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Published 9/1/2007

Readers respond to treatment guidelines, Medicare strategy

I generally welcome the clinical guidelines the Academy publishes (AAOS Now, July 2007), but wish to take exception to the recommendation, in the Clinical Guideline on Diagnosis of Carpal Tunnel Syndrome (CTS), regarding electrodiagnostic tests:

Recommendation 3.1c
The physician should obtain electrodiagnostic tests if clinical and/or provocative tests are positive and surgical management is being considered. (Level II and III, Grade B)

A good history and physical exam will usually yield a reliable diagnosis of carpal tunnel syndrome. I feel the recommendation should read:

The physician may obtain electrodiagnostic tests if … surgical management is being considered.

Most patients don’t need the test to confirm the diagnosis, and none of them likes the test, so why not just do it if there’s doubt about the diagnosis?

Thank you.
Gabriel Gluck, MD

Manassas, VA

Dr. Keith responds:
You raise a good point regarding the use of electrodiagnostic tests in the diagnosis of carpal tunnel syndrome. The Guidelines Committee carefully considered the language of the Guideline document and actually reviewed the hierarchical differences in the meaning of “must,” “should,” and “may” for each recommendation (
http://gem.med.yale.edu/default.htm, on the use of language and organi-zation of Guidelines, reviewed 08/07/07). These words are the formal alternatives in the careful application of a process of making “Recommendations.”

The evidence base in this case was strongly in support of the statement that the best results of treatment were obtained in those cases in which a clinical diagnosis of carpal tunnel syndrome was made and it was confirmed—that is, other diagnoses were excluded as well—by electromyography (EMG). Evidence-based studies showed that both EMG and clinical examination correlated with good surgical outcome better than either clinical examination or EMG alone.

We indicate that the test (cost, morbidity, delay) should be deferred as long as conservative management is intended, but at the point where an irreversible decision for choice of surgical technique, exposure, risk, and commitment to postoperative management was being made, the additional certainty of the EMG and nerve conduction study in the diagnosis would select those patients who would then have the best results with that surgery.

We recognize that clinicians with considerable experience treating carpal tunnel syndrome with surgery are more likely to have the certainty that you express in your letter, but as this guideline is written for a very broad audience who may never have followed a case from differential diagnosis to cure, performed an operation, or seen the results of treatment, we felt the stronger recommendation, Grade B, based on higher level evidence, levels 2 and 3, was the appropriate choice. For examples of other guidelines and their language, please refer to http://ngc.gov (reviewed 08/07/07).

Michael W. Keith, MD
Chair, CTS Guidelines Workgroup

I read Dr. Patel’s recent letter to AAOS Now (August 2007) with appreciation for his attitude toward the elderly. However, I was disheartened to read the comments by Dr. Hilibrand. Implicit in his response is the notion that if the orthopaedic community causes enough inconvenience to or increases the suffering of the elderly enough by our refusal to treat them, they may complain to policy makers, and our reimbursement for treating them may increase. (Of course, their complaints might also lead to something much less desirable, such as onerous new regulations designed to guarantee their access to the physician of their choice.)

We are not a profession of bankers; healing the sick and diminishing their suffering is our first concern. Finances are a secondary or even tertiary matter. The July issue of AAOS Now details a recent survey in which the mean orthopaedist’s income is $655,291 (“Orthopeadic Revenues and Expenses Keep Increasing”). This compares favorably to the most recent AAOS member survey in which orthopaedists reported a mean income of $394,000. Depending on the survey, our income is nearly 10 to 16 times the average worker’s income in this country and significantly greater than most other physicians.

These figures place us well within the top 1 percent of wage earners. Therefore, the refusal to treat Medicare patients is not an issue of economic survival or our need for greater reimbursement. It is an issue of compassion and generosity.

Every orthopaedist that I know would like to see himself as a generous and compassionate individual. By definition, this means one must make decisions that put others’ interests before one’s own. As actions define a person, one can neither be compassionate nor generous by withholding treatment from those seeking it in the hope of making more money.

I am not only a practicing orthopaedist, I am also a patient afflicted with recurrent non-Hodgkin’s lymphoma. I have undergone many treatments, including a stem cell transplant. I can assure my colleagues that the inconvenience, suffering, despair, and losses associated with illness are nearly beyond the capacity of the healthy to understand.

As individuals and as a profession, we are blessed to be in the position to alleviate this suffering; we should never by our actions or inaction do anything to increase the suffering, inconvenience, or worries of the ill, no matter what our motivation, and certainly not when we are already very highly compensated.

James B. Rickert, MD
Bloomington, Ind.