Surprising Study Conclusion: Might Want to Skip PT // Nearly 30% of Residents Are Depressed! // and More!

Skip the Formal PT, Says Rothman Study

Should hip patients ditch PT? In an effort to get beyond the assumption that all total hip arthroplasty (THA) patients require physical therapy (PT), surgeons at the Rothman Institute in Philadelphia undertook a study stratifying patients to those who received formal PT and non-formal PT. Led by Matthew Austin, M.D., an orthopedic surgeon, the researchers began by looking at the Holy Grail: cost. Dr. Austin told OTW, “We knew that post discharge care accounts for a huge percentage of the cost of THA. Our team decided to see whether hip replacement patients actually needed formal PT or whether they would fare just as well doing exercises at home. From the outset we knew that not all patients could conform to a single protocol. Someone who is 80 years old, lives alone, and has heart disease and THEN undergoes THA is vastly different from a 50 year old who was recently very active and has an in-home support system.”

“We looked at the population of patients who were active to see if they could go home after surgery and do exercises on their own. These patients were randomized to see if they required formal PT or if they could manage self-directed PT (with 60 patients in each group).”

“Our preliminary results show that at four weeks postop and 6-12 months postop there were no differences in the Hip Society scores or the WOMAC scores. At two weeks we offered all patients in the non-formal PT group the option to switch to the formal PT group. We expected that some patients would cross over from non-formal to formal PT; in fact, more patients crossed from formal to non-formal. These individuals cited copays, time, and inconvenience as the reasons for this move.”

“We were somewhat surprised to find that patients did equally well whether they undertook a formal PT program or stayed home to exercise. It is becoming clear that we need to better define what type of patients need what type of care. Someone who lives alone and has to navigate a narrow staircase is going to have different needs that someone living in the suburbs in a ranch home with their children in the same neighborhood. We can’t treat all patients the same; you may give too much to someone who needs less. Ideally, we need risk stratification for post discharge care.”

“Our future plans are to examine which patients need a rehab facility and which patients should go directly home. We need to look at what makes a home environment safe. There is a lot of room here to work collaboratively with homecare specialists.”

Almost 30% of Residents Are Depressed

A new study from Brigham and Women’s Hospital (BWH) has found that 28.8% of trainees screen positive for depression during their residency. The findings, published in the December 8, 2015 issue of The Journal of the American Medical Association (JAMA), came from a meta-analysis involving 54 studies (17, 560 physicians in training). The findings were similar across specialties and countries, say the authors, suggesting that the underlying causes of depression were common to the residency experience.

Corresponding author Douglas A. Mata, M.D., M.P.H., is a resident physician in pathology at Brigham and Women’s Hospital and clinical fellow at Harvard Medical School. Dr. Mata told OTW, “It’s an open secret that depression is rampant among medical trainees, who devote themselves to medicine at a young age when the end result might be different from their original expectations about the field. Ask anyone in medicine, and they’ll be able to rattle off a list of colleagues who have been through depression. Many of my medical friends have grappled with depression or burnout at some point in their careers. Many doctors will, unfortunately, also have an acquaintance or friend who committed suicide. I’ve known these things to happen to too many people that I know. That’s what led to my interest in the topic.”

“As you are likely aware, becoming a doctor involves studying and deferring gratification for years, taking on thousands of dollars in debt, missing out on important life events of friends and family due to work obligations, treating critically ill patients, and witnessing trauma and death in person. We’re conducting this study to bring real facts to the table, to show that depression among doctors and residents is not going away and we need to seek solutions. Coming up with a reliable estimate of the prevalence of depression among graduate medical trainees would help us identify causes of resident depression so we can begin to treat or prevent it.”

“We found that as many as 43% of residents screen positive for depression during any given year of their training. This is remarkable, and suggests that it is a near universal experience. We also found that the prevalence of physician depression might be getting worse with time. This is similarly remarkable given efforts by the ACGME [Accreditation Council for Graduate Medical Education] and others to ameliorate the problem. But in my opinion what they have tried (e.g., duty hour reforms) is not enough. It misses the fact that we need to fundamentally rethink the way medicine is taught in this country, much like we did when the Flexner report came out so many decades ago. We’ve got a public health crisis on our hands and it isn’t going away anytime soon.”

We asked Andreas Gomoll, M.D., an orthopedic surgeon with Brigham and Women’s Hospital, what he sees happening with their residents. He told OTW, “The first two years are still very stressful, but the work hour restrictions have helped a lot. Also, hiring mid level practitioners has helped. We occasionally see problems these days but less so than in the past.”

As for what staff orthopedic surgeons should keep an eye out for, Dr. Gomoll commented to OTW, “Changes in resident behavior, lower scores in board exams, tardiness, compromised patient care, increases in patient complaints. All signs of burn out and depression.”

New AAOS Guidelines on Knee OA Surgery

Thank goodness for the orthopedic surgeons willing to devote their time to clarify things for the rest of the field. David S. Jevsevar, M.D., M.B.A. is Acting Chair and Assistant Professor of Orthopaedic Surgery at the Dartmouth Geisel School of Medicine. Dr. Jevsevar is also Chair of the Committee on Evidence-Based Quality and Value (EBQV) at the American Academy of Orthopaedic Surgeons (AAOS). He tells OTW, “Most orthopedic surgeons simply do not have time to read all the literature and evaluate each article for its merits. That’s where we come in. Our group refines all of the content so that we can get down to the best of the literature. The result? Clinical practice guidelines (CPGs).”

“The most recent CPGs are related to adults undergoing surgery for knee osteoarthritis. At times, the evidence we find is contradictory to what we are doing in practice. Our work group consists of 12 people willing to have difficult conversations where the lines are blurred between evidence and practice. One of the things we struggle with is how to present that in a way that is appropriate.”

“An example of something that goes against what people are doing in practice is the routine use of postoperative drains. There are always patients who are different than other patients and for whom a drain may be necessary. The guidelines are aimed at 80% of patients. Another controversial recommendation is that the routine use of surgical navigation is not supported by current evidence. That doesn’t necessarily apply to all patients, and the workgroup discusses possible exceptions in the rationale for that recommendation. When we do CPGs we first look at what outcomes are important to patients. So with navigation, for example, it is hard to find in first two years after surgery a related outcome that is important to patients.”

“In doing this CPG we started out with over 10, 000 articles and pared it down to roughly 200. The workgroup composes the rationale for each recommendation after reviewing the evidence, and the resulting document is sent out for peer review (to interested parties or specialty societies), and then have a phone meeting to go through criticisms of peer-review concerns. Following this we send the CPG out for public comment, then the EBQV and Council on Research and Quality approve the CPG; finally, the AAOS Board of Directors reviews the document.”

“There are few organizations that invite patients into the process. We actually allow patients to ask questions that are important to them and integrate that information into the CPG. For this particular CPG, patients had specific questions about the types of knee implants, unicompartmental versus total knee, and continuous passive motion machines.”

“These are guidelines and not rules. First, use the best evidence available. Second, surgeons should consider their clinical expertise and experience. Third, take into account the patient’s unique values or social situation.”