Week 5

7/13

This week has been a very interesting week. I shadowed Dr. Rodeo for three days, two in out-patient clinic and one in surgery. I got to experience the “behind the scenes” clinicians daily work and how they make the discussions they make in term of patient communications and treatments. And I was surprised to realize that, especially in orthopedic, how much of those are influenced by the goals of the patients.

The patients received can be generally categorized into two groups: patients who are not very active and patients who are highly active/athletes. The treatment decisions are easy to make with the former, normally with goal of regaining daily function in mind starting from the least invasive options (such as physical therapy and/or injections of various sorts) and eventually to joint replacement. However, it is not the case with highly active patients and athletes. The them, the goal is to get back to the game which involve many high impact activities, and because of their past active lifestyles many of them have quite sever chondrophyte, tendinopathy, or both. For these patients, if they were to quit their current lifestyles, the best options would be to have total joint replaces. However, that often not what the patients came to HSS for, and unfortunately many of them are too young to be the ideal candidates for total joint replacements. In these cases, it is important for the clinicians to learn the goal of the patients and carefully communicate to them of what is realistic, then come up with a plan that will best suited for the particular patient. Sometimes these treatments may not seem to make sense for the patients’ conditions, however, is the “better” treatment will result in the patient never to be able to run/ski/surf like he/she wants ever again really a “better options”? There was this middle-aged lady that came in during one of the days I shadowed in out-patient clinic. She seemed to a very happy and optimistic lady, and you would not be able to tell how much pain she must be in by simply interacting with her. After examinations, it turns out that her ACL was long gone, which caused the MCL to be partially torn from over loading, the meniscus of both her knees were damaged and there was barely any cartilage left. She was very active—hiking, surfing, skiing, and was very good at pushing through pain. If not considering her goals, it would be the best for her to undergo total knee replacements on both sides and return to only mild to moderate exercises. However, this means that she would have to give up her live style that meant very much to her entirely, which not at al what she wanted. In the end, she walked out with PT prescriptions to strengthen her muscle groups around the knee (they are solely responsible to stabilize the knee joint in the absence of the tendons). Maybe she will eventually take a step back in term of extreme sports in a couple of years and undergo total joint replacements, but now is not a good time even though everything on paper would tell you otherwise. This is only one example of how the patients’ goals will affect clinicians’ decisions. There are other incidents that the clinicians’ assessment will realign the patients’ expectations. These are all achieved through good communication, which I know realize how important a role it plays in healthcare.