Cast & Curious

Tag: Orthopedics Practice

  • Blind Eye: Unabated rising number of motorcycle accidents

    Last Monday, on my way to Davao City, I was again a witness to two road accidents  involving motorcycles. In one roadside, a lifeless body, lay on the ground after he and his motorcycle drove straight underneath a hauler truck.  In another road just several miles away, another motorcycle rammed into another motorcycle head on.  Broken glass and blood are splattered all over the road. Both drivers were rushed to a hospital.These gory sights shocked even surgeons like me.

    Motorcycles accidents top the list of vehicular accidents in our country today. This is according to the Trauma Registry of the Philippine Orthopedic Association. In my orthopedic practice, approximately 60-75% of cases I’ve handled are related to motorcycle accidents.  In government health care institutions, more than half of the ward patients are victims of motorcycle accidents.

    A "shredded" motorcycle and its driver.(Photo from this site http://www.vf750fd.com/motorbikes/crashes/accident/motocrash.jpg)
    A “shredded” motorcycle and its driver.(Photo from this site http://www.vf750fd.com/motorbikes/crashes/accident/motocrash.jpg)

    The type of injuries that motorcycle accidents bring are not only complex, but also unique. These injuries pose great challenge to our surgeons and require costly, repeated operations that exhaust both the patients and health care providers.  I bet if the health care community do a cost analysis of treating motorcycle injuries and the amount at which government spend to save this patients, we’d be all shocked.

    Some observations I have regarding motorcycle accidents:

    1. Drunk driving or driving under the influence of alcohol. Illegal but rarely enforced.
    2. You only need Php 2,000.00 downpayment to get and drive your new motorcycle. The motorcycle industry is a huge market. Motorcycle makers really made acquiring motorcycles easy.
    3. Lukewarm or almost non existent enforcement of motorcycle laws and regulations.
    4. It’s very easy to get drivers license in the Philippines. Some say, in the Philippines, even a blind person can get a driver’s license.
    5. Teenagers sneakingly drive motorcycles and they drive like road kings.
    6. Some schools give parking spaces for students with motorcycles. I mean, do they check if these kids have driver’s license?
    7. Approximately half of motorcycle drivers nowadays have one violation or two in their motorcycle ” papers”. No or expired registration, etc..
    8. In the Philippines, because we are culturally magnanimous, we still shoulder medical expenses of motorcycle accident injuries  even if it was the motorcycle driver’s fault.
    9. Motorcycle injuries in my city dropped when there was a rise in motorcycle theft and deaths.
    10. Motorcycle injuries also dropped when the gasoline prices rose sky high.

    There I’ve said it. Well, authorities can simply deny all these and more and say we’re all fine. Lack of budget and manpower seem a pretty good excuse I suppose. But the fact still remains, motorcycle related  accidents keeps on rising. Just watch your TV channels evening news and you’ll know what I’m talking!

  • Will admitting medical errors publicly improve patient care?

    For this well known Massachusetts’s General and Harvard Medical School hand surgeon,  YES.  Admitting publicly should ultimately improve patient care according to Dr. David C. Ring. Or his “public admission” will all be in vain.

    Dr. David Ring, a well known hand surgeon at Massachusetts General Hospital, went public with his surgical mistake.

    Dr. David C. Ring, a well known hand surgeon and his colleagues at Massachusetts General Hospital, described in detail (New England Journal of Medicine) how a series of personal and system-wide mistakes led Dr. Ring to operate incorrectly on the hand of a 65-year-old woman with a painful “trigger finger.” Dr. Ring performed a carpal tunnel release, instead of a trigger finger release, a surgical error that would qualify as a wrong site and consequentially wrong surgery performed on the ” right ” patient. Realizing he made a surgical error fifteen minutes after the procedure,  Dr. Ring apologized to the patient and her family then asked the consent of the patient to perform the correct procedure.  When the patient consented, Dr. Ring reassembled his OR team and did the procedure without complications.

    Dr. Ring and his medical staff went through the process of  immediately rectifying the error post operatively.  But nothing could “undo” this mistake, according to Dr. Ring himself. Though such case didn’t resulted to litigation and malpractice suit for the surgeon,  such error put significant stress on both the patient and the surgeon.  He just hope that with his public admittance of this error,  other surgeons would improve on their patient safety protocols.

    Hopkins
    In this videograb from the first episode of 'Hopkins 24/7,' physicians gather behind closed doors in a Morbidity and Mortality conference. This is the first time Hopkins has allowed cameras access to a session. This is taken from John Hopkins Gazette

    My first reaction reading this article was a unbelieving “really?”. In academic and training institutions for physicians, mortality and morbidity conferences are regularly conducted to improve  patient care services and furtherance of the medical knowledge. But typically, they are for and amongst physicians only.  Such hospital process analysis is guarded by the cloak of confidentiality, if only to protect the patient first and foremost. The fact is nowadays, going public with such ‘admission’ is a mortal sin, tantamount to inviting a deluge of malpractice suits for both the physician and the institution.

    Thats why I am truly amazed by the act of Dr. Ring and his institution.  The courage and integrity by which they face this situation is only paralleled  by their unwavering desire to be at the forefront providing and improving the best of care for their patients. Such is characteristic of institutions of higher learning.

    Now as to whether we are ready for such sentinel public admission, I personally don’t think so.  Even if  malpractice suits are still uncommon in our health care system, a turnaround in terms of our healthcare education, knowledge, attitude and skills should be effected first before we reach the social and psychological maturity of our caucasian counterparts.  But this one should be an ideal goal. It might be utopian, but yes, it is still worth emulating.

    So, Dr. Ring, all I can say is “bravo!”. You made us all orthopedic surgeons proud of our profession.

  • Why I threw a patient’s ‘counsel’ out of my clinic

    Patients with a bantay or 'counsel' photo taken from this site (http://www.umc.org)

    It’s not uncommon to see a patient or a patient’s relative bringing along some unrelated individual as “counsel” in your clinic. This counsel is unique among my Filipino patients and such counsel’s role has baffled me ever since I started my medical career. Roles, that to my knowledge broadly range from just plain ambulatory assistant or worst, to a nagging and combative counsel to the patient. I have tolerated such roles before because at times they can be very helpful in educating patients and relatives who haven’t had any time to convene a family meeting on their health issues at hand. But a recent bad experience with a ‘counsel’ pushed me to institute a policy of “no non related guardians allowed” inside my clinic.

    My patient was a 10 year old girl who sustained a supracondylar fracture from falling over a park statue where she was playing with her cousins. The kid was brought to my clinic after 3 days, on a makeshift splint and after 3 sessions with a known bone setter in the area. The elbow is already grayish blue in color and is still swollen. The kid is wrenching in pain but  I can still feel the pulses and there are no signs of compartment syndrome. The mom brought with her a “counsel” after the bone setter allegedly ordered an xray. In my setting here, even if we’re already an urbanize city with a tertiary level hospital at that , bone setters are primarily the first one being sought by patients or their relatives when dealing with fractures. It’s even very common to hear bone setters manipulating fractures and ordering x-rays! Anyway, what bugged me that time was the way this ‘counsel’ is disrupting my talk with the patient’s mom.

    I was explaining the diagnosis and the treatment options to the mom, baring that a surgery is already needed in her daughters case. I could employ a conservative treatment (if cost is prohibitive to the parents) but the results, which I explained carefully to the mom, would be unacceptable and costly in the end. The ‘counsel” is impolite in drawing attention of the mom, and whispering barely audibles that as I can figure out was a urging the mom not to have the surgery done and bring back the patient to the bone setter. The mother was very much bothered and was in fact becoming inattentive to me because of the constant nudging of this counsel.  As it grew frustrating to me, I looked straight to the counsel’s eye but politely asked the mom what is this counsel’s relation to the patient or the mom. She was a neighbor, the mom told me. She was also the one who brought the kid to the bone setter for manipulation twice! I asked the mom again politely of course, to ask the counsel to leave the clinic now and just wait outside. I also urged the mother to call a family meeting and talk with her husband the treatment options I laidout for the patient.

    Well, that didn’t happen. The counsel refused to leave and worst, she kept on annoyingly nagging the patient’s mom.  This prompted me to talk directly at the counsel, ask her that if she doesn’t stop disrupting our conversation, she’d answer for all the complications her constant nagging has brought to the patient’s condition. And she’d be thrown off the clinic’s premises for good!

    Then there was this an uneasy silence. Everyone in the clinic knew that my usual cool composure got blown by this annoying ‘counsel’. Everyone was silent for at least 3 minutes. When the counsel was escorted out of the clinic, I apologized to the patient’s mom, not for throwing out the counsel, but for the disruption in our conversation. She just smiled and from that moment on. I know I won another loyal patron.

  • Reviving the physician’s administrative function

    Right. I almost forgot. The medical staff do have “dual” functions.

    The medical staff has a dual and overlapping management system- the administrative which involves the activities of a medico-administrative character, and professional, which concerns of the clinical aspects of its functions.

    The physician is typically absorbed with the clinical aspects of his profession and rarely bother with administrative functions unless he or she is managing a large group practice or a hospital. Private, solo practice large reduces the physician’s administrative function to bare minimum.

    This may not be necessarily true in a practice that involves a tertiary institution.

    This realization struck me as I was tasked an administrative position of setting up clinical services for a tertiary level health care facility. While defining clinical functions is not a “breeze”, setting up additional administrative functions for the involved physician is like “walking into a storm”. Again, this is seemingly related to physician’s preference to clinical functions rather than the administrative part. In reality, most physicians shy away from ANY administrative functions at all.  I now understood why physician administrators grow (or lose) gray hairs by the hundreds each day.

    physician as administrator
    physician as an administrator, what gives?

    The reason?  My personal observation is this: As a physician, we were trained mainly on the clinical aspects of our profession. The few that got some training on the administrative skills probably got stuck in such functions. This compartmentalization of functions seem to enhance productivity on either of such functions but not on both. We were trained to specialize. Even solo, private practice seem to support this observation. The other reason is that physicians are generally slow to adapt to any change. Our comfort zone is just to comfortable to let go suddenly.  Thus, physicians tiptoes and are slow to adapt to administrative changes intended to improved  health care delivery.

    This is where I am looking for ways to get viral and enthusiastic response from the medical staff. This dual function of hospital based physicians are intertwined and complementary. Defining such functions is necessary for providing top notch health care service and the smooth operations of the health care institution. I’m not just saying this because I’m now part of a hospital administration. As I’ve said before,  have I recognized administrative functions before in a solo practice, my practice would have been smoother and productive.

    In your practice, do you really care about administrative functions at all?

  • Balancing Act: Community and tertiary care orthopedic practice

    Barely five years into a private medical-surgical practice, some people got interested how I’m “doing” with my “kind” of orthopedic practice.  Orthopedic practice refers to an orthopedic surgeon’s working environment, the plethora of patients or cases he handles, the time, effort and money he or she invests on it as well the returns (monetary or otherwise) he gets from this professional career. This is rather a simplistic definition, one that is based on a business model, but roughly what approximates a “medical-surgical practice” in the real Philippine health care settings. This definition is further muddled by “subtypes” of an orthopedic practice as well as the mix and match attitude by most orthopedic surgeons practicing in this country.

    Before I’d shed light on my kind of orthopedics, let me describe what I think is the two extremes in orthopedic practice- the community type, generalist orthopedic practice  and the super specialist tertiary level academic orthopedics.

    A community type of orthopedic practice usually caters to patients with general orthopedics (osteomyelitis) and extremity trauma (fractures) problems and usually the first line of orthopedic care in the provinces. These patients are commonly admitted to a non specialist, primary to secondary level, health care institutions found within the surgeon’s community or area of practice. Academic orthopedics on the other hand,  is basically a tertiary, level I trauma care practice that deals with, specialized or complicated orthopedic problems (e.g. arthroplasty or spine cases) that requires super specialist institutions with supporting facilities (ICUs) . Such specialist type of orthopedic practice is usually coupled with training residents in the orthopedic specialty. Some hospitals add admitting and/or administrative privileges to the surgeon.

    The contrast between these two types of orthopedic practice is probably  apparent in the  amount of time and effort an orthopedic surgeon “invest” on each cases .  A super specialist academic orthopedics is generally thought to be more time, effort and learning  intensive, compared to a community type of orthopedics.  It is also perceived that specialist care are more lucrative, pay and prestige wise.  Of course there will be exceptions to this observation, as the delineation between “learning” in the country side versus the urban centers is gradually grayed by the advent of fast information and the internet. But for our purposes here, let me just simplify definitions to differentiate between the two.

    Why am I differentiating between these two types of practices?  Theoretically speaking, somewhere between these two practices is the middle ground which is for me, the logically desirable type of practice –time, effort and income wise.  Thus, a balanced orthopedic practice (in my opinion) is one that  involves continuous learning and at the same time, offers a “relaxed” environment that caters more to delivering quality orthopedic care in a community setting.

    Many surgeons believe such “balanced orthopedic practice” is not easy “find” , difficult to live with, or is unsustainable. The inherent affinity of the orthopedic practice to orthopedic implants and gadgetry as well as to a tertiary level health care institutions is believed to be the primary reason for such negative perception . While many many orthopedic surgeons still conglomerate on urbanized cities and tertiary level care institutions because of  this logistics necessity, a trend towards community type of orthopedic practice is picking up pace because of improved information technology and delivery of much needed orthopedic implants.

    One former mentor asked me if I’m happy with this dual type of orthopedic practice. I answered ” yes” although I qualified it immediately by saying “.. with some necessary lifestyle and living adjustments” . Personally, I find it natural that this two sub types of practice  complement each other. A community practice without continuous learning is boring. Likewise, teaching orthopedics without actually doing what you teach is too good to be true. Somewhere between these two “extreme” sphere of practices lies a compromise that I felt, will produce the balancing act.

    “But what about lifestyle modifications as you said?” I for one, chose this balancing act, because it fits my lifestyle. Compared to an urban, high volume, city practice, I certainly preferred the relatively relaxed working environment of a community practice. On the other hand, I cannot let go of the many opportunities for learning that these big academic institutions could give. Besides, I love teaching. Teaching could have  been my career if not for the ‘healer” awakening I got in college. Like one mentor said ,  “there’s no better way of learning than to help others learn“.

    Well, a community type of practice will rarely make you rich, but I’m pretty sure you’d be able to put food (or a house and a car perhaps along with some other perks) in your family’s table. A simple living will surely come handy in surviving this dual type of orthopedic practice. But it does pay well in the amount and quality of time you spent with your love ones! I guess it all boils down to what fits your lifestyle and your priorities. Mine just happened to be where I wanted to be years before I became a doctor.

    So which one do you prefer then, the community type of practice? the academe?or both?