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Scoliosis / Source: Wikimedia Commons and Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine.

As Disability, Scoliosis Ranks Very High // Using Art to Hone Doctors’ Observational Skills // and More!

Elizabeth Hofheinz, M.P.H., M.Ed. • Sun, March 27th, 2016

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As Disability, Scoliosis Ranks Very High

Are patients with diabetics in worse shape than those with scoliosis? Do people with hypertension suffer more than people with scoliosis? Shay Bess, M.D., associate professor of orthopedic surgery and director of adult spine deformity research at NYU Langone Medical Center, and the International Spine Study Group wanted to delve into these questions. Dr. Bess and International Spine Study Group recently published a study in Spine entitled, “The Health Impact of Symptomatic Adult Spinal Deformity in the U.S.” Dr. Bess told OTW, “We wanted to demonstrate the disability involved in scoliosis and evaluate how it compares to other chronic diseases such as hypertension and diabetes. Interestingly, we found that people with adult spine deformity are as disabled as those with other chronic conditions. This runs counter to prior studies indicating that scoliosis in adults doesn’t cause much disability other than back pain.”

“We parsed things out and found that depending on the type of deformity there are varying degrees of disability. Stuart Weinstein’s classic study found that patients with scoliosis had complaints of back pain. But they didn’t look at the different types of scoliosis or obtain lateral X-rays on any patients. We found that as scoliosis got into the lumbar region there was markedly more disability. Furthermore as the deformities appeared in the sagittal plane, we found that patients who were severely sagittally malaigned functioned worse than amputees. We also found that patients with severe sagittal malalignment combined with lumbar scoliosis reported greater disability in function than patients who are blind.”

“We selected to evaluate patients that had no prior history of spine surgery because we wanted to ensure that there would be no confounding effect of prior surgery. It is important to ‘dig into’ the general health of patients with adult spinal deformity and examine the impact of the different types of spinal deformity on their quality of life. For the future, however, what is even more important is to compare the effectiveness of different treatment modalities. Does surgery for patients with adult spinal deformity have the same impact on the disease as antihypertensive drugs for patients with hypertension? And when considering cost, does the initial expense of the surgery outweigh the cost of a lifetime of medications and doctor appointments? These are questions we must answer in the future to have a true impact on how we deliver effective healthcare.”

Brigham and Women’s Hones Doctors’ Observational Skills Via Art!

The next time you go on rounds, consider bringing along an art educator. Before you skip the next few paragraphs, hear what Joel Katz, M.D., vice chair for Education at Brigham and Women’s Hospital (BWH) has to say. Dr. Katz, director of the Internal Medicine Residency Program at BWH, tells OTW, “Doctors are well trained in their trade, in anatomy and in surgical decision making…patients rarely complain about doctors’ technical skills. However, disjointed care, poor teamwork, and poor communication are things that do upset patients. ‘I called the doctor’s office and no one got back to me, ’ or ‘I heard different messages from various members of the team’ are typical complaints. We set out to develop a curriculum that would help medical teams function more effectively and deliver better patient care.”

“Over the past five years various accreditation organizations have recognized the problem and begun to require teamwork trainings. We have had success at the Museum of Fine Arts in Boston (MFA) with other curricula over past 15 years so we decided to take on this challenge. With that in mind, the residency, nursing staff and a group of professional arts educators designed a new curriculum to improve inter-professional collaboration, or as we call it ‘Teamwork.’”

“One evening we take all of the team members (nurses, physical therapists, students, residents, attendings, care coordinators, etc.) out to a simple dinner so they can get to know one another. We then head to the MFA and they go through exercises about hierarchy, collaboration and communication, all of which are focused on art observation and art making. It starts out simply and by the end we move to complicated scenarios involving the interpretation of complex artwork (‘What is meaning of this Jackson Pollock painting?’). This experience helps doctors appreciate the contribution that other team members have to make.”

In developing a related program to help medical students improve their physical diagnosis skills, Dr. Katz works alongside Simon Helfgott, M.D., a BWH rheumatologist at Brigham and Women’s Hospital in Boston. Commenting on these innovative arts-based teaching efforts, he told OTW, “An educational method known as visual thinking strategies (VTS) merges visual art concepts with physical diagnosis. VTS, developed by Abigail Housen, D.Ed., a cognitive psychologist, and Philip Yenawine, an art educator, can be applied to our daily practice as physicians. We should approach patient interactions with a bit of the art critic’s mindset, indeed learning how to read and interpret patients’ gestures and expressions. Was there eye contact when speaking with the patient? Was her smile crooked, or that eye a bit droopy, telltale signs of a facial palsy? Don’t get caught just looking at the obvious, to where the eye is initially drawn. As VTS teaches, try to see what is going on ‘in the shadows.’ Some of the imagery of medicine can be grotesque; the initial reflex of the viewer might be to look away. A careful observation of some of the finer details of the image may stimulate a more thoughtful response.”

Dr. Katz continues, “The day before we bring the team to the museum we have an arts educator observe everyone conducting patient rounds so they can get a sense of where any dysfunction—or opportunities for improvement—may be in the team’s daily routines. Then they employ specific examples of activities around art that could address deficiencies. For example, first, the team will be instructed to work together as a group to understand a Renaissance painting…something with a story whose meaning they can collaboratively decode. These young doctors in training start to realize pretty quickly, ‘Oh boy. The ward clerk knows things that I don’t.’ This helps them listen carefully, appreciate alternative perspectives and build on one another’s observations.”

“One person says that the man in the painting is running away; another team member comments that the man is running toward something. Each team member is asked to say what evidence led them to that conclusion. Another activity may be taking an ambiguous painting and dividing the group into two sections. Group one creates a two line poem from the standpoint of the family member of subject of the painting and what they wish care team knew about their loved one. Group B takes the perspective of the care team and writes about what they wish the family knew. Then each team rearranges these into a poem. The two groups then read their poem to the other group.”

“Often we like to wrap up the MFA Teambuilding session by observing a piece of art that is abstract, and thereby more impenetrable and harder to find evidence to attribute meaning. When facing a crisis on the orthopedic floor or in the operating room it is best to have the skills needed to improvise, listen and communicate when things are unclear or unexpected. It is enlightening to see that the physical therapist may make very relevant observations that a surgeon never thought about, and how much more quickly they arrive at the best answer if they share respect and open avenues of discussion.”

“At the very end, the arts educator discusses metacognition and offers his/her observations as to how the team might function more efficiently. The next day on rounds things typically run much more smoothly. The future of healthcare involves a team-based approach...and we are proud of how this program has helped in that regard.”

The best proof? “Our most ardent supporters are those who were once skeptics.”

Dr. Katz emphasized how impressed he has been with the group of professional arts educators, who co-design the curriculum and lead all of the MFA sessions. For those who are curious to see if such a curriculum could be implemented at their institution, he suggests starting by approaching the Education Department of your local museum, which is how he got started.

Terry Canale, M.D. Receives William J. Tipton, Jr., M.D. Award

During the recent annual meeting of the American Academy of Orthopaedic Surgeons (AAOS), S. Terry Canale, M.D. was recognized for his outstanding work in the realms of education, research…he received the William W. Tipton Jr., M.D., Leadership Award.

Dr. Canale, former president of both AAOS and the Pediatric Orthopaedic Society of North America, received his medical degree from the University of Tennessee Health Science Center in 1967. He completed an orthopedic residency at Jefferson Medical College in Philadelphia and spent a year at the U.S. Army hospital in Fort Hood, Texas. He joined the staff of the Campbell Clinic in 1974, eventually becoming chief of staff. At present, Dr. Canale is professor and chairman of the University of Tennessee-Campbell Clinic (UTCC) department of orthopedic surgery and president of the Campbell Foundation.

Asked about his ‘theory’ of leadership, Dr. Canale told OTW, “My ‘theory’ of leadership is to lead by example and surround yourself with good people. I believe that if people see you doing the right thing, they will follow your example. Telling people what to do doesn’t work if the leader is just talking the talk but not walking the walk. Everyone needs to feel invested in whatever issue is at hand and not feel as if they are simply cogs in the machine. The more of myself I invest—in the form of longer hours, more responsibility, increased participation—the more I can expect from those I lead.”

As for a difficult leadership challenge, Dr. Canale noted, “One of the most difficult leadership challenges in my role as Chief-of-Staff of the Campbell Clinic was the decision to close our original long-time location in the medical district and build a new facility in the suburbs. Knowing this would entail a lot of money, effort, and time, many of our staff members were hesitant about making such a drastic move. I was able to allay many of their misgivings by making sure that all the negotiations and plans were clearly transparent and by expressing my certainty that the move would be beneficial for the clinic, not just for me. I believe that my continued expressions of confidence in the wisdom of this decision played a big part in convincing my partners to feel the same.”

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