AAOS Bulletin - June, 2005

Letters from our readers

Pay for performance?

Medicare and insurance companies want to pay physicians more for better performance. Good idea?

Physicians give better care to patients who pay more for their performance. Same good idea!

People are already used to getting a better car for more money, a better burger for more money and a better haircut for more money. Why should they not have the same choice in medical care?

As physicians, we have bent over backward to give everyone the best care regardless of the amount of money we receive. We have given more and more for less and less. Now our patients expect everything for nothing. It is the only product or service I can think of that does this. And, we have let our government enforce this policy. Go to an emergency room and the government guarantees that you get free medical care. Try that sort of thing at Wal-Mart, McDonald’s or even the water company.

We should be pushing for “performance for pay” instead of “pay for performance.” That would make patients as responsible for their medical care as they are for their lunch.

David Hubler, MD

Ada, Okla.

Doctors for Medical Liability Reform

Dr. Weinstein is proud of the accomplishment of helping to elect new senators that have pledged to support medical liability reform (Bulletin, April 2005). I agree that reform is needed.

Doctors for Medical Liability Reform (DMLR) and AAOS have the goal of protecting patient access to health care. Better medical liability laws will help.

Unfortunately, the new senators are members of the Republican party and the Republican party is largely responsible for the growing national debt. The annual interest payments on our present debt of $8 trillion are about $400 billion. The debt will soon be $10 trillion and, as the dollar falls in value, the interest rates will rise and may cost $1 trillion each year.

The federal government pays much of the annual $2 trillion cost of health care. As taxes rise and/or the U.S. economy falls under the debt payments and inflation due to the falling dollars, “patient access to health care” will be in trouble.

I hope that the members of AAOS and DMLR will use their influence with the new senators and other congressmen and urge them to balance the ever-expanding federal budget. Physicians and others have saved money recently with the tax cuts. That amount will look small as soon as health care providers are required to further reduce their compensation for providing patient care.

William B. Pratt, MD

Bosque Farms, N.M.

Response to Jane Brody column

While I did not have the opportunity to read the “painful column” by writer Jane Brody, I did read the excerpt from Academy President Stuart Weinstein’s response to the New York Times (Bulletin, April 2005) which, in my opinion, was a drab milk toast explanation that smacked of political correctness.

It has been clear to me for some time that the best surgeons are, in fact, the ones who do the most talking with their patients, who explain exactly what is going to happen and that, no matter what happens, he or she is going to be with you throughout the process. The vast majority of our elite orthopaedic brethren who are regionally or nationally known for their technical expertise and/or paper-writing ability have always been the same group most uniformly deficient in their communication skills. The AAOS seems to have failed these surgeons. The AAOS started a public relations program several years ago to help improve our image as a whole and to help our members with their communication inadequacies. Has the AAOS become like the federal government, telling us what we should be doing but all the while not ascribing to the same rules or advice?

Furthermore, I have never understood why a surgeon (let alone a patient) would want to perform bilateral simultaneous knee replacements in the first place. I routinely talk my patients out of the idea quickly and, in 15 years, have only done one simultaneous total knee replacement. This patient was a semi-celebrity who begged me, and I submitted. I remember telling him that he had a higher incidence for DVT, fat emboli and infection, not to mention that he would not have “a good leg to stand on” during his initial phase of rehab. I cannot see any benefit to the patient whatsoever in having bilateral elective procedures at the same time. Every single one of my patients that has had bilateral disease has returned at the 4- to 12-month interval to have the other side done.

Maybe the surgeon for Ms. Brody has learned something from his experience, but if his response is anything remotely similar to the Academy’s, I seriously doubt it.

Mark L. Mudano, MD

Milledgeville, Ga.

In Salem, Ore., we do 900 hip and knee replacements per year including revisions. We always encourage the use of a spinal anesthetic, and we add a narcotic (approximately 0.2 mg to 0.3 mg of morphine sulfate) to create a preemptive analgesia for approximately 30 hours. In total knees, we add a femoral nerve block. This will keep the patient even more comfortable over half-a-dozen hours, adding to the preemptive analgesia.

When I started this approach about 12 to 15 years ago, the nurses on the orthopaedic floor noted a significant difference in patients’ comfort after a total knee. This has become a standard among the 22 of us in Salem.

It is important we teach our colleagues about the benefit of preemptive analgesia and also about the benefit of femoral nerve block when knee replacement is done. Another model of this is outpatient anterior cruciate ligament repairs. We do popliteal nerve blocks for ankle fractures, for example.

A spinal narcotic requires monitoring overnight; about 1 percent to 2 percent of patients have decreased respiratory rate. All that is needed is a reversal with Narcan if you have any concerns.

Harold S. Boyd, MD

Salem, Ore.

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