Category: Blog

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Enjoy a Safe Holiday Season

I love this time of year.  Halloween speaks to the inner child in everyone.  Thanksgiving fuses some of my biggest passions; football, food, and family.  Christmas has always been special, and it has taken on added importance now that I have children of my own.

Unfortunately, my recent weekend of emergency department call has highlighted a downside of the season.  With the wet weather, our landscape changes which places our musculoskeletal health in unique jeopardy. 

The rain makes our urban landscape a much more treacherous place.  The many painted surfaces of our streets and sidewalks are particularly slippery when wet as are the manhole covers and various metal coverings that we encounter as pedestrians.  So please exercise caution when walking around our fair city, especially with arms full of gifts and packages. 

When we escape to more rugged spaces for some outdoor fun, similar problems arise.  While the splash and squelch from the newly formed mud and puddles add pure fun to your normal path and trails, they also inexorably change them.  You may not have the same traction or footing.  Slipping and falling becomes almost a certainty.  I am not saying that you shouldn’t blast throw the mud or leap from tree root to rock, but situational awareness can make the difference between a good story and a trip to the emergency department.  And always wear appropriate protective equipment. 

But should you find yourself in need of orthopedic care, we would be glad to see you in timely fashion.  Please enjoy a safe and happy holiday season.

-Robert J. Purchase, MD

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Finding the Art of Medicine

Over the last the last three years, my family and I have become reluctant consumers of medical care.  During this time, two members of my nuclear family have been diagnosed with cancer.  Gradually, my understanding of how to be a good doctor, being on the other side of the doctor-patient relationship, has changed.  I have learned that subtle behaviors make a significant impact. I would like to share some of my thoughts with you now.

  1. The doctor should sit.  Even subtle body language is very easy to read.  While no one truly to expects the doctor to spend hours with them, the time he or she spends with the patient should not feel pressured or rushed.
  2. Share with the patient.  While it is not appropriate for the doctor to dominate the conversation with their own stories, they should be engaged.
  3. Touch the patient and do a relevant physical examination. My wife is a breast cancer survivor.  During her oncology follow-up visits, the doctor carefully assesses her for pulses in her feet but never feels into her armpit. I’m telling you, if my young, active wife loses the pulses in her feet, we have real trouble. But the armpit is a very likely site of cancer recurrence.  It does not inspire confidence.
  4. Say “I don’t know”. It is hard to hear, and it is hard to say.  A lot of questions are truly difficult to answer definitively.  It is better to explain your best estimate than fudge your way through a guess.
  5. Even the strongest patient needs a cheerleader. As a doctor, you want to hear that your patients are improving. When that doesn’t happen, you should find a way to empathize with the patient and help the patient find perspective of how their current condition fits into their overall recovery. Don’t take the patient’s negative report as a condemnation of your skill.
  6. Listen. It seems silly, but listen. Just don’t pause while you wait for your turn to talk.

While I have exposed to similar themes before, I needed to be a patient’s husband and father to truly understand the importance and impact of them.  While wearing my doctor hat, I know that I don’t always follow my own advice.  But I’m trying.

-Robert J. Purchase, MD

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Getting Ready for Joint Replacement

I am going to discuss some tips for getting ready for joint replacement surgery.  The surgeons are very astute at discussing the technical aspects of an operation, what kind of installation would be used and what kind of prosthesis, but we are not very good identifying and clarifying what expectations the patient should have both before surgery to get ready and following surgery to have a best outcome and results.  I think many patients do not recognize how much work involves after a joint replacement.  Total knee replacements require a lot more rehabilitation in order to get range of motion than ever admitted whereas a partial knee replacement is a much easier rehabilitation because the incisions are smaller and scar tissue will be less.

Preoperatively, the best thing that patient can do is try to lose 5-10 pounds, and get in some basic shape cardio wise.  If the pain in the joint is too significant to walk then get in a pool and do some deep-water bicycle, running, or walking in the water in order to get your muscles toned and strengthened.  Doing some basic knee exercises (which we do have on our website) including straight leg raises, quadricep, hamstring curls and very importantly practicing the exercises your doctor gives you to do after surgery; practice them preoperatively everyday for the two weeks before your operation.  Learning to use crutches and getting your balance in tiptop shape will also help recovery.  If you are fearful of using crutches or a walker, ask your doctor one or two visits of preoperative physical therapy to not only teach you the exercises also to have you practice how to use crutches.  Make your house safe at home; try to make enough space to move around your downstairs or upstairs in bedroom so that you can get easy access to the bathroom or your favorite couch or chair.  Having pillows available to elevate your leg are important.

I cannot say enough about getting adequate vitamin D preoperatively.  There is an interesting study on total hip replacement that show patients that have a normal vitamin D level do better postoperatively than patients whose vitamin D is low before surgery.  Check into things such as railings for your bathtub or raised toilet seat.  These will make life much easier for bathing.

Many times in the hospital the patients except physical therapists to come around twice a day with their smiling faces and help you do your exercises.  With cost cutting in many hospitals now, the physical therapists may get around to see you but their primary goal is to get you walking, not doing your exercises such as your strengthening exercises or teaching you how to bend your knee at the bedside or sitting in a chair.  So, again practice these before surgery and be ready to do as much as you can on your own.  While the therapists will make sure that you are safe to go home from a walking standpoint or a stair-climbing standpoint, their only focus is now to get the patients out of the hospital sooner, once you are safe but not necessarily as far long as your rehabilitation used to be when you would stay in the hospital five to seven days.  Be your own physical therapy advocate postoperatively.  Ask your therapist what other exercises you can do.

-Lesley J. Anderson, MD

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Total Joint Replacements

I love to do total joint replacements.  They can reliably and predictably decrease a patient’s pain and increase function, resulting in a significant improvement in a patient’s quality of life.  With all clichés aside, that’s what it is all about.  From a more technical perspective, they are wonderful exercises in applied 21st century orthopedics. 

However, I have found that patient’s expectations can be out of synch with what a total joint can actually do. For example, young patients with a worn out knee have a hard time understanding why it might not be in their best interest to proceed with the joint replacement at that time.  And one of the hardest things, as a surgeon, occurs when a patient is not happy about their outcome, especially when I would consider it a success.  For example, a Wall Street Journal article about 4 months ago reported that, while surgeon “satisfaction” for a particular patient outcome was over 90%, the patient rated satisfaction was in the low 70’s.  If you need to kneel to do your job as a carpet layer, or you did not know that a small area of skin might be numb, or thought you could return to running, or did not expect a scar; you might not be perfectly happy while your surgeon is trying to convince you that the outcome is “perfect”.  So, there are many things to discuss with your surgeon when one is considering a total joint replacement.   

There are many reasons for this.  The total joint implant companies run marketing campaigns that are very effective. Remember the “female knee?” The lay media is full of anecdotal stories of wonderful outcomes that fail to capture or communicate some very important details.  And yes, orthopedic surgeons are partly to blame as well.  At a bare minimum, trying to digest all the information that needs to be presented during an office visit is akin to drinking from a fire hose.

So you can imagine my surprise when I stumbled upon a well-written depiction of some of the hardest concepts for doctors to communicate to patients surrounding total joint replacements in the August edition of Money Magazine.  Did I mention the author did this on one page? 

Despite the fact that it is a well written orthopedic article intended for mass consumption, there are some points that require further discussion.

The article’s first point is that an artificial joint does not last forever.  Whether I agree with the cited expert’s opinion that the typical joint last 20 years or not is immaterial.  What is important is that the author highlights the importance of non-operative treatment of arthritis.  While the details change in each clinical scenario, I wholeheartedly agree with the message that “physical therapy, anti-inflammatory drug treatment, and cortisone shots … may buy a couple more years.”

There has been a veritable feeding frenzy around total hip replacements lately.  If you do not know what I am referring to, type “total hip replacement” and “lawyer” into your computer’s search engine, and see what you get.  Needless to say, I read the section entitled “Newer Doesn’t Always Mean Better,” with great interest.  Ultimately, I thought it was a fair treatment of the issue.  The truth is that any “advance” can have unintended consequences, some of which do not become apparent for several years.  Using the recent total hip situation as an example, a well-respected company with a good track record produced a new total hip design that was anticipated to increase the longevity of the artificial joint.  Unfortunately, too many of those hips were failing within the first five years, the reasons for which are only partially known.  As a result, the product needed to be recalled.  While it is necessary to adopt newer, better treatments, some new technologies do not always deliver upon their promises.  One of my most trusted mentors is fond of saying “If mom’s apple pie tastes good, don’t change the recipe.”  Orthopedic surgeons’ desire to be perceived by their patients as being on the cutting edge of technology must be balanced by the whether the new product or technique is in fact any better than the tried-and-true way.

Finally, the article speaks of some of those issues that make my heart sink when patients tell me about post-operatively.   Specifically, the total cost of the procedure does go further than the out-of-pocket expense or the deductible.  Often times, certain equipment is required post-operatively, such as walkers, crutches, and elevated commodes.  While most of these are covered by most insurers, there can be exceptions.  More importantly, there are hidden costs.  If you are of still of working age, any total joint replacement will require a period of time away from work.  Depending on many factors (the exact nature of your job, your benefits, the surgical factors, etc) your income may be negatively impacted during your recovery.  Furthermore, there may be household tasks that you are temporarily unable to do and need to hire or have help to perform, such as landscaping, laundry, house cleaning, etc.  None of these represent insurmountable obstacles, but all of them are best anticipated and planned for, at least to the best of your abilities. For example, give your friends who ask what they can do (no not another casserole!) some of these tasks.

This blog entry and the magazine article that I referred to, barely scratch the surface.  While it is impossible to be completely prepared for a total joint replacement, more well-done and even-handed mainstream pieces like the one I found in the August edition of Money Magazine would certainly help.

-Robert J. Purchase, MD

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I’m Excited to Join the Practice

After 3 years practicing in California’s Central Valley, my family and I could not be more excited to be back in San Francisco. 

I was born in Western Pennsylvania and remained there until after college.  It was during college that I became interested in orthopedic surgery as a career.  As a collegiate varsity football player, I had the unfortunate opportunity to get to know our team’s orthopedic surgeon on several occasions.  However, I was able to capitalize on that relationship and, after shadowing him for one month, my career path was set.  Orthopedics allows me to pursue many of my interests, such as biology; mechanics; and athletics to name a few.  It also allows me to treat patients from every stage of life.

I travelled to the eastern portion of Pennsylvania for medical school and attended Temple University School of Medicine in Philadelphia, PA.  I was fortunate enough to stay at Temple to complete my orthopedic residency. 

Temple University Hospital is the tertiary care hospital in an urban neighborhood of North Philadelphia.  After a busy residency, I felt very comfortable treating the whole gamut of musculoskeletal pathology.  However, I had a particular interest in the shoulder and the ever-increasing functionality of arthroscopy to treat orthopedic conditions so I supplemented my orthopedic residency with a sports medicine and shoulder surgery fellowship in San Francisco. 

I believe in the ability of arthroscopy as a tool to improve intra-operative diagnosis and visualization of pathology as well as the decreased soft tissue damage of an arthroscopic procedure as opposed to similar open procedures. In addition to these benefits, the constant improvement of tools and techniques allow arthroscopic repairs to approach or surpass the historic open techniques. 

As a fully trained shoulder replacement surgeon, I feel equally comfortable with all the open reconstructive techniques, from hemi-resurfacing procedures to revision shoulder replacements. 

However, I do not want to become super-specialized.  I put an equal amount of time and effort developing myself as a general orthopedic surgeon during my residency and continue to refine those skills.   I routinely perform treatment of all manner of boney and soft tissue traumatic injuries, replacements of the knee and hip, knee arthroscopic procedures, and routine upper extremity work. 

My philosophy of care is anchored in my belief that a well-informed patient will do better clinically.  The word “doctor” is derived from a Latin word meaning “teacher”.  Therefore, my primary role is to serve as an advisor to my patients.  This allows you the patient to be an active participant in your care.

On a more personal level, it was during my time in Philadelphia that I met my wife, and we started our family that has been blessed with three wonderful children.  I try to remain active and fit despite a busy career and a young family.  During residency, I lost track of my physical fitness.  Due to time constraints, I began to jog a couple of mornings a week to lose weight.  Almost a decade later, I run consistently and have raced a handful of half-marathons despite being hampered with physical tools appropriate for more anaerobic pursuits.  Despite never competitively swimming, I am contemplating my first triathlon.  In the time left, I love to cook.  I have always enjoyed good food, but cooking allows one to experience the process on a deeper level. 

Thank you for taking the time to get to know me, and I look forward to getting to know you better in the office. 

-Robert J. Purchase, MD

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Robert Purchase MD joining our practice

I am very excited to announce that as of August 1st I will have a new physician, Robert Purchase MD, join me in the practice. He is a wonderful doctor who has been practicing in the Valley for the past 3 years, and is now coming back to the Bay Area. I believe he has many of the same values I have felt are critical for providing care to patients.  He will be able to see you for most all orthopedic problems, not just knee and shoulder problems, (although he does have a subspecialty expertise in these areas.)

After 22 years in solo practice, I am excited to take a vacation longer than a week if I want to and know my practice is in good hands. No, I am NOT retiring or slowing down, although the rumors will fly, I imagine. The workaholic in me won’t let that happen.  I am adding services to the practice, which I have not been able to do in the past.

Dr. Purchase will also be contracted with Blue Cross PPO and Blue Shield PPO (pending) which many of you will appreciate. If you are BTMG, he is not yet contracted, so have your PCP send a referral to me and he will be able to see you.  He is also accepting new Medicare patients.

I appreciate all the loyalty many of you have shown me over the years, and now our “family” is growing and I hope we can enhance your experience in the office.

Please check his bio in the provider section of our web site.

-Lesley J Anderson MD

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Orthopedics and stress and pain! Oh my!

I see patients frequently in my office who work high stress jobs all day, on the computer, on deadlines, demanding bosses, carting the kids all over after school, after work; who come in with pain in the back of their shoulders, or neck.  I have also seen patients come in with pain in their knee after standing a long day at a conference they really did not want to be at.  What these both have in common is that the pain is real.  The tenderness in the muscles, soft tissues, and joint are definitely there, but after a thorough examination there is not really a specific anatomic structure that we can define as the source of the pain. 

We live in a very high stress environment these last few years and I think it is important to remember that our bodies have an amazing ability to tell us that the stress level is getting too high in ways other than what would one normally see such as chest pain, heart attack, and ulcers.  In orthopedics, the body does talk to us when stress levels get too high.  It is always a good idea to have an orthopedic condition checked out by a capable practitioner, but I think it is also important to check in on your own “life pulse”; to check in with yourself about what is going on in your personal life, your work life, your relationship, when the pain started, when it gets better (vacation is always a good barometer). Many reduce stress through exercise, basic walking is probably the best and safest, meditation and yoga (but be careful of the child’s pose and downward dog). But if you hurt, these activities may not be comfortable or possible. So, consider reading or just spending some quiet time with the cellphone, texting, and TV all turned off.  Just enjoy this beautiful area we live in on the bay area. Look at the scenery around you, breathe, and relax.

It is easy for me just to go out in my garden and look at the beautiful flowers and landscape.  I have worked hard to create, although like most people, it only usually last 5 or 10 minutes until I start looking at the tree that needs to be pruned or weeds that need to be pulled. But I try to make the time.

Have you ever heard the term “I feel like I have the weight to the world on my shoulders”, or “so and so is the pain in the neck”, or “I do not feel like I can take another step”.  These phrases would definitely show up in our body when stress gets too high.  The purpose of my blog today is really to remind us all of the value of taking 15 minutes daily to just stop with the texting, turn off the phone, turn off the TV and just find a comfortable place to sit, lie, run, or move to  wherever you body finds a restful place.

-Lesley J. Anderson, MD

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Rotator Cuff Part 4

In April, our annual meeting of the Arthroscopy Association of North America took place in San Francisco. This is the premier society for arthroscopic surgeons (I was the first woman admitted to the Association over 20 years ago). Approximately 2000 surgeons came and there are always new things to learn. 

One of the common themes running through the weekend was that it takes much longer for a patients’ real function to improve than we tell them it will take for rotator repair. In other words, we should help our patients have realistic expectations for when they will be “all better”.  We, as surgeons, tell our patients that after rotator cuff repair surgery, they are going to get better in four months or so. This IS true for day to day activities. I usually tell patients it will take 4-6 months to really feel like you have your shoulder back for day to day activities. This is because some patients get stiff postoperatively (if you are a middle aged female or have diabetes, for example, you have a higher risk for getting stiff- so you should work harder avoiding it) Others’ just sail through their rehab. EveryBODY is different. The consensus at the meeting is that we tell our patients shorter time periods for recovery, because our patients would freak out if they hear that it might be up to a year for all their strength, sporting activities and work function to be as close to normal as possible. I think it is always best to be as honest and clear as you can with a patient in terms of expectations> Although some surgeons act and may even think they ARE the well, ummm, god, we aren’t, and it is our responsibility help you have as realistic expectations as we can. I know I have lost a few patients to other surgeons for just that reason, just because of that, but I do sleep better at night.

In fact, it does take much longer for the shoulder to completely get back to as close to 100% as possible, because the tissues take a long time to mature, the muscles to strengthen and for the whole shoulder to work as a unit again.  So, if you have had rotator cuff surgery, be patient, continue to do exercises, do not be discouraged, and keep in mind that your symptoms will get better up to at least a year if you keep working on your exercises.

-Lesley J. Anderson, MD

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Rotator Cuff Part 3

A few weekends ago, our annual meeting of the Arthroscopy Association of North America took place in San Francisco. This is the premier society for arthroscopic surgery (I was the first woman admitted to the Association many years ago). Approximately 2000 surgeons came and there are always new things to learn.  One of the common themes running through the weekend was that it takes longer for patients’ real function to improve than we tell them.  We as surgeons tell our patients that after rotator cuff repair surgery, they are going to get better in four months or so. Frankly it is because our patients would freak out if they hear that it might be up to a year.  In fact, it does take much longer for the shoulder to completely get back to as close to 100% as possible, because the tissues take a long time to mature, the muscles to strengthen and for the whole shoulder to work as a unit again.  So, if you have had rotator cuff surgery, be patient, continue to do exercises, do not be discouraged, and keep in mind that your symptoms can get better up to at least a year if you keep working on your exercises.

-Lesley J. Anderson, MD

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Rotator Cuff Part 2

The last blog dealt with understanding what the rotator cuff is and basically an overview about rotator cuff.

 How do I know if I have rotator cuff problems?

Contrary to popular belief, history and physical examination is still an incredibly accurate way to diagnose whether you have a rotator cuff problem.  An MRI is not always necessary.  If you have rotator cuff disease, you will have pain during or after an activity.  It will usually be located on the side of your shoulder and occasionally radiates down towards your elbow, but not below it.  Sometimes it will go up towards your neck, but that is usually if it is more severe.  If you have pain which wakens you from a sound sleep, it is much more likely you have a complete full-thickness tear.  Weakness with reaching and overhead work is also a sign of a partial or complete tear. 

Initial treatment of rotator cuff problems, in the acute setting can be use of ice 2-3 times a day and be really careful about your posture, keeping your shoulder blades back and down, and Aleve or Advil on routine schedule for several days, 5-7 days.  These are things that you can do to help at home, but if the pain does not get better, and you need to finally go to the doctor, some of the preliminary treatments have already been done.

Now that you have figured your rotator cuff problem, what is the next step?

As I mentioned, history and physical examination are still the gold standard and are amazingly accurate if done thoroughly for diagnosing rotator cuff pathology. I will next do an office ultrasound to examine the rotator cuff, which is convenient, accurate and less expensive than an MRI. You also do not have to go into a closed tube!

 I personally believe that MRI should be done if:

1.       I cannot figure out what is going on in my history and physical.

2.       If I am considering surgery on a patient, then it will help you in the decision making process.

3.       If there has been 6 weeks of treatment and the pain continues

4.       The ultrasound suggests a tear.

There are lots of variations in the quality of MRI scans as well as those reading them.  Closed MRIs are far superior to open MRIs in terms of quality and accuracy.  If you are claustrophobic, then Valium can also be given before the test to sedate you.  If that is not useful, then we will obtain an open MRI or a test called CT arthrogram could be done.  If it is positive, then the next step will be to discuss surgical options.

– Lesley J. Anderson, MD