On quality initiatives…

We enjoyed the coverage of the inaugural meeting of the Orthopaedic Quality Institute (“Who defines quality in orthopaedics?” AAOS Now, December 2011). The meeting reflects two critical aspects of a strategy to improve the delivery and quality of musculoskeletal care: collaboration and communication.

The Orthopaedic Quality Institute represents a paradigm shift in healthcare reform. No longer is it “us versus them”; we must work together. The article is also a wonderful reminder of the need for open dialogue—to articulate the value of registries and show the value of our healthcare system.

Throughout our medical education, professors and mentors impress upon us the importance of communication with our patients. Business school is no different, often dedicating entire courses to the subject. Fundamental to communication, however, is understanding the language and perspective of the audience. Just as we use different jargon when speaking with colleagues and patients, we must communicate with payers, government officials, and others in appropriate terms.

Although residents must master our craft so we can confidently and competently care for our patients, understanding the “other” side of medicine will ultimately make us more effective patient advocates. Offering business education as part of medical training is not necessarily meant to make us practice managers or even more savvy businesspersons; rather, it is intended to develop the next generation of physician leaders. 

To keep a receptive audience with administrators and policy makers, we must understand our profession and our value proposition from multiple perspectives and communicate that value clearly. We may not like the system, but to change it, we must understand it.
James M. Saucedo, MD, MBA and Lalit Puri, MD
Chicago

On resident education…
No one is addressing the problem of orthopaedic residents who finish training programs and are incompetent. Some orthopedic residents are unable to pass their Board exams, but failing the exams and never becoming board-certified does not keep them from practicing in the community. As an organization, the AAOS should not allow this to continue, because its mission is to provide a better standard for all patients, as it relates to orthopedic care.

To get a medical license, one must pass a State Board examination. No test, however, is given at the end of a residency program. The in-service examination does not determine whether one finishes the program or not. Perhaps orthopaedic training should have a final examination, or residents should eventually have to pass the Boards.

I propose that an orthopaedic surgeon who fails the Board examination three times must go back and repeat a year of residency. This would likey force residency programs to be more in-tune to the needed training of the orthopaedic residents to make them competent.

Although the Board failure rate is low, it is not acceptable and should not be occurring. Either our standards are too high or our residency programs are actually producing incompetent orthopaedic surgeons. In my opinion, making sure that doctors who finish qualified programs eventually become board-certified may have as big an impact on society as the recertification process. At the very least, it should be something that the AAOS, as an organization, should consider, emphasizing that everyone who wants to practice orthopaedic surgery must become board-certified.
Gary L. Painter, MD
Loma Linda, Calif.

Editor’s note: The American Board of Orthopaedic Surgery (ABOS), not the AAOS, establishes standards for the education of orthopaedic surgeons and evaluates achievement of those standards through examinations and practice evaluations. Active fellowship in the AAOS is limited to orthopaedic surgeons who have been certified by the ABOS, have a full and unrestricted medical license, and practice in the United States or Canada.

On childhood obesity…
We would like to commend the authors of “The battle against childhood obesity” (AAOS Now, December 2011) for their advocacy efforts. Orthopaedic surgeons need to take a leadership role in addressing childhood obesity.

The 2011 Leadership Fellows class, working with Academy staff, has put together a public education campaign that addresses childhood obesity. Get Up! Get Out! Get Moving! is something any member can do in his or her local community to help influence healthy behaviors.

Orthopaedic surgeons need to take a leadership role and work together with patients, parents, teachers, coaches, pediatricians, and other healthcare providers to help combat this growing epidemic. Any Academy member interested in our interactive program can start by setting up an appointment at their local elementary school to teach students the importance of healthy eating and daily exercise.

Get Up! Get Out! Get Moving! materials include an introductory letter; a short, interactive PowerPoint presentation; AAOS public service advertisements and activity worksheets (word finds, crossword puzzles, and exercise sheets), all available on the AAOS website (www.aaos.org).

We challenge each and every AAOS fellow to make just one school presentation—it’s a great way to get involved in the community and make a difference. Get Up, Get Out, and Get Moving!
AAOS Leadership Fellows Class of 2011

On antibiotic prophylaxis ...
We read the article “Should Vancomycin Be a Routine Perioperative Antibiotic Prophylaxis for TJR Patients?” (AAOS Now, January 2011) with great concern. We were surprised by the publication of this preliminary study presentation in light of the AAOS official guidelines with regard to antibiotic prophylaxis.

Although these findings are relevant and the topic of optimal antibiotic prophylaxis is something we strive for in all of our patients, we fear that the statement this article makes will encourage widespread use of a very powerful antibiotic without much data.

A recent systematic review of this treatment strategy found only three studies (including this one) that examined this strategy. When the results were meta-analyzed, no difference was found between vancomycin-augmented prophylaxis and standard of care prophylaxis. In a study at our institution, adding vancomycin to standard of care antibiotics resulted in no difference in infection rates.

This is the only study to date that we are aware of (out of four) that has shown a difference. As such, it may have been a statistical anomaly. Only another two patient events (infections) in either group would have been required to cause these authors to retain their null hypothesis; as such, it is difficult to justify a change in practice based on these results. Their design (using historical patients as controls) could easily account for two infections.

Other factors may have been in play that decreased infection rates or one or two events (infections) may have been misclassified. Even assuming that the results are true, the number needed to treat to prevent one infection is around 170, so this hardly represents a clinically effective treatment.

Vancomycin prophylaxis is by no means a free ride. In a Veterans Administration population, patients who received vancomycin prophylaxis had a higher infection rate in the absence of a carrier state. Additionally, AAOS guidelines recommend against the routine use of vancomycin prophylaxis except in the presence of B lactam allergy or known methicillin-resistant Staphylococcus aureus colonization. The Centers for Disease Control and Prevention also agree.

We agree with the authors that further study is warranted, because antibiotic resistance patterns have clearly changed since the study on B lactam antibiotics in total hip replacements was performed. At this point, however, we believe that to conclude that vancomycin is a useful prophylaxis against surgical site infection would require a randomized controlled trial. We sincerely hope this practice does not result in creation of a resistant bug we cannot treat.
Keith Baldwin, MD, MPH and Gwo-Chin Lee, MD
Philadelphia

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