Dear Dr. Canale

I take exception to two of the comments in your editorial, “My New Total Hip Replacement—not MoM” (AAOS Now, May 2012). First is the contention that only through direct experience can we surgeons understand the conditions we treat. We certainly need to have empathy, but our profession demands that we remain aloof and objective as we attempt to understand and manage the myriad problems that confront us.

Second is that the pain associated with total hip replacement (THR) is so severe that it cannot be managed. Although you selected your surgeon based on his good long-term results, you could have had an entirely different experience if you had been as selective in picking a surgeon who also focuses on managing postoperative pain. In my own small practice, I have found that the judicious application of a multimodal pain management program has made an enormous difference in the comfort level my patients experience after THR surgery. It is not uncommon for my patients to say that on a 0 (least) to 10 (most) pain scale, their pain level is 0 or 1 on the first morning after surgery, when the physical therapist arrives.

Although multimodal pain control has generated considerable interest among orthopaedic surgeons, it has not yet achieved a high level of acceptance in actual practice. I hope your experience will motivate you to promote modern multimodal postoperative pain management services for patients.
Owen A. Nelson, MD
Belfast, Maine

Update on IMG “loophole”
European physicians share many of the same concerns about medicine that physicians have in the United States, as a recent fellowship trip reminded me. Among these concerns are the devaluation of physicians’ contributions to society and quality of life, the poor reimbursement given the long educational process, and the amount of government interference adversely affecting delivery of care.

I was surprised at how many physicians and residents asked about an “institutional license” as a way to avoid the Educational Commission for Foreign Medical Graduates’ (ECFMG) established process and as a back door to a U.S. medical license without board certification or any Accreditation Council on Graduate Medical Education (ACGME)-certified training. The countries of the European Union produce many more physicians than can be offered positions, so the surplus must go to other countries to find employment. The United States is an attractive outlet, but only if a way can be found to avoid the stringent process established by the American Board of Medical Specialties, the ACGME, and the ECFMG.

The teaching or institutional license will continue to be a viable alternative for international medical graduates (IMGs) unless this loophole is closed. The individual state licensing boards must reevaluate and eliminate an alternative that has no nationally recognized standards for certification, but relies on the recommendations of a dean or department head in a medical school.
William A. Grana, MD, MPH
Tucson, Ariz.

Setting Now Straight
If you want to set AAOS Now straight, send your letters to the Editor, AAOS Now, 6300 N. River Rd., Rosemont, Ill. 60018; fax them to 847-823-8033; or email them to aaoscomm@aaos.org