostic but also noninvasive. However, as Dr. Strauss suggests, in some patients, the history alone, if more classic for chronic exertional compartment syndrome, may make it reasonable to
proceed with compartment pressure measurements initially. I also agree that if the diagnosis of chronic exertional compartment syndrome can be made from the resting compartment pressure measurements alone, additional needlesticks post-exercise may not be necessary. I still believe that the standard diagnostic protocol, as described by Pedowitz and colleagues,1 should be used to set the diagnostic criteria for chronic exertional compartment syndrome. Even in the runner who required 45 minutes before the chronic exertional compartment symptoms manifested themselves, it is possible that, with the standard protocol, elevation of compartment pressures may have existed prior to, immediately after,
or 5 minutes after exercise as well.
Once again, I greatly appreciate Dr. Strauss’s insight. I do agree that further research in the diagnosis of chronic exertional compartment syndrome is needed. I hope that our article demonstrating a representative case of this entity with
an encompassing literature review was a help to readers.
Harlan Selesnick, MD
Coral Gables, FL
Reference
1. Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990;18(1):35-40.
I thank Dr. Strauss for his comments regarding our article—“Chronic Exertional Compartment Syndrome in a Collegiate Soccer Player: A Case Report and Literature Review” (Am J Orthop. 2008;37(7):374-377).
The history in most cases alone is not sufficient to justify compartment pressure measurements as the first diagnostic test. Many athletes with leg pain have the more common diagnosis of tibial periostitis or stress fracture, and certainly radiographs and an MRI scan may not only be diagnostic but also noninvasive. However, as Dr. Strauss suggests, in some patients, the history alone, if more classic for chronic exertional compartment syndrome, may make it reasonable to
proceed with compartment pressure measurements initially. I also agree that if the diagnosis of chronic exertional compartment syndrome can be made from the resting compartment pressure measurements alone, additional needlesticks post-exercise may not be necessary. I still believe that the standard diagnostic protocol, as described by Pedowitz and colleagues,1 should be used to set the diagnostic criteria for chronic exertional compartment syndrome. Even in the runner who required 45 minutes before the chronic exertional compartment symptoms manifested themselves, it is possible that, with the standard protocol, elevation of compartment pressures may have existed prior to, immediately after,
or 5 minutes after exercise as well.
Once again, I greatly appreciate Dr. Strauss’s insight. I do agree that further research in the diagnosis of chronic exertional compartment syndrome is needed. I hope that our article demonstrating a representative case of this entity with
an encompassing literature review was a help to readers.
Harlan Selesnick, MD
Coral Gables, FL
Reference
1. Pedowitz RA, Hargens AR, Mubarak SJ, Gershuni DH. Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med. 1990;18(1):35-40.
Re-examining the Safety Issues of Ceramic-on-Ceramic Bearing Surface
In this month’s E-publishing section, we will read more interesting and clinically pertinent articles, including an article by Tateiwa and colleagues on “Ceramic Total Hip Arthroplasty in the United States: Safety and Risk Issues Revisited.”
The article, by a group of internationally recognized investigators, attempts, and accomplishes, a summary of the safety of alumina ceramic-on-ceramic bearing surface for use in THA. The main emphasis of the article is to highlight the findings of reports in the United States regarding the safety of the ceramic-on-ceramic bearing surface in general and the risk of fracture in particular.
That the article is well written and elegantly organized is not to be disputed. That the article presents the findings of various publications in an unbiased fashion is also not to be doubted. The authors nicely convince the reader that the ceramic-on-ceramic bearing surface is an important part of the armamentarium at the disposal of orthopedic surgeons who surgically treat arthritis of the hip in the young, and hence it is here to stay. I hope the authors will forgive me if I present the argument from a different and less “pro-ceramic” perspective.
First, the authors are, in my opinion, a little unfair and somewhat dramatic in their view on the conventional polyethylene and its new sister, the highly cross-linked polyethylene. I quote the authors: “In the past, however, clinical experience with ‘new and improved’ polyethylenes has seldom been exemplary, and current clinical experience is but a blip on the radar screen. It is also likely that the adverse conditions in the hips of our high-activity patients will severely challenge even the newest cross-linked polyethylene cups.” We all know conventional polyethylene
needed improvement. It did, however, serve hundreds of thousands of young patients very well without having any of the “problems” of the modern-day ceramic. The highly cross-linked polyethylene goes further in helping all patients, including the young ones. The “blips on the radar” are adding up as more investigators report their favorable experience with the highly cross-linked polyethylene.
I have another bone to pick with the authors. What happened to the other problems and “safety hazards” of ceramic-on-ceramic? The authors make no mention of the recent and not so infrequent problem with squeaking! Although some may brush the latter aside as mere “noise,” patients experiencing the
problem see it otherwise! In fact, some of these patients are so disheartened
by the problem that they heed the call of lawyers to go after the industry for “mis-manufacturing” these components. The problem is not so infrequent. According to a questionnaire survey by Dr. Ranawat, up to 4% of patients
reported squeaking of ceramic-on-ceramic hips. Our center, the Rothman Institute, has detected a 2% incidence of squeaking with the modern generation of ceramic-on-ceramic bearing surfaces. What is most disturbing is that the etiology of this noise-generating problem remains elusive.
Although the quoted figures for fracture of modern design ceramic heads are based on the available literature and are correct, some surgeons may feel that they are
an underestimation. I am sure the authors have, since the submission of their paper, seen the most recent article from Korea that reports a 1.4% incidence of fracture of femoral heads made of third-generation ceramic.
So, as a surgeon who believes in the incredible marvel of ceramic-on-ceramic bearing surface in substantially reducing wear, I merely want to say that ceramic-on-ceramic is not without its problems either. Depending on one’s viewpoint, one bearing surface may be better than another. One thing that remains certain is that the perfect bearing surface is still the articular cartilage. Regardless of how hard we try, we will never be able to emulate the Almighty.
In this month’s E-publishing section, we will read more interesting and clinically pertinent articles, including an article by Tateiwa and colleagues on “Ceramic Total Hip Arthroplasty in the United States: Safety and Risk Issues Revisited.”
The article, by a group of internationally recognized investigators, attempts, and accomplishes, a summary of the safety of alumina ceramic-on-ceramic bearing surface for use in THA. The main emphasis of the article is to highlight the findings of reports in the United States regarding the safety of the ceramic-on-ceramic bearing surface in general and the risk of fracture in particular.
That the article is well written and elegantly organized is not to be disputed. That the article presents the findings of various publications in an unbiased fashion is also not to be doubted. The authors nicely convince the reader that the ceramic-on-ceramic bearing surface is an important part of the armamentarium at the disposal of orthopedic surgeons who surgically treat arthritis of the hip in the young, and hence it is here to stay. I hope the authors will forgive me if I present the argument from a different and less “pro-ceramic” perspective.
First, the authors are, in my opinion, a little unfair and somewhat dramatic in their view on the conventional polyethylene and its new sister, the highly cross-linked polyethylene. I quote the authors: “In the past, however, clinical experience with ‘new and improved’ polyethylenes has seldom been exemplary, and current clinical experience is but a blip on the radar screen. It is also likely that the adverse conditions in the hips of our high-activity patients will severely challenge even the newest cross-linked polyethylene cups.” We all know conventional polyethylene
needed improvement. It did, however, serve hundreds of thousands of young patients very well without having any of the “problems” of the modern-day ceramic. The highly cross-linked polyethylene goes further in helping all patients, including the young ones. The “blips on the radar” are adding up as more investigators report their favorable experience with the highly cross-linked polyethylene.
I have another bone to pick with the authors. What happened to the other problems and “safety hazards” of ceramic-on-ceramic? The authors make no mention of the recent and not so infrequent problem with squeaking! Although some may brush the latter aside as mere “noise,” patients experiencing the
problem see it otherwise! In fact, some of these patients are so disheartened
by the problem that they heed the call of lawyers to go after the industry for “mis-manufacturing” these components. The problem is not so infrequent. According to a questionnaire survey by Dr. Ranawat, up to 4% of patients
reported squeaking of ceramic-on-ceramic hips. Our center, the Rothman Institute, has detected a 2% incidence of squeaking with the modern generation of ceramic-on-ceramic bearing surfaces. What is most disturbing is that the etiology of this noise-generating problem remains elusive.
Although the quoted figures for fracture of modern design ceramic heads are based on the available literature and are correct, some surgeons may feel that they are
an underestimation. I am sure the authors have, since the submission of their paper, seen the most recent article from Korea that reports a 1.4% incidence of fracture of femoral heads made of third-generation ceramic.
So, as a surgeon who believes in the incredible marvel of ceramic-on-ceramic bearing surface in substantially reducing wear, I merely want to say that ceramic-on-ceramic is not without its problems either. Depending on one’s viewpoint, one bearing surface may be better than another. One thing that remains certain is that the perfect bearing surface is still the articular cartilage. Regardless of how hard we try, we will never be able to emulate the Almighty.
In this month’s E-publishing section, we will read more interesting and clinically pertinent articles, including an article by Tateiwa and colleagues on “Ceramic Total Hip Arthroplasty in the United States: Safety and Risk Issues Revisited.”
The article, by a group of internationally recognized investigators, attempts, and accomplishes, a summary of the safety of alumina ceramic-on-ceramic bearing surface for use in THA. The main emphasis of the article is to highlight the findings of reports in the United States regarding the safety of the ceramic-on-ceramic bearing surface in general and the risk of fracture in particular.
That the article is well written and elegantly organized is not to be disputed. That the article presents the findings of various publications in an unbiased fashion is also not to be doubted. The authors nicely convince the reader that the ceramic-on-ceramic bearing surface is an important part of the armamentarium at the disposal of orthopedic surgeons who surgically treat arthritis of the hip in the young, and hence it is here to stay. I hope the authors will forgive me if I present the argument from a different and less “pro-ceramic” perspective.
First, the authors are, in my opinion, a little unfair and somewhat dramatic in their view on the conventional polyethylene and its new sister, the highly cross-linked polyethylene. I quote the authors: “In the past, however, clinical experience with ‘new and improved’ polyethylenes has seldom been exemplary, and current clinical experience is but a blip on the radar screen. It is also likely that the adverse conditions in the hips of our high-activity patients will severely challenge even the newest cross-linked polyethylene cups.” We all know conventional polyethylene
needed improvement. It did, however, serve hundreds of thousands of young patients very well without having any of the “problems” of the modern-day ceramic. The highly cross-linked polyethylene goes further in helping all patients, including the young ones. The “blips on the radar” are adding up as more investigators report their favorable experience with the highly cross-linked polyethylene.
I have another bone to pick with the authors. What happened to the other problems and “safety hazards” of ceramic-on-ceramic? The authors make no mention of the recent and not so infrequent problem with squeaking! Although some may brush the latter aside as mere “noise,” patients experiencing the
problem see it otherwise! In fact, some of these patients are so disheartened
by the problem that they heed the call of lawyers to go after the industry for “mis-manufacturing” these components. The problem is not so infrequent. According to a questionnaire survey by Dr. Ranawat, up to 4% of patients
reported squeaking of ceramic-on-ceramic hips. Our center, the Rothman Institute, has detected a 2% incidence of squeaking with the modern generation of ceramic-on-ceramic bearing surfaces. What is most disturbing is that the etiology of this noise-generating problem remains elusive.
Although the quoted figures for fracture of modern design ceramic heads are based on the available literature and are correct, some surgeons may feel that they are
an underestimation. I am sure the authors have, since the submission of their paper, seen the most recent article from Korea that reports a 1.4% incidence of fracture of femoral heads made of third-generation ceramic.
So, as a surgeon who believes in the incredible marvel of ceramic-on-ceramic bearing surface in substantially reducing wear, I merely want to say that ceramic-on-ceramic is not without its problems either. Depending on one’s viewpoint, one bearing surface may be better than another. One thing that remains certain is that the perfect bearing surface is still the articular cartilage. Regardless of how hard we try, we will never be able to emulate the Almighty.
When Orthopedic Physicians Become Employees
If you believe in conspiracies, then I have a plot for you to ponder. The methodical and continuous suppression of the medical delivery system with special emphasis on the provider will and has driven the clinician to seek security in employment. The logical employer is the hospital or large corporate medical provider. They too are under pressure but have far more resources than an individual clinician.
With the individual practitioner becoming an employee, there is only one entity to deal with – the hospital. Now the government can control and ratchet down reimbursement as well as overregulate one entity. It will leave the doctor control to the hospital or corporate entity. When the books do not balance at the hospital, it is obvious who will feel the pressure: the physician, who is the ultimate provider of services. The insurance companies will merely jump on the tails of government regulators and dictate without input from the medical community the type and quality of services that they will pay for. Although there are a number of entities involved, this begins to look like a single-payer system.
Recent resident and fellow graduates are seeking salaried employment at a rate of over 50% of their graduating classes. This number also seems to be growing rapidly, particularly in urban areas. The current graduate continues to look for an entity that will allow him more time with his specialty and family and less with administrative tasks. They also fear the risk of failure and are seeking out the
security of employment, but they do not recognize that there are some inherent risks in employment by a large corporate entity.
When they choose corporate employment, they are working with a group of physicians of all specialties that they have not chosen to work with. What happens when you are forced to make referrals to a particular department or individual that you would not have done so under the private practice situation? What happens when the hospital loses a contract and must cut its workforce by 20%? Will you be in that 20%? If so, you will not have the opportunity to create a practice and bring patients with you, as they will all belong to the institution that you just left. This will usually require being hired by another large institution in the area or relocating geographically.
Business relationships, partnerships, friendships, and marriages start very easily and oftentimes are very uplifting. Separations, divorce, and breakups are very painful and ugly. Recently there appear to be more and more breakups and dissolutions than there were in the past. Much of this arises from the unrealistic expectations at the end of a very lucrative contract that has a 2- or 3-year guarantee on it. The fine print on these contracts is oftentimes shocking.
Many of the hospitals and large medical delivery systems couch themselves as “nonprofit.” That does not deter them from very large corporate salaries for administration. It certainly never appears to reflect itself in physician compensation. A recent report in the San Diego County area listed the salaries of the top 10 not-for-profit executives; 9 of the 10 were in the hospital and medical care delivery sector. Millions of dollars in salary are being paid to these executives, with little attention to physicians and other health care employees. This will eventually lead to physicians being treated as common laborers, requiring continued negotiations between labor and management. This is a significant distraction from our main goal of providing patient care. We should never be put in a position where our Hippocratic Oath is challenged. We have taken our eye off the ball and have relinquished control, and it is unlikely that we will be able to recapture it. One only needs to look at all the remaining developed countries and
realize that we are the last to fall.
In an attempt to raise corporate profits, avoid onerous regulations, and also fight for survival, many CEOs and hospitals have run into significant problems with the Department of Justice and other government agencies. There have been over 100 hospital bankruptcies in California over the last 7 to 10 years. The press is always
reporting on the dismissal, investigation, or indictment of hospital officials. We rely on hospital administrators rather than MDs to run our hospitals, contrary to the Canadian model. When remuneration for services rendered sinks to untenable levels, even good people oftentimes are driven to break the law and deviate from their ethics. What happens when, as a young surgeon, you are part of that organization and building a practice in a hospital that then becomes subject to prolonged investigations and loss of reputation? Our young surgeons need to make these decisions on employment very carefully and look to some of their elders for guidance. ◾
If you believe in conspiracies, then I have a plot for you to ponder. The methodical and continuous suppression of the medical delivery system with special emphasis on the provider will and has driven the clinician to seek security in employment. The logical employer is the hospital or large corporate medical provider. They too are under pressure but have far more resources than an individual clinician.
With the individual practitioner becoming an employee, there is only one entity to deal with – the hospital. Now the government can control and ratchet down reimbursement as well as overregulate one entity. It will leave the doctor control to the hospital or corporate entity. When the books do not balance at the hospital, it is obvious who will feel the pressure: the physician, who is the ultimate provider of services. The insurance companies will merely jump on the tails of government regulators and dictate without input from the medical community the type and quality of services that they will pay for. Although there are a number of entities involved, this begins to look like a single-payer system.
Recent resident and fellow graduates are seeking salaried employment at a rate of over 50% of their graduating classes. This number also seems to be growing rapidly, particularly in urban areas. The current graduate continues to look for an entity that will allow him more time with his specialty and family and less with administrative tasks. They also fear the risk of failure and are seeking out the
security of employment, but they do not recognize that there are some inherent risks in employment by a large corporate entity.
When they choose corporate employment, they are working with a group of physicians of all specialties that they have not chosen to work with. What happens when you are forced to make referrals to a particular department or individual that you would not have done so under the private practice situation? What happens when the hospital loses a contract and must cut its workforce by 20%? Will you be in that 20%? If so, you will not have the opportunity to create a practice and bring patients with you, as they will all belong to the institution that you just left. This will usually require being hired by another large institution in the area or relocating geographically.
Business relationships, partnerships, friendships, and marriages start very easily and oftentimes are very uplifting. Separations, divorce, and breakups are very painful and ugly. Recently there appear to be more and more breakups and dissolutions than there were in the past. Much of this arises from the unrealistic expectations at the end of a very lucrative contract that has a 2- or 3-year guarantee on it. The fine print on these contracts is oftentimes shocking.
Many of the hospitals and large medical delivery systems couch themselves as “nonprofit.” That does not deter them from very large corporate salaries for administration. It certainly never appears to reflect itself in physician compensation. A recent report in the San Diego County area listed the salaries of the top 10 not-for-profit executives; 9 of the 10 were in the hospital and medical care delivery sector. Millions of dollars in salary are being paid to these executives, with little attention to physicians and other health care employees. This will eventually lead to physicians being treated as common laborers, requiring continued negotiations between labor and management. This is a significant distraction from our main goal of providing patient care. We should never be put in a position where our Hippocratic Oath is challenged. We have taken our eye off the ball and have relinquished control, and it is unlikely that we will be able to recapture it. One only needs to look at all the remaining developed countries and
realize that we are the last to fall.
In an attempt to raise corporate profits, avoid onerous regulations, and also fight for survival, many CEOs and hospitals have run into significant problems with the Department of Justice and other government agencies. There have been over 100 hospital bankruptcies in California over the last 7 to 10 years. The press is always
reporting on the dismissal, investigation, or indictment of hospital officials. We rely on hospital administrators rather than MDs to run our hospitals, contrary to the Canadian model. When remuneration for services rendered sinks to untenable levels, even good people oftentimes are driven to break the law and deviate from their ethics. What happens when, as a young surgeon, you are part of that organization and building a practice in a hospital that then becomes subject to prolonged investigations and loss of reputation? Our young surgeons need to make these decisions on employment very carefully and look to some of their elders for guidance. ◾
If you believe in conspiracies, then I have a plot for you to ponder. The methodical and continuous suppression of the medical delivery system with special emphasis on the provider will and has driven the clinician to seek security in employment. The logical employer is the hospital or large corporate medical provider. They too are under pressure but have far more resources than an individual clinician.
With the individual practitioner becoming an employee, there is only one entity to deal with – the hospital. Now the government can control and ratchet down reimbursement as well as overregulate one entity. It will leave the doctor control to the hospital or corporate entity. When the books do not balance at the hospital, it is obvious who will feel the pressure: the physician, who is the ultimate provider of services. The insurance companies will merely jump on the tails of government regulators and dictate without input from the medical community the type and quality of services that they will pay for. Although there are a number of entities involved, this begins to look like a single-payer system.
Recent resident and fellow graduates are seeking salaried employment at a rate of over 50% of their graduating classes. This number also seems to be growing rapidly, particularly in urban areas. The current graduate continues to look for an entity that will allow him more time with his specialty and family and less with administrative tasks. They also fear the risk of failure and are seeking out the
security of employment, but they do not recognize that there are some inherent risks in employment by a large corporate entity.
When they choose corporate employment, they are working with a group of physicians of all specialties that they have not chosen to work with. What happens when you are forced to make referrals to a particular department or individual that you would not have done so under the private practice situation? What happens when the hospital loses a contract and must cut its workforce by 20%? Will you be in that 20%? If so, you will not have the opportunity to create a practice and bring patients with you, as they will all belong to the institution that you just left. This will usually require being hired by another large institution in the area or relocating geographically.
Business relationships, partnerships, friendships, and marriages start very easily and oftentimes are very uplifting. Separations, divorce, and breakups are very painful and ugly. Recently there appear to be more and more breakups and dissolutions than there were in the past. Much of this arises from the unrealistic expectations at the end of a very lucrative contract that has a 2- or 3-year guarantee on it. The fine print on these contracts is oftentimes shocking.
Many of the hospitals and large medical delivery systems couch themselves as “nonprofit.” That does not deter them from very large corporate salaries for administration. It certainly never appears to reflect itself in physician compensation. A recent report in the San Diego County area listed the salaries of the top 10 not-for-profit executives; 9 of the 10 were in the hospital and medical care delivery sector. Millions of dollars in salary are being paid to these executives, with little attention to physicians and other health care employees. This will eventually lead to physicians being treated as common laborers, requiring continued negotiations between labor and management. This is a significant distraction from our main goal of providing patient care. We should never be put in a position where our Hippocratic Oath is challenged. We have taken our eye off the ball and have relinquished control, and it is unlikely that we will be able to recapture it. One only needs to look at all the remaining developed countries and
realize that we are the last to fall.
In an attempt to raise corporate profits, avoid onerous regulations, and also fight for survival, many CEOs and hospitals have run into significant problems with the Department of Justice and other government agencies. There have been over 100 hospital bankruptcies in California over the last 7 to 10 years. The press is always
reporting on the dismissal, investigation, or indictment of hospital officials. We rely on hospital administrators rather than MDs to run our hospitals, contrary to the Canadian model. When remuneration for services rendered sinks to untenable levels, even good people oftentimes are driven to break the law and deviate from their ethics. What happens when, as a young surgeon, you are part of that organization and building a practice in a hospital that then becomes subject to prolonged investigations and loss of reputation? Our young surgeons need to make these decisions on employment very carefully and look to some of their elders for guidance. ◾
Orthopedic Infections: Important Issues in Prevention and Diagnosis
Infections in orthopedic patients are among the most frequent postoperative complications and are known to cause significant morbidity, increased healthcare costs, and prolonged hospital stays.1 Infections of implanted hardware can be especially devastating and difficult to treat, usually requiring removal of the hardware and prolonged courses of antibiotics; in some cases, amputation becomes necessary. In this month’s E-publishing section of The American Journal of Orthopedics focusing on infections in orthopedic practice, several types of these infections are discussed.
Taken together, these papers highlight two distinct concepts that pertain to orthopedic practice:
1. The prevention and management of infections of primary joint arthroplasties and the importance of following evidence-based practice guidelines to minimize the risk of postoperative infections
2. The need to consider underlying risk factors when formulating a differential diagnosis in a patient with an atypical orthopedic presentation; in these cases, a careful history and physical examination by the surgeon can lead to timely diagnosis and may reveal other medical conditions requiring referral.
In “Wichita Fusion Nail for Patients With Failed Total Knee Arthroplasty and Active Infection,” Barsoum and colleagues highlight the management dilemmas of treating failed total knee arthroplasties due to active infection and present their experience using a modular fusion nail. Kuper and Rosenstein review the literature in “Infection Prevention in Total Knee and Total Hip Arthroplasties” and present their experience in reducing the risk of infection after total knee and hip arthroplasties. Rates of infections after joint arthroplasty have declined substantially since the introduction of such prevention measures as antimicrobial
prophylaxis and “ultraclean” air in operating rooms.1 Data collected from approximately 300 hospitals participating in the National Nosocomial Infection
Surveillance System (NNIS, now the National Healthcare Safety Network) from 1992 to 2004 showed that pooled mean rates of infection for total knee and hip arthroplasties were < 1 per 100 operations for the lowest-risk patients and slightly more than 2 per 100 for the highest-risk patients.2 Hospitals performing these procedures can use these aggregated data to evaluate their own rates of infection.
The importance of prevention measures cannot be overemphasized. In a multicenter study involving over 8000 total hip and knee replacements, Lidwell and colleagues3 found that while both ultraclean air and antimicrobial prophylaxis reduced the incidence of surgical site infection (SSI), antimicrobial prophylaxis alone led to a greater reduction (reducing SSI from 3.4% to 0.8%) than ultraclean
air. While data strongly support that the first dose of cefazolin should be given within 1 hour (preferably within 30 minutes) of incision, the optimal duration of prophylaxis remains unclear; current data do not support continuing beyond 24 hours.1 Following evidence-based guidelines, conducting close surveillance for SSI appropriately stratified by risk and reporting operation-specific, risk-stratified infection rates to surgical team members are critical measures to prevent these devastating complications.4
The issue of diagnosing patients with atypical orthopedic presentations is highlighted in “Psoas Abscess: A Diagnostic Dilemma” by Ebraheim and colleagues. Patients with a psoas abscess often present with vague signs and symptoms in the
buttock, hip, or thigh. Psoas abscesses most commonly result from direct extension of an adjacent source of infection, such as an intra-abdominal infection, perinephric abscess, infected retroperitoneal hematoma, or vertebral osteomyelitis, or less commonly by hematogenous seeding.5 Close attention to the patient’s history in all the cases presented revealed previous conditions or procedures that may have predisposed them to psoas abscess. The authors point out that computed tomography is the best modality for diagnosing the abscess and often the source of the infection.
In “Atypical Presentation of Soft-Tissue Mass With Gonococcal Infection in the Hand,” Hurst and colleagues present a case of gonococcal infection manifested by an atypical presentation of a soft-tissue mass in the thenar eminence with focal flexor tenosynovitis in an otherwise healthy man. Culture of purulent fluid from incision and drainage revealed Neisseria gonorrhoeae. Further questioning revealed a history of unprotected sex. The diagnosis of one sexually transmitted disease necessitates appropriate workup for other sexually transmitted coinfections, such as HIV and syphilis, as well as education and screening of sexual partners. Although this is typically outside the realm of the orthopedic surgeon’s practice,
the appropriate referral can have a major impact in the life of patients and their contacts.
References
1. ASHP Commission on Therapeutics Task Force. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 1999;56(18):1839-1888.
2. CDC NNIS System. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32:470-485.
3. Lidwell OM, Elson RA, Lowbury EJ, et al. Ultraclean air and antibiotics for prevention of postoperative infection. A multicenter study of 8,052 joint replacement operations. Acta Orthop Scand. 1987;58(1):4-13.
4. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, The Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:250-278.
5. Pasternack MS, Swartz MN. Myositis. In: Mandell GL, Bennett JE, Dolin R, eds.
Principles and Practice of Infectious Diseases. 6th Ed, Vol. 1. Philadelphia: Churchill
Livingstone, 2005:1200-1201.
Infections in orthopedic patients are among the most frequent postoperative complications and are known to cause significant morbidity, increased healthcare costs, and prolonged hospital stays.1 Infections of implanted hardware can be especially devastating and difficult to treat, usually requiring removal of the hardware and prolonged courses of antibiotics; in some cases, amputation becomes necessary. In this month’s E-publishing section of The American Journal of Orthopedics focusing on infections in orthopedic practice, several types of these infections are discussed.
Taken together, these papers highlight two distinct concepts that pertain to orthopedic practice:
1. The prevention and management of infections of primary joint arthroplasties and the importance of following evidence-based practice guidelines to minimize the risk of postoperative infections
2. The need to consider underlying risk factors when formulating a differential diagnosis in a patient with an atypical orthopedic presentation; in these cases, a careful history and physical examination by the surgeon can lead to timely diagnosis and may reveal other medical conditions requiring referral.
In “Wichita Fusion Nail for Patients With Failed Total Knee Arthroplasty and Active Infection,” Barsoum and colleagues highlight the management dilemmas of treating failed total knee arthroplasties due to active infection and present their experience using a modular fusion nail. Kuper and Rosenstein review the literature in “Infection Prevention in Total Knee and Total Hip Arthroplasties” and present their experience in reducing the risk of infection after total knee and hip arthroplasties. Rates of infections after joint arthroplasty have declined substantially since the introduction of such prevention measures as antimicrobial
prophylaxis and “ultraclean” air in operating rooms.1 Data collected from approximately 300 hospitals participating in the National Nosocomial Infection
Surveillance System (NNIS, now the National Healthcare Safety Network) from 1992 to 2004 showed that pooled mean rates of infection for total knee and hip arthroplasties were < 1 per 100 operations for the lowest-risk patients and slightly more than 2 per 100 for the highest-risk patients.2 Hospitals performing these procedures can use these aggregated data to evaluate their own rates of infection.
The importance of prevention measures cannot be overemphasized. In a multicenter study involving over 8000 total hip and knee replacements, Lidwell and colleagues3 found that while both ultraclean air and antimicrobial prophylaxis reduced the incidence of surgical site infection (SSI), antimicrobial prophylaxis alone led to a greater reduction (reducing SSI from 3.4% to 0.8%) than ultraclean
air. While data strongly support that the first dose of cefazolin should be given within 1 hour (preferably within 30 minutes) of incision, the optimal duration of prophylaxis remains unclear; current data do not support continuing beyond 24 hours.1 Following evidence-based guidelines, conducting close surveillance for SSI appropriately stratified by risk and reporting operation-specific, risk-stratified infection rates to surgical team members are critical measures to prevent these devastating complications.4
The issue of diagnosing patients with atypical orthopedic presentations is highlighted in “Psoas Abscess: A Diagnostic Dilemma” by Ebraheim and colleagues. Patients with a psoas abscess often present with vague signs and symptoms in the
buttock, hip, or thigh. Psoas abscesses most commonly result from direct extension of an adjacent source of infection, such as an intra-abdominal infection, perinephric abscess, infected retroperitoneal hematoma, or vertebral osteomyelitis, or less commonly by hematogenous seeding.5 Close attention to the patient’s history in all the cases presented revealed previous conditions or procedures that may have predisposed them to psoas abscess. The authors point out that computed tomography is the best modality for diagnosing the abscess and often the source of the infection.
In “Atypical Presentation of Soft-Tissue Mass With Gonococcal Infection in the Hand,” Hurst and colleagues present a case of gonococcal infection manifested by an atypical presentation of a soft-tissue mass in the thenar eminence with focal flexor tenosynovitis in an otherwise healthy man. Culture of purulent fluid from incision and drainage revealed Neisseria gonorrhoeae. Further questioning revealed a history of unprotected sex. The diagnosis of one sexually transmitted disease necessitates appropriate workup for other sexually transmitted coinfections, such as HIV and syphilis, as well as education and screening of sexual partners. Although this is typically outside the realm of the orthopedic surgeon’s practice,
the appropriate referral can have a major impact in the life of patients and their contacts.
References
1. ASHP Commission on Therapeutics Task Force. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 1999;56(18):1839-1888.
2. CDC NNIS System. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32:470-485.
3. Lidwell OM, Elson RA, Lowbury EJ, et al. Ultraclean air and antibiotics for prevention of postoperative infection. A multicenter study of 8,052 joint replacement operations. Acta Orthop Scand. 1987;58(1):4-13.
4. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, The Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:250-278.
5. Pasternack MS, Swartz MN. Myositis. In: Mandell GL, Bennett JE, Dolin R, eds.
Principles and Practice of Infectious Diseases. 6th Ed, Vol. 1. Philadelphia: Churchill
Livingstone, 2005:1200-1201.
Infections in orthopedic patients are among the most frequent postoperative complications and are known to cause significant morbidity, increased healthcare costs, and prolonged hospital stays.1 Infections of implanted hardware can be especially devastating and difficult to treat, usually requiring removal of the hardware and prolonged courses of antibiotics; in some cases, amputation becomes necessary. In this month’s E-publishing section of The American Journal of Orthopedics focusing on infections in orthopedic practice, several types of these infections are discussed.
Taken together, these papers highlight two distinct concepts that pertain to orthopedic practice:
1. The prevention and management of infections of primary joint arthroplasties and the importance of following evidence-based practice guidelines to minimize the risk of postoperative infections
2. The need to consider underlying risk factors when formulating a differential diagnosis in a patient with an atypical orthopedic presentation; in these cases, a careful history and physical examination by the surgeon can lead to timely diagnosis and may reveal other medical conditions requiring referral.
In “Wichita Fusion Nail for Patients With Failed Total Knee Arthroplasty and Active Infection,” Barsoum and colleagues highlight the management dilemmas of treating failed total knee arthroplasties due to active infection and present their experience using a modular fusion nail. Kuper and Rosenstein review the literature in “Infection Prevention in Total Knee and Total Hip Arthroplasties” and present their experience in reducing the risk of infection after total knee and hip arthroplasties. Rates of infections after joint arthroplasty have declined substantially since the introduction of such prevention measures as antimicrobial
prophylaxis and “ultraclean” air in operating rooms.1 Data collected from approximately 300 hospitals participating in the National Nosocomial Infection
Surveillance System (NNIS, now the National Healthcare Safety Network) from 1992 to 2004 showed that pooled mean rates of infection for total knee and hip arthroplasties were < 1 per 100 operations for the lowest-risk patients and slightly more than 2 per 100 for the highest-risk patients.2 Hospitals performing these procedures can use these aggregated data to evaluate their own rates of infection.
The importance of prevention measures cannot be overemphasized. In a multicenter study involving over 8000 total hip and knee replacements, Lidwell and colleagues3 found that while both ultraclean air and antimicrobial prophylaxis reduced the incidence of surgical site infection (SSI), antimicrobial prophylaxis alone led to a greater reduction (reducing SSI from 3.4% to 0.8%) than ultraclean
air. While data strongly support that the first dose of cefazolin should be given within 1 hour (preferably within 30 minutes) of incision, the optimal duration of prophylaxis remains unclear; current data do not support continuing beyond 24 hours.1 Following evidence-based guidelines, conducting close surveillance for SSI appropriately stratified by risk and reporting operation-specific, risk-stratified infection rates to surgical team members are critical measures to prevent these devastating complications.4
The issue of diagnosing patients with atypical orthopedic presentations is highlighted in “Psoas Abscess: A Diagnostic Dilemma” by Ebraheim and colleagues. Patients with a psoas abscess often present with vague signs and symptoms in the
buttock, hip, or thigh. Psoas abscesses most commonly result from direct extension of an adjacent source of infection, such as an intra-abdominal infection, perinephric abscess, infected retroperitoneal hematoma, or vertebral osteomyelitis, or less commonly by hematogenous seeding.5 Close attention to the patient’s history in all the cases presented revealed previous conditions or procedures that may have predisposed them to psoas abscess. The authors point out that computed tomography is the best modality for diagnosing the abscess and often the source of the infection.
In “Atypical Presentation of Soft-Tissue Mass With Gonococcal Infection in the Hand,” Hurst and colleagues present a case of gonococcal infection manifested by an atypical presentation of a soft-tissue mass in the thenar eminence with focal flexor tenosynovitis in an otherwise healthy man. Culture of purulent fluid from incision and drainage revealed Neisseria gonorrhoeae. Further questioning revealed a history of unprotected sex. The diagnosis of one sexually transmitted disease necessitates appropriate workup for other sexually transmitted coinfections, such as HIV and syphilis, as well as education and screening of sexual partners. Although this is typically outside the realm of the orthopedic surgeon’s practice,
the appropriate referral can have a major impact in the life of patients and their contacts.
References
1. ASHP Commission on Therapeutics Task Force. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 1999;56(18):1839-1888.
2. CDC NNIS System. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32:470-485.
3. Lidwell OM, Elson RA, Lowbury EJ, et al. Ultraclean air and antibiotics for prevention of postoperative infection. A multicenter study of 8,052 joint replacement operations. Acta Orthop Scand. 1987;58(1):4-13.
4. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, The Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:250-278.
5. Pasternack MS, Swartz MN. Myositis. In: Mandell GL, Bennett JE, Dolin R, eds.
Principles and Practice of Infectious Diseases. 6th Ed, Vol. 1. Philadelphia: Churchill
Livingstone, 2005:1200-1201.
The nonurgent ‘urgent’ phone call
I don’t mind taking other doctor’s calls, even if they need to interrupt me with a patient. In this business, sometimes things are urgent.
Patients usually don’t mind either. They figure that, if it was them in an emergency, they’d want the doctor to be willing to get on the phone, too.
What really irks me is when they have me interrupted for bogus reasons. My secretary will come get me if a doctor says it’s urgent, and I have no problem with that. I’d rather err on the side of caution rather then miss a phone call about a true emergency.
Unfortunately, this privilege gets abused. I’ve been pulled away from patients for "urgent" calls from:
• Radiologists marketing their MRI facility,
• Dentists wanting to offer me a "special" on teeth cleaning for my family and staff,
• PhDs or MDs working for a pharmaceutical company who want to tell me of some new drug or indication, and
• Financial advisers posing as doctors ("your secretary wouldn’t let me talk to you otherwise") who don’t seem to realize this is not going to make a good impression.
Most recently, a doctor who read one of my columns here called "urgently" to get me to sell a line of vitamin supplements out of my office. He claimed to have read all these columns, but obviously missed the one where I talked about how I’m opposed to the vitamin schemes.
When this happens I get off the phone, fast, and turn my attention back to the patient with an apology.
I don’t understand why people do this. Obviously, I have no interest in working with someone who’s dishonest enough to lie to my secretary about their true intentions or credentials. I can’t imagine they sucker other doctors, either, after an introduction like that.
Such behavior doesn’t lend itself to good business, good relationships, or good patient care. But I’ll keep taking their calls, because I’d rather hang up on 100 of them than miss one legitimate call from a doctor who needs my help in a pinch.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I don’t mind taking other doctor’s calls, even if they need to interrupt me with a patient. In this business, sometimes things are urgent.
Patients usually don’t mind either. They figure that, if it was them in an emergency, they’d want the doctor to be willing to get on the phone, too.
What really irks me is when they have me interrupted for bogus reasons. My secretary will come get me if a doctor says it’s urgent, and I have no problem with that. I’d rather err on the side of caution rather then miss a phone call about a true emergency.
Unfortunately, this privilege gets abused. I’ve been pulled away from patients for "urgent" calls from:
• Radiologists marketing their MRI facility,
• Dentists wanting to offer me a "special" on teeth cleaning for my family and staff,
• PhDs or MDs working for a pharmaceutical company who want to tell me of some new drug or indication, and
• Financial advisers posing as doctors ("your secretary wouldn’t let me talk to you otherwise") who don’t seem to realize this is not going to make a good impression.
Most recently, a doctor who read one of my columns here called "urgently" to get me to sell a line of vitamin supplements out of my office. He claimed to have read all these columns, but obviously missed the one where I talked about how I’m opposed to the vitamin schemes.
When this happens I get off the phone, fast, and turn my attention back to the patient with an apology.
I don’t understand why people do this. Obviously, I have no interest in working with someone who’s dishonest enough to lie to my secretary about their true intentions or credentials. I can’t imagine they sucker other doctors, either, after an introduction like that.
Such behavior doesn’t lend itself to good business, good relationships, or good patient care. But I’ll keep taking their calls, because I’d rather hang up on 100 of them than miss one legitimate call from a doctor who needs my help in a pinch.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I don’t mind taking other doctor’s calls, even if they need to interrupt me with a patient. In this business, sometimes things are urgent.
Patients usually don’t mind either. They figure that, if it was them in an emergency, they’d want the doctor to be willing to get on the phone, too.
What really irks me is when they have me interrupted for bogus reasons. My secretary will come get me if a doctor says it’s urgent, and I have no problem with that. I’d rather err on the side of caution rather then miss a phone call about a true emergency.
Unfortunately, this privilege gets abused. I’ve been pulled away from patients for "urgent" calls from:
• Radiologists marketing their MRI facility,
• Dentists wanting to offer me a "special" on teeth cleaning for my family and staff,
• PhDs or MDs working for a pharmaceutical company who want to tell me of some new drug or indication, and
• Financial advisers posing as doctors ("your secretary wouldn’t let me talk to you otherwise") who don’t seem to realize this is not going to make a good impression.
Most recently, a doctor who read one of my columns here called "urgently" to get me to sell a line of vitamin supplements out of my office. He claimed to have read all these columns, but obviously missed the one where I talked about how I’m opposed to the vitamin schemes.
When this happens I get off the phone, fast, and turn my attention back to the patient with an apology.
I don’t understand why people do this. Obviously, I have no interest in working with someone who’s dishonest enough to lie to my secretary about their true intentions or credentials. I can’t imagine they sucker other doctors, either, after an introduction like that.
Such behavior doesn’t lend itself to good business, good relationships, or good patient care. But I’ll keep taking their calls, because I’d rather hang up on 100 of them than miss one legitimate call from a doctor who needs my help in a pinch.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
ADHD medication is not working
Welcome to a new column designed to provide practical advice regarding issues related to child mental health. It will be a joint effort, featuring contributions from several child psychiatrists working at the University of Vermont and the Vermont Center for Children, Youth, and Families. While psychopharmacology will certainly be a part of many of the columns, all of us here feel strongly that medications should be only one part of a comprehensive family-oriented plan. We encourage you to submit questions that you would like us address in future issues to [email protected].
Case summary
A 10-year-old boy presents for a follow-up appointment. He was diagnosed by another pediatrician in the practice 2 months ago with attention-deficit/hyperactivity disorder (ADHD) and now returns to the office with continued symptoms and a complaint from the mother that medication "isn’t working." The boy was started on an extended-release preparation of methylphenidate at 18 mg to take each morning. The child is in the fifth grade and weighs 80 lb (36 kg). He lives with his mother and 8-year-old brother. The father is no longer involved in the patient’s life, which puts added stress on the mother. The diagnosis of ADHD was made by the pediatrician based upon the history, the child’s hyperactive and intrusive behavior in the office, and the results of a standardized rating scale that was completed by the mother, who now requests that the pediatrician "try something different."
Discussion
Many children and adolescents respond extremely well to ADHD medications. Some, however, do not, and the parental complaint that the "medication isn’t working" is a frequent expression heard in pediatrician offices across the country. It is also one of the primary reasons a family is referred to a child psychiatrist. In the course of performing hundreds of these consultations, I have found that there are several possibilities to consider before assuming the medication simply isn’t effective.
We will start with simpler problems and work our way toward more challenging reasons.
• The dose is too low. Methylphenidate often needs to be dosed over 1 mg/kg/day to be effective. If the patient reports minimal response to the medication while experiencing no side effects, an increase may certainly be reasonable.
• The medication is working but wearing off. Despite the advertisements of long-acting stimulants continuing their therapeutic effect for 10-12 hours, many children seem to lose the benefit of the medication much faster. Gathering some data from the school or asking the mother about weekend mornings compared with evenings can be useful. If indeed such a wear-off is found, adding a dose of an immediate-release stimulant in the early afternoon may help.
• Symptoms are being caused by something other than ADHD. Hyperactivity due to exposures such as lead may not change your management of the symptoms, but certainly could necessitate other types of intervention. Chronic sleep problems and inadequate nutrition, especially when it comes to breakfast, also should be queried and can lead to problems with concentration.
• There is psychiatric comorbidity. Unlike many differentials in other specialties, psychiatric differential diagnosis is often a matter of "and" rather than "or." Anxiety disorders, for example, can frequently masquerade as ADHD or be present in addition to ADHD. Oppositional behavior is also very commonly present with ADHD and suggests additional types of treatment.
• There is noncompliance. This problem can surface frequently in two ways. Older children may be responsible at home for taking their medications and forget or refuse to do so. I often ask, "Are you taking the medication every single day?" Diversion is also a potential problem from the parents or for an adolescent. Checking if the refills are occurring on time can provide a clue here, and some states have systems to check for duplicate prescriptions from multiple clinicians.
• Side effects are appearing as untreated ADHD. Sometimes medications are the problem, not the solution, and a failure to recognize this phenomenon can lead to unnecessary and sometimes harmful polypharmacy. Stimulants in some children can lead to increased agitation, anger outbursts, and impulsivity. Trying a medication holiday for several days can sometimes reveal the need to back off rather than add medications.
• Family is expecting improvement for non-ADHD symptoms. Asking what particular behaviors the family is hoping to improve can sometimes expose a situation in which parents expect change in non-ADHD domains. Unfortunately, there is no pill to make kids respect their parents more or want to do their homework. Being clear from the outset about what behaviors are and are not medication responsive can sometimes prevent this problem.
• There is substance abuse. In addition to the potential problem of abuse of the stimulants described previously, other substances such as cannabis can sabotage the benefits of medications.
• There is over-reliance on medications as the sole modality of treatment. ADHD is best treated using a wide range of strategies. Nonpharmacological interventions such as exercise, good nutrition and sleep, parent behavioral training, organizational help, regular reading, screen time reduction, and school supports are critical components of a comprehensive treatment approach.
• There is parental psychopathology. In our opinion, this area is one of the most frequently neglected aspects of child mental health treatment and can have huge implications. ADHD in particular is known to have very high heritability (similar to height). If a mother or father shares the condition, their struggles can frequently contribute to an environment that can exacerbate the child’s symptoms. A pattern in which the ADHD symptoms are more prominent at home compared with school is one clue to look in this direction. When addressing parental psychopathology, it can be important not to come off as blaming the parents for their child’s problems, but rather to convey how challenging dealing with ADHD can be as a parent and how they need to be functioning at their highest mental level as well.
Of course, sometimes the medication truly is not working, and it is time to try something else.
Dr. David C. Rettew is associate professor of psychiatry and pediatrics, director of the child and adolescent psychiatry fellowship, and director of the pediatric psychiatry clinic at the University of Vermont, Burlington.
Welcome to a new column designed to provide practical advice regarding issues related to child mental health. It will be a joint effort, featuring contributions from several child psychiatrists working at the University of Vermont and the Vermont Center for Children, Youth, and Families. While psychopharmacology will certainly be a part of many of the columns, all of us here feel strongly that medications should be only one part of a comprehensive family-oriented plan. We encourage you to submit questions that you would like us address in future issues to [email protected].
Case summary
A 10-year-old boy presents for a follow-up appointment. He was diagnosed by another pediatrician in the practice 2 months ago with attention-deficit/hyperactivity disorder (ADHD) and now returns to the office with continued symptoms and a complaint from the mother that medication "isn’t working." The boy was started on an extended-release preparation of methylphenidate at 18 mg to take each morning. The child is in the fifth grade and weighs 80 lb (36 kg). He lives with his mother and 8-year-old brother. The father is no longer involved in the patient’s life, which puts added stress on the mother. The diagnosis of ADHD was made by the pediatrician based upon the history, the child’s hyperactive and intrusive behavior in the office, and the results of a standardized rating scale that was completed by the mother, who now requests that the pediatrician "try something different."
Discussion
Many children and adolescents respond extremely well to ADHD medications. Some, however, do not, and the parental complaint that the "medication isn’t working" is a frequent expression heard in pediatrician offices across the country. It is also one of the primary reasons a family is referred to a child psychiatrist. In the course of performing hundreds of these consultations, I have found that there are several possibilities to consider before assuming the medication simply isn’t effective.
We will start with simpler problems and work our way toward more challenging reasons.
• The dose is too low. Methylphenidate often needs to be dosed over 1 mg/kg/day to be effective. If the patient reports minimal response to the medication while experiencing no side effects, an increase may certainly be reasonable.
• The medication is working but wearing off. Despite the advertisements of long-acting stimulants continuing their therapeutic effect for 10-12 hours, many children seem to lose the benefit of the medication much faster. Gathering some data from the school or asking the mother about weekend mornings compared with evenings can be useful. If indeed such a wear-off is found, adding a dose of an immediate-release stimulant in the early afternoon may help.
• Symptoms are being caused by something other than ADHD. Hyperactivity due to exposures such as lead may not change your management of the symptoms, but certainly could necessitate other types of intervention. Chronic sleep problems and inadequate nutrition, especially when it comes to breakfast, also should be queried and can lead to problems with concentration.
• There is psychiatric comorbidity. Unlike many differentials in other specialties, psychiatric differential diagnosis is often a matter of "and" rather than "or." Anxiety disorders, for example, can frequently masquerade as ADHD or be present in addition to ADHD. Oppositional behavior is also very commonly present with ADHD and suggests additional types of treatment.
• There is noncompliance. This problem can surface frequently in two ways. Older children may be responsible at home for taking their medications and forget or refuse to do so. I often ask, "Are you taking the medication every single day?" Diversion is also a potential problem from the parents or for an adolescent. Checking if the refills are occurring on time can provide a clue here, and some states have systems to check for duplicate prescriptions from multiple clinicians.
• Side effects are appearing as untreated ADHD. Sometimes medications are the problem, not the solution, and a failure to recognize this phenomenon can lead to unnecessary and sometimes harmful polypharmacy. Stimulants in some children can lead to increased agitation, anger outbursts, and impulsivity. Trying a medication holiday for several days can sometimes reveal the need to back off rather than add medications.
• Family is expecting improvement for non-ADHD symptoms. Asking what particular behaviors the family is hoping to improve can sometimes expose a situation in which parents expect change in non-ADHD domains. Unfortunately, there is no pill to make kids respect their parents more or want to do their homework. Being clear from the outset about what behaviors are and are not medication responsive can sometimes prevent this problem.
• There is substance abuse. In addition to the potential problem of abuse of the stimulants described previously, other substances such as cannabis can sabotage the benefits of medications.
• There is over-reliance on medications as the sole modality of treatment. ADHD is best treated using a wide range of strategies. Nonpharmacological interventions such as exercise, good nutrition and sleep, parent behavioral training, organizational help, regular reading, screen time reduction, and school supports are critical components of a comprehensive treatment approach.
• There is parental psychopathology. In our opinion, this area is one of the most frequently neglected aspects of child mental health treatment and can have huge implications. ADHD in particular is known to have very high heritability (similar to height). If a mother or father shares the condition, their struggles can frequently contribute to an environment that can exacerbate the child’s symptoms. A pattern in which the ADHD symptoms are more prominent at home compared with school is one clue to look in this direction. When addressing parental psychopathology, it can be important not to come off as blaming the parents for their child’s problems, but rather to convey how challenging dealing with ADHD can be as a parent and how they need to be functioning at their highest mental level as well.
Of course, sometimes the medication truly is not working, and it is time to try something else.
Dr. David C. Rettew is associate professor of psychiatry and pediatrics, director of the child and adolescent psychiatry fellowship, and director of the pediatric psychiatry clinic at the University of Vermont, Burlington.
Welcome to a new column designed to provide practical advice regarding issues related to child mental health. It will be a joint effort, featuring contributions from several child psychiatrists working at the University of Vermont and the Vermont Center for Children, Youth, and Families. While psychopharmacology will certainly be a part of many of the columns, all of us here feel strongly that medications should be only one part of a comprehensive family-oriented plan. We encourage you to submit questions that you would like us address in future issues to [email protected].
Case summary
A 10-year-old boy presents for a follow-up appointment. He was diagnosed by another pediatrician in the practice 2 months ago with attention-deficit/hyperactivity disorder (ADHD) and now returns to the office with continued symptoms and a complaint from the mother that medication "isn’t working." The boy was started on an extended-release preparation of methylphenidate at 18 mg to take each morning. The child is in the fifth grade and weighs 80 lb (36 kg). He lives with his mother and 8-year-old brother. The father is no longer involved in the patient’s life, which puts added stress on the mother. The diagnosis of ADHD was made by the pediatrician based upon the history, the child’s hyperactive and intrusive behavior in the office, and the results of a standardized rating scale that was completed by the mother, who now requests that the pediatrician "try something different."
Discussion
Many children and adolescents respond extremely well to ADHD medications. Some, however, do not, and the parental complaint that the "medication isn’t working" is a frequent expression heard in pediatrician offices across the country. It is also one of the primary reasons a family is referred to a child psychiatrist. In the course of performing hundreds of these consultations, I have found that there are several possibilities to consider before assuming the medication simply isn’t effective.
We will start with simpler problems and work our way toward more challenging reasons.
• The dose is too low. Methylphenidate often needs to be dosed over 1 mg/kg/day to be effective. If the patient reports minimal response to the medication while experiencing no side effects, an increase may certainly be reasonable.
• The medication is working but wearing off. Despite the advertisements of long-acting stimulants continuing their therapeutic effect for 10-12 hours, many children seem to lose the benefit of the medication much faster. Gathering some data from the school or asking the mother about weekend mornings compared with evenings can be useful. If indeed such a wear-off is found, adding a dose of an immediate-release stimulant in the early afternoon may help.
• Symptoms are being caused by something other than ADHD. Hyperactivity due to exposures such as lead may not change your management of the symptoms, but certainly could necessitate other types of intervention. Chronic sleep problems and inadequate nutrition, especially when it comes to breakfast, also should be queried and can lead to problems with concentration.
• There is psychiatric comorbidity. Unlike many differentials in other specialties, psychiatric differential diagnosis is often a matter of "and" rather than "or." Anxiety disorders, for example, can frequently masquerade as ADHD or be present in addition to ADHD. Oppositional behavior is also very commonly present with ADHD and suggests additional types of treatment.
• There is noncompliance. This problem can surface frequently in two ways. Older children may be responsible at home for taking their medications and forget or refuse to do so. I often ask, "Are you taking the medication every single day?" Diversion is also a potential problem from the parents or for an adolescent. Checking if the refills are occurring on time can provide a clue here, and some states have systems to check for duplicate prescriptions from multiple clinicians.
• Side effects are appearing as untreated ADHD. Sometimes medications are the problem, not the solution, and a failure to recognize this phenomenon can lead to unnecessary and sometimes harmful polypharmacy. Stimulants in some children can lead to increased agitation, anger outbursts, and impulsivity. Trying a medication holiday for several days can sometimes reveal the need to back off rather than add medications.
• Family is expecting improvement for non-ADHD symptoms. Asking what particular behaviors the family is hoping to improve can sometimes expose a situation in which parents expect change in non-ADHD domains. Unfortunately, there is no pill to make kids respect their parents more or want to do their homework. Being clear from the outset about what behaviors are and are not medication responsive can sometimes prevent this problem.
• There is substance abuse. In addition to the potential problem of abuse of the stimulants described previously, other substances such as cannabis can sabotage the benefits of medications.
• There is over-reliance on medications as the sole modality of treatment. ADHD is best treated using a wide range of strategies. Nonpharmacological interventions such as exercise, good nutrition and sleep, parent behavioral training, organizational help, regular reading, screen time reduction, and school supports are critical components of a comprehensive treatment approach.
• There is parental psychopathology. In our opinion, this area is one of the most frequently neglected aspects of child mental health treatment and can have huge implications. ADHD in particular is known to have very high heritability (similar to height). If a mother or father shares the condition, their struggles can frequently contribute to an environment that can exacerbate the child’s symptoms. A pattern in which the ADHD symptoms are more prominent at home compared with school is one clue to look in this direction. When addressing parental psychopathology, it can be important not to come off as blaming the parents for their child’s problems, but rather to convey how challenging dealing with ADHD can be as a parent and how they need to be functioning at their highest mental level as well.
Of course, sometimes the medication truly is not working, and it is time to try something else.
Dr. David C. Rettew is associate professor of psychiatry and pediatrics, director of the child and adolescent psychiatry fellowship, and director of the pediatric psychiatry clinic at the University of Vermont, Burlington.
The Razor’s Edge
Years ago, when asked to describe the difference between internal medicine and emergency medicine, I said that it was a little bit like the difference between Occam’s razor and Gillette’s Trac II. Let me explain.
William of Occam, the 14th-century English logician, is credited with advancing the idea that “plurality should not be posited without necessity.” Also known as the “Law of Parsimony,” it was adapted to the practice of medicine some 500 years later by Sir William Osler, who postulated (loosely) that “a single explanation that can account for all of a patient’s signs and symptoms usually is correct.” The 19th-century diseases that best exemplified this principle were tuberculosis, bacterial endocarditis, and diabetes, none of which could be cured or effectively treated at that time.
The deductive reasoning required to identify the underlying cause of a patient’s problems is one of the most intellectually stimulating exercises associated with the practice of internal medicine. If you have never seen a master internist arrive at a correct diagnosis by reasoning based on the history, physical examination, and laboratory evidence, you may want to watch a rerun of “House” on television.
Enter emergency medicine, where time and extensive diagnostic testing are severely limited. It seems obvious that deductive-reasoning skills would be valuable, if not essential, to quickly diagnose and treat serious acute or life-threatening illnesses.
But, with the notable exception of diagnosing toxicologic syndromes, it never really turned out that way. On the contrary, it seems there is hardly ever a single explanation for anything. A sign or symptom, such as loss of consciousness, frequently is the result of two or more etiologies—for example, a depressant drug precipitating trauma, which in turn results in a subdural hematoma. The unfortunate EP who identifies only one of several causes and stops there will inevitably hear later from an esteemed medical or (worse) pathology colleague about the diagnoses that were missed.
In 1971, what was originally the Gillette Safety Razor Company introduced a product that seemed to serve as a better paradigm than Occam’s razor for our newly evolving specialty—the Trac II. This razor, with its tightly spaced twin blades, promised the closest shave ever: the hairs that the first blade missed would surely be sliced off by the second. With this paradigm in mind, the clinician can avoid the risk of (with apologies to the Lovin’ Spoonful) “picking up on one and leaving the other behind.”
Medical decision-making is the subject of the 2007 New York Times best-seller How Doctors Think, by Jerome Groopman, MD, chair of medicine at Harvard Medical School. In one chapter, Groopman examines the problems faced by EPs who must make decisions under time constraints and without the benefits of knowing the patient for more than a few minutes or having sufficient information.
To prevent the diagnostic errors resulting from thinking inside the box—committing prematurely to a wrong or inadequate diagnosis—Groopman cites the example of an endocrinologist who, even when dealing with a patient with an apparently obvious diagnosis, always asks, “What else could this be?” A version of this question that has served many EPs well over the years is “What is the worst thing this patient could have?”
The skilled clinician must be able to apply whichever paradigm is most appropriate for a particular patient. Pattern and syndrome recognition must immediately come to mind when applicable, while the possibility of more than one cause should not be overlooked just because Osler may have suggested otherwise. Added to this decision-making responsibility must be some sense of how far to go in pursuing different diagnoses in the ED without breaking the bank or overtaxing limited resources.
These days, Gillette is offering as many as six blades, promising the closest shave ever. But in the critical area of diagnostic decision-making, I believe our specialty has made even more progress.
An earlier version of this editorial appeared in the June 2007 issue of Emergency Medicine.
Years ago, when asked to describe the difference between internal medicine and emergency medicine, I said that it was a little bit like the difference between Occam’s razor and Gillette’s Trac II. Let me explain.
William of Occam, the 14th-century English logician, is credited with advancing the idea that “plurality should not be posited without necessity.” Also known as the “Law of Parsimony,” it was adapted to the practice of medicine some 500 years later by Sir William Osler, who postulated (loosely) that “a single explanation that can account for all of a patient’s signs and symptoms usually is correct.” The 19th-century diseases that best exemplified this principle were tuberculosis, bacterial endocarditis, and diabetes, none of which could be cured or effectively treated at that time.
The deductive reasoning required to identify the underlying cause of a patient’s problems is one of the most intellectually stimulating exercises associated with the practice of internal medicine. If you have never seen a master internist arrive at a correct diagnosis by reasoning based on the history, physical examination, and laboratory evidence, you may want to watch a rerun of “House” on television.
Enter emergency medicine, where time and extensive diagnostic testing are severely limited. It seems obvious that deductive-reasoning skills would be valuable, if not essential, to quickly diagnose and treat serious acute or life-threatening illnesses.
But, with the notable exception of diagnosing toxicologic syndromes, it never really turned out that way. On the contrary, it seems there is hardly ever a single explanation for anything. A sign or symptom, such as loss of consciousness, frequently is the result of two or more etiologies—for example, a depressant drug precipitating trauma, which in turn results in a subdural hematoma. The unfortunate EP who identifies only one of several causes and stops there will inevitably hear later from an esteemed medical or (worse) pathology colleague about the diagnoses that were missed.
In 1971, what was originally the Gillette Safety Razor Company introduced a product that seemed to serve as a better paradigm than Occam’s razor for our newly evolving specialty—the Trac II. This razor, with its tightly spaced twin blades, promised the closest shave ever: the hairs that the first blade missed would surely be sliced off by the second. With this paradigm in mind, the clinician can avoid the risk of (with apologies to the Lovin’ Spoonful) “picking up on one and leaving the other behind.”
Medical decision-making is the subject of the 2007 New York Times best-seller How Doctors Think, by Jerome Groopman, MD, chair of medicine at Harvard Medical School. In one chapter, Groopman examines the problems faced by EPs who must make decisions under time constraints and without the benefits of knowing the patient for more than a few minutes or having sufficient information.
To prevent the diagnostic errors resulting from thinking inside the box—committing prematurely to a wrong or inadequate diagnosis—Groopman cites the example of an endocrinologist who, even when dealing with a patient with an apparently obvious diagnosis, always asks, “What else could this be?” A version of this question that has served many EPs well over the years is “What is the worst thing this patient could have?”
The skilled clinician must be able to apply whichever paradigm is most appropriate for a particular patient. Pattern and syndrome recognition must immediately come to mind when applicable, while the possibility of more than one cause should not be overlooked just because Osler may have suggested otherwise. Added to this decision-making responsibility must be some sense of how far to go in pursuing different diagnoses in the ED without breaking the bank or overtaxing limited resources.
These days, Gillette is offering as many as six blades, promising the closest shave ever. But in the critical area of diagnostic decision-making, I believe our specialty has made even more progress.
An earlier version of this editorial appeared in the June 2007 issue of Emergency Medicine.
Years ago, when asked to describe the difference between internal medicine and emergency medicine, I said that it was a little bit like the difference between Occam’s razor and Gillette’s Trac II. Let me explain.
William of Occam, the 14th-century English logician, is credited with advancing the idea that “plurality should not be posited without necessity.” Also known as the “Law of Parsimony,” it was adapted to the practice of medicine some 500 years later by Sir William Osler, who postulated (loosely) that “a single explanation that can account for all of a patient’s signs and symptoms usually is correct.” The 19th-century diseases that best exemplified this principle were tuberculosis, bacterial endocarditis, and diabetes, none of which could be cured or effectively treated at that time.
The deductive reasoning required to identify the underlying cause of a patient’s problems is one of the most intellectually stimulating exercises associated with the practice of internal medicine. If you have never seen a master internist arrive at a correct diagnosis by reasoning based on the history, physical examination, and laboratory evidence, you may want to watch a rerun of “House” on television.
Enter emergency medicine, where time and extensive diagnostic testing are severely limited. It seems obvious that deductive-reasoning skills would be valuable, if not essential, to quickly diagnose and treat serious acute or life-threatening illnesses.
But, with the notable exception of diagnosing toxicologic syndromes, it never really turned out that way. On the contrary, it seems there is hardly ever a single explanation for anything. A sign or symptom, such as loss of consciousness, frequently is the result of two or more etiologies—for example, a depressant drug precipitating trauma, which in turn results in a subdural hematoma. The unfortunate EP who identifies only one of several causes and stops there will inevitably hear later from an esteemed medical or (worse) pathology colleague about the diagnoses that were missed.
In 1971, what was originally the Gillette Safety Razor Company introduced a product that seemed to serve as a better paradigm than Occam’s razor for our newly evolving specialty—the Trac II. This razor, with its tightly spaced twin blades, promised the closest shave ever: the hairs that the first blade missed would surely be sliced off by the second. With this paradigm in mind, the clinician can avoid the risk of (with apologies to the Lovin’ Spoonful) “picking up on one and leaving the other behind.”
Medical decision-making is the subject of the 2007 New York Times best-seller How Doctors Think, by Jerome Groopman, MD, chair of medicine at Harvard Medical School. In one chapter, Groopman examines the problems faced by EPs who must make decisions under time constraints and without the benefits of knowing the patient for more than a few minutes or having sufficient information.
To prevent the diagnostic errors resulting from thinking inside the box—committing prematurely to a wrong or inadequate diagnosis—Groopman cites the example of an endocrinologist who, even when dealing with a patient with an apparently obvious diagnosis, always asks, “What else could this be?” A version of this question that has served many EPs well over the years is “What is the worst thing this patient could have?”
The skilled clinician must be able to apply whichever paradigm is most appropriate for a particular patient. Pattern and syndrome recognition must immediately come to mind when applicable, while the possibility of more than one cause should not be overlooked just because Osler may have suggested otherwise. Added to this decision-making responsibility must be some sense of how far to go in pursuing different diagnoses in the ED without breaking the bank or overtaxing limited resources.
These days, Gillette is offering as many as six blades, promising the closest shave ever. But in the critical area of diagnostic decision-making, I believe our specialty has made even more progress.
An earlier version of this editorial appeared in the June 2007 issue of Emergency Medicine.
