Practice management for residents
I appreciate the recent editorial on teaching residents about practice management in an open minded and realistic manor. About 10 years ago, I started offering “The Business of Medicine” for orthopaedic residents at the Medical University of South Carolina (MUSC). I wanted residents to be better prepared for the real world than I was.

I had acquired enough knowledge through my multiple mistakes to understand that I really did not know much, so I enlisted local experts (certified public accountants and financial planners, attorneys, registered real estate agents) to talk to residents. Topics range from choosing a practice and evaluating employment contracts to contract negotiations, debt management, and asset protection. It’s really more of a “Life Skills” curriculum than a “How to Run a Practice” course. The lectures are among the best attended in the department.

The goal is to educate and not to “sell” any products or services. Talks by the local experts are screened to ensure the education mission is foremost. If not, they are asked not to come back.

The program has been so well received that residents from other departments have requested that these topics be added to their curricula. Now 15 different residency and postgraduate programs at MUSC offer them, and several other teaching institutions have requested the curriculum. We are currently designing a web-based course so that we can bring these much-needed topics to other residency programs.

Our experience speaks to the need of teaching residents about the financial aspects of the real world, how to avoid the “piranhas,” how to find good advisers, and how to plan for their future to maximize the enjoyment of their practice and make more time for their families and hobbies.
Joseph J. Calandra, MD
Mount Pleasant, S.C.

Just read the great editorial on practice management for residents and could not agree more. About 5 years ago, Tally E. Lassiter Jr., MD, started a program for Duke residents that he called “Leaving the Duke Nest.” This evening seminar was held about once every 2 months on various aspects of running and managing a practice. He invited speakers from Duke and the community, and the overwhelming resident response was positive. Since he has left Duke, however, the program has lapsed somewhat.

Count me in if you need support for this idea. It is long overdue. I always tell our shoulder and elbow fellows that they absolutely need to go to a KarenZupko coding course.
William J. Mallon, MD
Durham, N.C.

Editor’s note: Dr. Mallon is a member of the AAOS Practice Management Committee and editor-in-chief of the Journal of Shoulder and Elbow Surgery.

No more mandates!
I just finished reading the July 2012 edition of AAOS Now and am relieved that I am in the twilight of my career. The ongoing and upcoming administrative mandates, government dictates, and new AAOS/ABOS rules and regulations are overwhelming to any reasonable practicing orthopaedic surgeon.

Within this issue, I found about 20 new and ongoing practice intrusions, all under the guise of patient safety or quality care, ranging from FDA regulations to mandated resident education, and from electronic health records to ICD-10. Don’t forget all the vendor ads, too.

With all of these government and peer agencies working to keep us out of the office, no wonder that a study cited in this issue found reduced patient access to health care.

As I like to tell anyone who will listen, I’m mad as hell and not going to do it anymore! Let the politicians and bureaucrats cover the emergency department for awhile. It’s time all of us just said no.
Joel E. Cleary, MD, MHA
Helena, Mont.

Increasing diversity

I have been a practicing orthopaedic surgeon for 20 years and love the practice of orthopaedic surgery. I hope and pray that anyone who is interested in orthopaedics is considered regardless of race or sex.

Orthopaedics remains one of the most sought-after residencies, and frankly, I can’t imagine doing anything else. I considered myself very fortunate to have secured a residency position after a tremendous amount of sacrifice and hard work. I applaud the AAOS for its efforts to promote orthopaedics. In my medical school class, although 12 students wanted to match in orthopaedics, only 2 of us did. I think the desire on the part of medical students is definitely there, and unfortunately only so many spots are available.

A few years ago, I proposed a mandatory orthopaedic surgery mission trip to some part of the United States or the world as part of the recertification process. This would far better serve our world than the myriad of tests and having to provide charts and cases to the American Board of Orthopaedic Surgery. 
Daniel G. Kalbac, MD
Miami, Fla.

Metal-on-metal
In my opinion, the metal-on-metal (MoM) hip in resurfacing or modular form is a benighted technology. The annual rate of failure of MoM resurfacings is 2- to 5-fold that of the Charnley low-friction arthroplasty of the 1970s. Adverse reactions to metal debris can lead to soft-tissue and bone deficiencies within several years of implantation, resulting in premature, complex, and complication-prone revision surgeries.

Systemic exposure to chrome/cobalt nanoparticles generated at a MoM hip bearing can result in damage to the central and peripheral nervous systems, the heart, and the thyroid gland and places patients at an increased risk for lymphoma, immune abnormalities, and chromosomal aberrations.

I consider the implantation of these hips an indication of the entrepreneurial corruption of our surgical practice, educational processes, and governance.

The theoretical promise of the MoM hip was presented at past AAOS annual meetings by panels of arthroprosthetic “thought leader” design surgeons who profited from the sales of these devices. These surgeons then minimized the frequency and severity of the complications from this technology at the 2012 meeting, without taking questions from the audience.

I do not believe that the best interests of the MoM hip implantee who requires monitoring or the arthritic patient who is considering a hip replacement are being served by such an educational program. The community arthroprosthetic surgeon is also compromised in that he or she will bear the burden of the failed arthroplasty and will be held accountable for failure to recognize and manage local or systemic complications that might progress beyond remediation. I attempted to redress this deficiency by organizing a panel of professors without commercial interest to address the relative merits of the MoM hip at the 2013 meeting, but my application for a symposium slot was rejected by the Central Program Committee.

I believe the AAOS has failed to allow experts without commercial interest to candidly address the alternatives, risks, and benefits of the MoM hip. I equate the failure of surgeons to monitor patients systematically for the presence and complications of chrome-cobalt metallosis to patient abandonment.
Stephen S. Tower, MD
Anchorage, Alaska

Editor’s note: Dr. Tower is the author of “Arthroprosthetic Cobaltism: Neurological and Cardiac Manifestations in Two Patients with Metal-on-Metal Arthroplasty: A Case Report,” The Journal of Bone and Joint Surgery (December 2010) and is himself one of the patients discussed in the report. Citations for the studies Dr. Tower cites in his letter can be found below.

1. Berry DJ, Harmsen WS, Cabanela ME, Morrey BF. Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements: factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg Am 2002;84-A(2):171-7.
2. Prosser GH, Yates PJ, Wood DJ, Graves SE, de Steiger RN, Miller LN. Outcome of primary resurfacing hip replacement: evaluation of risk factors for early revision. Acta Orthop 2010;81(1):66-71.
3. de Steiger RN, Miller LN, Prosser GH, Graves SE, Davidson DC, Stanford TE. Poor outcome of revised resurfacing hip arthroplasty. Acta Orthop 2010;81(1):72-6.
4. Polyzois I, Nikolopoulos D, Michos I, Patsouris E, Theocharis S. Local and systemic toxicity of nanoscale debris particles in total hip arthroplasty. J Appl Toxicol 2012;32(4):255-69.
5. Tower SS. Arthroprosthetic Cobaltism: Neurological and Cardiac Manifestations in Two Patients with Metal-on-Metal Arthroplasty: A Case Report. J Bone Joint Surg Am 2010;92(17):2847-51.
6. Hart AJ, Skinner JA, Winship P, Faria N, Kulinskaya E, Webster D, et al. Circulating levels of cobalt and chromium from metal-on-metal hip replacement are associated with CD8+ T-cell lymphopenia. J Bone Joint Surg Br 2009;91(6):835-42.

According to the AAOS Annual Meeting Committee, 72 symposia applications were received for 28 slots; 10 applications were received for the three slots on adult hip. The AAOS has issued three Patient Safety Alerts on MoM, and AAOS Now continues to provide research and regulatory updates and reports on the status of MoM bearings, including three articles in this issue. For links to these and additional AAOS educational resources on MoM bearings, see the online exclusive “AAOS Resources on Metal-on-Metal Bearings.”

Setting Now Straight
AAOS Now welcomes reader comments and efforts to “set AAOS Now straight.” We reserve the right to edit your correspondence for length, clarity, or style. 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