Category: Technology

Posted on

What is an MRI?

Sometimes we physicians get very accustomed to ordering a test and assume the patients understand what the test involves.  This blog will attempt to clarify what an MRI is and also a make your experience less scary and more understandable.

While an x-ray is still the mainstay in orthopedics since it looks at the bones for fractures, calcium deposits, loose bodies, and arthritis of the joints, an MRI (or magnetic resonance imaging) is a test that has revolutionized diagnosis and treatment of soft tissue, ligaments, and bone injuries. It has enhanced the diagnosis of many bone conditions in orthopedic surgery.  In the knee, an MRI can look at the tissues in great detail to determine if there are tears of the meniscus, tears of the tendons, and in a higher quality scan even degeneration of the articular cartilage in its early stages.

It is important to know that MRIs do not have any radiation.  Unlike an x-ray which has a very small dose of radiation or a CT scan which has a higher dose of radiation, an MRI has none, and for this reason it is extremely safe.  It is not used in patients that have pacemakers, metal clips, or metal fragments near vital structures.  For example, metal near the brain as in a sheet metal worker could be a contraindication to an MRI.  However, plates, screws, orthopedic hardware, and total joints are not affected by the magnets and MRIs can be safely done in these situations.  The center where the MRI is being ordered will ultimately determine if there are any reasons that your MRI needs to be rescheduled or canceled when you do your scheduling questionnaire.

The quality of the MRI is very important in order to get the best images possible. The strength of the magnet where the MRI is being done will determine the quality of the images that the radiologist and your orthopedic surgeon will see.  The higher the magnet strength, generally the better the pictures.  Some of the newer 3.0 Tesla magnets have incredible detail capabilities. Lower strength magnets such as 0.3 T and 1.0T are older magnets and may have much grainier and not as clear of images.

There are two types of MRIs.  The best quality MRI is a closed MRI, i.e. the patient goes into a tube and the quality of the images from these machines is much better.  An open MRI is often heavily marketed as being “easier, more comfortable”, but as a good consumer you should also know that many times the quality of the MRI in an open scanner can be poor and therefore the level of detail is often not as good. There has been no clinical advantage to a “standing MRI.”

I try to reassure my patients if they have concerns about claustrophobia. For example, if they are having a knee or ankle MRI, their head is not all the way in the tube and therefore it is much more comfortable.  A shoulder MRI, however, is a bit more difficult and less comfortable. Make sure if you are worried about being claustrophobic then consider some sedation first, or if you are sure you cannot tolerate a closed MRI, then an open one would be needed. I have no difficulties giving these patients a sedative such as Valium to make the examination much easier.

Many times the MRI center will have ear plugs or earphones that you can wear while you are having your examination as the machine can be quite loud and depending on your personality some can find the rhythmic sounds pleasing and  fall asleep, while others do get somewhat anxious. Ask for a sedative if your feel like you will be anxious, but just make sure someone drives you home after if you take a sedative.

The test itself takes about 45 minutes.  The cost of the MRIs do vary, so make sure your insurance is covering it. If not, ask your doctor if there is a place to have a “cash pay” for those patient’s that are paying out of pocket since they may work with you on pricing.

MRIs are probably one of the most important medical advances of the 2oth century, but as I always say, it is not the first test. The first “test” is to take a good history and physical exam. Your doctor should actually examine your injured joint. Most of the time that usually gives me the diagnosis, and the MRI is a test to help determine if surgery is necessary.

____________________

Lesley J. Anderson, M.D.

Posted on

Medical Literatures

Those readers who have had an office visit with me know that I like to base our discussions on available scientific literature. Those of you who have visited my facebook page know that I remain cautiously optimistic about the reform of our health care delivery system.  However, one of the proposed changes has me slightly concerned. The reforms suggest that all clinical recommendations, and the administrative rules that stem from them, should be based on the information within the body of literature.

The idea of using peer-reviewed double-blinded placebo-controlled studies to guide our decisions is the goal of every physician. It is the widely recognized ideal. The problem lies within the reality of the current state of the medical literature. There are not just gaps in the body of knowledge; there are wide chasms of unknown between the sharp cliffs of fact.

Take for instance, the common problem of blood clots (Deep Vein Thrombosis, aka DVT) after total joint replacement and the rare but potentially fatal secondary problem of those clots migrating to the lungs (pulmonary embolism, aka PE). The April issue of the Journal of Bone and Joint Surgery published the updated American Academy of Orthopaedic Surgeons Clinical Practice Guideline on Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty. This is a document intended to take all the current scientific literature on the topic in consideration and distill it into clear, concise clinical recommendations. Of the 12 recommendations that were generated, only one was rated as “strong”. Based on the literature, the American Academy of Orthopaedic Surgeons could recommend against the routine post-operative screening for DVT’s with an ultrasound test in the absence of symptoms.

Regarding the rest of the recommendations, the literature was found to be either incomplete, contradictory, or sometimes completely absent. I posted a summary of all the recommendations on my Facebook page for your review.  DVT’s are common in orthopedic surgery, and the rare PE is devastating. As a result, a great deal of time and effort is directed to their research. Even at that, there are many unknowns.

One of my first lessons in med school stressed the dichotomy of doctoring. It is equal part science and art. It has been true of medicine in the past, remains true, and will remain so well past the end of my career. I celebrate the focus on science in the health care reforms since it a worthy goal and a challenge to the research community. But it needs to be tempered by reality. Treatment guidelines and protocols need to recognize the gaps in the literature. There needs to be awareness that these guidelines and protocols cannot be a substitute for appropriate decision-making, the kind of decision making that doctors work hard to develop during their training and throughout their careers. I am afraid of the consequences of a health care delivery system that loses sight of either the science or the art of medicine.

-Robert J Purchase, MD

Posted on

Where Is The Service?

Have you tried to get anything fixed these past few weeks?  I am not talking about a knee or shoulder, but my example is about Comcast.  Recently, I had my internet go out in my home. Kind of important as I have an electronic medical record and could not access the patients charts. Anyways…it took three weeks, 15 phone calls, 7 visits from various technicians; all of whom had a different idea of the problem and a different solution. During each phone call after they left and the problem was not fixed, I was asked to take a satisfaction survey while on hold.  As you know, you think if you agree to take the survey, that  your call will be answered sooner.   Nope, it doesn’t work, you still wait a long time- but you do think maybe you waited less than the guy who did not agree to take the survey. Interesting psychology around that.  Well, after 7 visits from Comcast, which of course I had to be home for, one no show, no communication between any of them. It didn’t get fixed until I told them they couldn’t leave until it was fixed. You see, a new neighbor signed up and was added to the Comcast rolls, and they split our cable line, which cut our signal in half.  Think about it this way, each service person charges for their time to come out, whether or not the problem is fixed, they get paid either way. Yes, they come in 24-48 hours, but what is the use, if nothing is fixed. Kind of like the airlines telling you they have a 90% on time arrival time, when they build in 45 minutes sitting on the tarmac as to the flight time. Is this service in the new decade???

This blog is not about my woes with Comcast.  God knows, we all have our own stories about our various telecommunication providers.  But this reminded me about is how grateful I am about the unique and amazing staff I have in my office.  This past week, we have been down two staff members, both due to illness in their families.   As many of you know, our office really tries hard to provide real service; we answer the phones, not an answering machine, you know the name of the person answering the call. We call to provide appointment reminders, our staff tries to get back to you within 24 hours unless it is an urgent message and respond to concerns or complaints in the best manner that we can.

I have often told the staff that the reason a I am busy or successful is not necessarily only about my happy-go-lucky sunny disposition (right?), but really, it is as much about the service that is provided by one’s staff as well as the skills and care the surgeon provides. 

After my experience with Comcast, I wanted to provide some gratitude and appreciation of the hard work that my staff puts in everyday to go way beyond in terms of providing real care and support for our patients.  Yes, they get cranky from time-to-time, we all do, and occasionally aren’t up to our best. Sometimes we are late, too. And we all know that patients are not always the most polite people when they are in pain. But on the other hand, in this day of changing healthcare where people will become just an MRI or CT scan, a number or statistic for the government to track like Big Brother (no-not the TV show), we don’t mind being called a  “dinosaur”-  because that means we are providing care like it used to be performed and provided, and I thank my staff for allowing me to do that.

-Lesley J. Anderson, MD

Posted on

Physicians as Educators

As I had mentioned in a previous blog, I have been attending meetings to stay abreast of the many changes in healthcare. One of these meetings was hosted by a hospital system. The hospital wanted to lay out their strategy to deal with the anticipated changes to the healthcare landscape.

One of their basic tenets rang true to me. Their goal was increase the number of patients that would choose their hospital by providing what they called “a differentiated patient experience.” This is something that Dr. Lesley Anderson and I strive to do every single day.

One of the most important roles that a doctor fulfills is the gatekeeper of information. Due to their expertise, doctors have the key to a vast amount of knowledge. They can enlighten a patient about their disease/problem and potential treatments. In the information world, they can direct patients to reputable sources of information and steer them away from unreliable sources.

This is one of the more challenging aspects to the job. First of all, education takes time. Performing a thorough evaluation, formulating a treatment plan, and answering the patient’s questions doesn’t leave much time for education. Secondly, it can be very difficult to explain medical topics at the appropriate level. Finally, it is well known that it is difficult to communicate more than 2 or 3 important facts in one office visit.

Dr. Anderson and I take our role as educator very seriously. The practice’s website is full of educational content. Even this long-running blog, initiated by Dr. Anderson, is an attempt to educate our patients about issues that do not fit nicely into a disease-defined box.

However, we can do better. We are actively pursuing educational tools to supplement our patient’s office experience.  We anticipate adding to the current educational content with both commercially available content and some “homemade” offerings.  I have been emailing informational links to patients that speak to their unique musculoskeletal problem. With an eye to making this interaction more robust, we are looking at new software to facilitate communication and dissemination of information. In the spirit of exploring social media and medicine, I have started a professional facebook page www.facebook.com/pages/Robert-Purchase-MD/148246755251988?ref=tn_tnmn. It allows me to explore musculoskeletal topics in a completely different way. Hopefully, it is a non-traditional source of medical information that benefits the community at large.

Dr. Anderson and I have always been fully committed to our role as educators. It has always been and will remain key to our attempts to provide high quality orthopedic care and a differentiated patient experience.

-Robert J Purchase, MD

Posted on

Advancements in Running Shoes

As a runner and an orthopedic surgeon, I have two reasons to keep abreast of the advances in running shoe design. The design of running shoes is experiencing a revolution. What started as a fringe movement of barefooted runners morphed into a fad of minimalist shoes and is now becoming a more mainstream trend towards light weight shoes with low heel heights.

All of this began with Christopher MacDougall’s book Born to Run in which he tells of the Tarahumara Indians who can run unlimited miles while only wearing what can best be described as a thin-soled sandal. The author observed that these Indians had a mid-foot strike which is vastly different than the heel-first strike, typical of most shoe-wearing runners.

The belief is that a natural running stride begins by landing on your mid-foot. This allows the foot to absorb the impact, store that energy, and ultimately release it at toe-off. It is hypothesized that the foot has evolved for this particular purpose. However, the modern shoe developed big, cushy heels that allowed for a heel strike. This heel-first approach stops forward motion and theoretically exposes the hip, knee, and ankle to greater forces and unnecessary stress.

From a biomechanical and evolutionary point of view, this made sense to me. Furthermore, there is literature to support the above theories. Studies have shown that runners wearing traditional shoes hit heel first and with greater force than barefoot runners, that shoes with a higher heel place greater stress on the knees, and that runners with a mid-foot or fore-foot strike experience less stress on certain joints. However, I have to say that no one has been able to show a direct cause-and-effect relationship between shoe wear and injuries.

So, despite being a relatively heavy, flat-footed runner who had never worn anything but bulky stability shoes, I experimented with minimalist shoes. I started with light weight trainers with a low heel height. And while I haven’t run barefoot since that one night in college, I do have a pair of Vibram FiveFingers. I can say one thing for sure; I will never wear my old stability shoes again. Not only are my lighter, lower shoes a blast to wear, they even look fast.

In my mind, there is something to these minimalist shoes, but you have to be careful. Long before I started changing my footwear, I started changing my stride, making a conscious effort to avoid a heel strike. A fore-foot strike produces approximately 42% more force in your Achilles tendon than a heel-strike, not to mention the additional stress on the plantar fascia. Predictably, my calves and Achilles tendon required some time to adapt (read pain and tendinitis). With any such drastic change, do it slowly and give it time. Finally, we are all a little different. For many biomechanical reasons, I will never be able to log more than a couple miles every once in awhile in my Vibrams while others may actually be able to run barefoot.

Either way, running shoes will never be the same, and our knees and hips have much to celebrate as a result.

-Robert J Purchase, MD

Posted on

Changes in Orthopedics

Two weeks ago, the American Academy of Orthopedic Surgeons (AAOS) held its annual meeting in San Francisco. The meeting brings orthopedic surgeons from around the world together for a week of education, exchange of ideas, and camaraderie.  

Physicians, like many other professionals, must continually renew their base of knowledge and update it as the field evolves. While not every technological advance outperforms the current standard, medicine is advancing at a rapid pace. It is important for physicians to remain current in their field. I am inspired and humbled by the collection of thinkers and innovators that this meeting brings together.  

In my lifetime, orthopedics has changed completely. When my older brother tore his ACL, surgical reconstruction was not recommended. He continued to have difficulties that ultimately cut short his collegiate wrestling career. Armed with that historical perspective and with the latest reconstructive techniques, a non-operative approach in the young, athletic population is not common today. Likewise, the shoulder techniques I learned during my training were cutting-edge just a few short years ago. As a shoulder fellow, I published a description of an advanced arthroscopic technique to help solve very unstable shoulders. At this year’s meeting, I saw several posters, presentations, and papers about that technique.

That is not to say that all of the advances in orthopedics have come recently. Some of the fracture techniques we still use are based on principles that have been around for decades or more, and all of today’s advances rest on the bedrock of sound orthopedic principles.

The point is that it is meetings like this one force us all to re-evaluate what we are doing. The opportunity to discuss and debate the merits of new techniques makes us all better doctors. I am grateful for the opportunity to reaffirm and challenge my knowledge base and participate in the community of orthopedic surgeons.

– Robert J Purchase, MD

Posted on

A little perspective to our electronic health records

As most of you know, the new health care legislation puts a lot of pressure on physicians to implement electronic medical records in our offices.  In fact, there are supplements and subsidies for those who do so.  I thought I would just put a little perspective on using them as I have had them in my office for the last 11 years.

There area a lot of advantages for using EMRs.  The main one is communication with all the office staff.  Gone are all the little yellow stickies, post-it notes, messages on my telephone, patients calling on weekends for refills and not knowing if they were in fact my patient or what they need. Communication between health care providers will be one of the greatest benefits of the electronic medical records.

On the other hand, studies have shown that it takes physicians 15% more time to do the same amount of work than before electronic health records.  Of course, this makes the folks at Medicare quite happy in that we are required to now document more clearly very important things than an orthopedist’s examination such as what your great grandmother died of, remote past medical history etc.  It used to be that I would review the very detailed history form you fill out when you come to the office, and that was good enough.  Now we have to actually document all the details in electronic format so that if our charts are ever audited that we have dotted our “i” and crossed our “t” to get paid for the level of service that we have billed for.  This will be a great fund of information for the auditors and their HMOs to track.  We do not really have a problem with this because obviously we should never charge for something we did not do.

However, millions of dollars that this will require will take away from direct patient care in the name of saving money and another level of paper and paperwork extra staff have to do. What IS important is that doctors still take the time with the patient, spend time looking at them, not a computer screen, are able to touch, lay hands and examine completely, reassure, and comfort the patient when they are distressed, and not worry if you have documented the physical examination properly for the HMO or payors.  I worry that healthcare will go the way of your doctor looking at a computer, never making eye contact, looking at study results, but never listening to your fears and worries, examining your knee or shoulder, and using most of the skills that we spent years learning in medical school and residency in order to provide care and compassion for patients.  Let us hope that our government’s desire for more electronic formatting of patients take the humanism out of your relationship with your physician as well.

-Lesley J. Anderson, MD