Inside the Mind of Your Local Orthopedist
“There is something you should understand about the way I work. When you need me but do not want me I must stay. When you want me but no longer need me I must go.” - Nanny Mcphee
My goal for the Real House MD is to help you get healthier so you can prevent orthopedic surgery wherever possible. For each of us, having less surgery in our lifetime has physical, mental, social, and financial benefits.
Although it’s a part of my profession, I don’t need to operate on you to make a living. Orthopedics is unique compared to most medical specialities because we can make a living helping you heal without surgery. If you are fortunate enough to improve your health to routinely avoid your orthopedist, odds are your appointment in the office and the surgical schedule will be taken by someone else.
As obesity rates rise and the population gets sicker, there are patients who would benefit from surgery, but are not safe candidates. By improving their overall health, one patient may avoid knee replacement surgery whereas another may become a candidate for it because they lost weight and improved their health issues and can now focus on their bad knee. One patient may improve their strength, balance, and agility and avoid a wrist fracture, but their slot on the surgery schedule might be taken by someone who stayed healthy and broke their wrist snowboarding well past middle age.
What It’s Like to Be an Orthopedic Surgeon
The Musculoskeletal Specialists
Orthopedic surgeons are the medical specialists of the musculoskeletal system. They take care of both the operative and the non-operative care of all four extremities and the spine.
Most physicians decide during their third year of medical school whether they want to be a surgeon or a medical doctor. A medical heart doctor is a cardiologist and the surgical heart doctor is a cardiac surgeon. Most body systems have a medical doctor with their surgical counterpart. The pulmonologist and the thoracic surgeon, the pediatrician and the pediatric surgeon, the oncologist and the oncologic surgeon, the nephrologist and the urologist, the neurologist and the neurosurgeon etc. Even the OB/GYN has mostly subdivided into the obstetrician and the gynecologic surgeon. The future orthopedic surgeon often makes the surgical choice without being aware of how much non-operative care they will be providing to their future patients.
Orthopedic Subspecialities
Orthopedists often subspecialize in spine surgery, hand surgery, foot and ankle surgery, shoulder and elbow surgery, sports medicine, joint arthroplasty, and orthopedic trauma. Every orthopedic surgeon has completed a training program where they are qualified in each of these subspecialities. Many do a “fellowship” which involves extra training in one area of a subspecialty. However, most will focus their career on one subspeciality.
There are some exceptions. A well known joint arthroplasty surgeon did a hand fellowship and a sports medicine pioneer did a hand fellowship as well. A few orthopedists will stop operating and become non-cooperative orthopedic specialists. They maximize non-operative care and transfer patients to the appropriate orthopedic subspecialist when needed. Occasionally an orthopedist will have an operative practice where patients are referred by other orthopedists and are teed up for surgery. This means most of their patients are either coming in for a pre-op appointment to discuss their surgery or a post-op appointment. Trauma surgeons will generally have an operative practice where they receive most of their patients from a trauma center or emergency room coverage.
The Operative and Non-Operative Specialist
The vast majority of orthopedists have several clinic days where they concentrate on non-operative patients with the occasional surgical patient. The truth is the vast majority of patients we see do not need surgery. Some diagnoses never need surgery and patients can be treated with non-operative techniques or they will be able to heal on their own. A small subset of patients will absolutely need surgery unless they choose to live with a permanent disability. These patients usually have certain fractures, ligament or tendon injuries, or nerve damage. The vast majority of our patients only need surgery if non-operative care fails. Often there are protocols of non-operative care to follow prior to considering surgery to remain within the standard of care.
Tears, Ruptures, Breaks, and Sprains Are Not Treated Equally
The chosen course of operative versus non-operative treatment can often be confusing for patients. For example, an anterior cruciate ligament tear in the knee should be treated with reconstruction in healthy patients with non-arthritic knees. The ligament will not heal on its own. Although generations of patients have lived with the resulting knee instability, there is a concern that this instability will result in severe arthritis, which will mean surgery later on.
This is very different from ankle ligament tears which almost always heal on their own and rarely need surgery. Operating on ankle ligaments before allowing the ligaments a chance to heal is outside the standard of care.
Treatment of tendon injuries also has a wide variety of options depending on which tendon is injured. The quadricep and patellar tendon ruptures will almost always need surgery. The tennis elbow and golfer's elbow tendon tears almost always heal on their own. My patients will often hear me say there is a 1 in 20 chance you will need surgery on these elbow tendons. This means if we have done hundreds of these surgeries we have seen thousands of patients with this injury. The rotator cuff tendons and achilles tendons are in a gray area. Depending on the severity some will heal and some will leave the patient with a functional deficit if they do not have surgery.
It is important to note that fractured bones and broken bones are the same thing. Non-displaced fractures are fractures where the bone is in place and will usually not need surgery. Displaced fractures often need the bone realigned and then held in place with surgical instrumentation (screws, pins, plates, and rods). Although, children can often tolerate some displacement because they will correct their alignment as they grow. In summary some fractures are surgical cases, some are not, and others are in a gray area where the surgeon and patient will make a decision based on the risks and benefits of each treatment option.
Age and severity of the damage matters as well. An older, less active patient may tolerate a certain degree of disability without interference in their daily activities. On the other hand an active patient may constantly struggle with the same injury. It is important that the patient and the physician consider the biological age as well as the chronological age. For some 50 is the new 30 but for others 30 is the new 50.
All tears, ruptures, breaks, and sprains are not treated equally. Young people tend to have large knee meniscus tears that require surgery whereas older people tend to have smaller degenerative tears with some arthritis. For them, early treatment is often aimed at treating the inflammatory flare-up of both the degenerative tear and the arthritis.
Sutton’s Law
When notorious bank robber Willie Sutton was asked why he robbed banks he replied, “Well, that’s where the money is”.
The Finances of Orthopedics
Orthopedics is a big business. You may notice many hospital systems advertise their orthopedic practices because it is a money maker. The individual orthopedist will be paid well if they work hard. This is not to say we do not struggle within the healthcare system to be paid fairly. It is a constant battle within the system.
Although we are paid for surgery we are also paid for non-operative care. The private practice orthopedist is really a small business owner who often owns their own physical therapy, brace distribution, radiology, and surgery center. They get paid for bracing, casting, and splinting as well as providing injections and writing prescriptions.
Orthopedists employed by the hospital system typically do not own the components of their practice. They are often paid a salary with a performance bonus. The hospital tracks how many patients they refer to the hospital’s radiology, operating rooms, brace distribution, and physical therapy. They will then base the salary offer off of these numbers and it will still reflect their non-operative and operative care.
As a result of being the expert in both operative and non-operative musculoskeletal care the majority of us do not have a financial bias on how you are treated. For this reason, we can support you as you try to overhaul your health even if this means you will need us less in the future.
Ideally you would no longer need us to treat the disease of chronic inflammation at 60 years old, but would instead need us at 90 when you injure yourself skateboarding with your great grandchild.
Movement to Lower Medical Costs
There is a movement to get patients with musculoskeletal complaints into an orthopedist quickly during the disease process to lower medical costs. There are many diagnoses we can treat conservatively with excellent results if we see patients in a timely fashion. Often an early start to physical therapy, a brace, or a well timed injection can prevent much bigger surgical costs down the road.
One of the biggest ways an orthopedist will reduce costs involves avoiding unnecessary radiology studies. We commonly see MRIs ordered to locate rotator cuff tears in elderly patients, who are no longer candidates for rotator cuff repair. We also see MRIs looking for meniscal tears in patients with severe arthritis, who are no longer candidates for meniscal repair surgery.
Seeing your orthopedist will ensure that the correct Xrays are ordered and/or the correct brace is placed. Many surgical patients will have better outcomes and experience a shorter recovery at a lower cost if they can get to an orthopedic surgeon quickly. These and many more examples lead to cost savings down the road.
As this movement accelerates we, orthopedists, will not be sitting around twiddling our thumbs even if the population makes a drastic effort to improve their overall health. There are plenty of patients who will still need an orthopedic surgeon.