Personas Part 2

Part
01
of fourteen
Part
01

General Surgeon Persona: Pain Management Options

Surgeons often learn about new medical technology, including medications, from medical sales representatives, experience working in the field, and through the social media channels that they follow. Unfortunately, specific information on the primary or top methods used by general surgeons to find or learn about new options for mitigating pain in patients is not available.


KEY FINDINGS

  • Medical sales representatives are expected to be experts on the devices and tools they sell. Furthermore, they provide technical assistance to surgeons during surgical procedures.
  • Justin Barad, MD, co-founder and CEO of Osso VR argues that surgeons become increasingly reliant on Medical sales representatives to inform them of what to do during the surgery, especially if something goes wrong."
  • According to research published by Harvard Business Review, surgeons are using social media to share and learn new skills.
  • Surgeons on social media channels like Facebook engage in numerous online discussions every day among practicing surgeons worldwide.
  • The American Surgical Association is the premier organization for surgical science. They provide a national forum for presenting new surgery technologies. Furthermore, they promote high standards within the medical/surgical profession.
  • Uptodate is one of the medical educational support resources associated with improving outcomes and providing the most recent medical information to surgeons. The website also provides the latest updates in general surgery.


RESEARCH STRATEGY

We began this research by looking through scholarly articles and reports that included information on the top or primary methods surgeons use to learn about alternative or new ways to mitigate pain in patients. While we were able to find multiple sources discussing new ways to mitigate pain in patients, we could not find any that specifically referenced how surgeons typically look for this information themselves.

As a second approach, we referenced the official websites for top surgeon associations such as Americansurgical, AANA, and AAST to see if these sites have published any information on primary or top sources/methods used by general surgeons to learn about new options for mitigating pain in patients. However, this strategy did not work as the information found was about the education courses, conferences, and other similar materials.

Next, we looked for interviews with top general surgeons in the United States with a focus on those who discuss alternative or new ways of managing pain in patients. We aimed to see if any general surgeons mentioned their process when it comes to determining new ways of mitigating pain after surgery. However, when discussing their practice, surgeons typically focus on best practices for surgery and new techniques during surgery.

As a final method, we expanded our scope to include information on how general surgeons learn about any new medicines. We referenced industry-specific blogs and journals, scholarly articles, and press releases on the topic. We had hoped this data would provide insight into how general surgeons learn about new ways to mitigate pain in patients. However, the majority of the information regarded pain killers used by general surgeons for various types of surgeries. Additionally, we found information on how surgeons learn about technology and new surgery methods. However, there was no information on how general surgeons learn about new ways to manage a patient's post-surgery pain.
Part
02
of fourteen
Part
02

Orthopedic Surgeon Persona: Pain Management Options

While information specific to pain mitigation is not available in the public domain, there are sources suggesting that the top sources of information of orthopedic surgeons in the United States for determining the best treatment for their patients are journals or scientific literature, training courses/workshops, scientific congresses/conventions, meetings with colleagues, and medical videos, podcasts, or webcasts. Most surgeons, including orthopedic surgeons, meet with sales representatives to learn about new products.

JOURNALS OR SCIENTIFIC LITERATURE

  • Orthopedic surgeons consider peer-reviewed journals trustworthy sources of "high-quality, evidence-based literature."
  • Print sources, such as peer-reviewed journals, are sources orthopedic surgeons use to collect information about which products are best for their patients.
  • Fifty-one percent of orthopedic surgeons rate scientific literature as a very good source of information for determining treatment for patients, while 43% rate it as a good source.
  • Among the highly valued journals is the Journal of Bone and Joint Surgery. Its well-trusted and peer-reviewed scientific process makes it one of the top-rated journals in the field of orthopedic surgery.
  • Sixty-three percent of surgeons find current medical journal issues in print important.
  • Ninety-three percent of surgeons are reached by current medical journal issues in print.
  • Fifty-five percent of surgeons find online or app versions of current medical journal issues important.
  • Eighty-one percent of surgeons are reached by online or app versions of current medical journal issues.

TRAINING COURSES/WORKSHOPS

  • Thirty-six percent of orthopedic surgeons rate training courses or workshops conducted by independent organizations as a very good source of information for determining treatment for patients, while 52% rate them as a good source.

SCIENTIFIC CONGRESSES/CONVENTIONS

  • Thirty-two percent of orthopedic surgeons rate scientific congresses as a very good source of information for determining treatment for patients, while 54% rate them as a good source.
  • Fifty-six percent of surgeons recognize the importance of attending conventions.
  • Seventy-two percent of surgeons recognize the importance of attending continuing medical education (CME) meetings.
  • The Annual Future of Spine + The Spine, Orthopedic and Pain Management-Driven ASC Conference appears to be a well-attended scientific congress. It has been held for 17 consecutive years already. This year's conference, which was held in Chicago last June, had over 1,100 attendees.

MEETINGS WITH COLLEAGUES

  • Twenty-three percent of orthopedic surgeons rate "local meetings with colleagues" as a very good source of information for determining treatment for patients, while 51% rate them as a good source.

MEDICAL VIDEOS, PODCASTS, AND WEBCASTS

OTHER SOURCES OF INFORMATION

  • Twenty-three percent of orthopedic surgeons rate textbooks as a very good source of information for determining treatment for patients, while 50% rate them as a good source.
  • Twelve percent of orthopedic surgeons rate training courses or workshops conducted by manufacturers as a very good source for determining treatment for patients, while 42% rate them as a good source.
  • Twelve percent of orthopedic surgeons rate "information from the Internet" as a very good source of information for determining treatment for patients, while 31% rate it as a good source.
  • Two percent of orthopedic surgeons rate newsletters or white papers from manufacturers as a very good source of information for determining treatment patients, while 18% rate them as a good source.
  • Fifty-seven percent of surgeons find sales representatives important.
  • Sixty-four percent of surgeons who meet with sales representatives say they do so because sales representatives have new products to discuss.that they would like to learn about.

RESEARCH STRATEGY

We first checked if there are sources in the public domain that readily indicate how orthopedic surgeons find new options for mitigating patient pain. We did this by looking for articles or reports that focus on this particular topic and searching publications or websites that focus on orthopedic surgery. Examples of sources we consulted include Healio's Orthopedic Today and the American Academy of Orthopaedic Surgeons. This strategy led us to a number of articles on pain management and the role of orthopedic surgeons in it, but unfortunately, these articles do not contain any information on how orthopedic surgeons find out about new options for mitigating pain.

Because our first strategy did not produce helpful results, we proceeded to research the top sources of information of orthopedic surgeons. We figured that if we know what the most commonly used information sources are, we could perform more focused searches. We assumed as well that the most common types of sources orthopedic surgeons consult will likely remain the same regardless of the type of information the orthopedic surgeons are seeking. Thankfully, this second strategy proved more effective than our first strategy. After consulting sources such as those published by Kantar Media, NCBI, and BioMed Central, we were able to learn that, as revealed by surveys, scientific literature, training workshops conducted by independent organizations, scientific congresses, meetings with colleagues, and medical videos, webcasts, and podcasts are the top sources of information of orthopedic surgeons in determining the best treatment for their patients. We found too that most surgeons, including orthopedic surgeons, meet with sales representatives to learn about new products. Please note that one of our sources is based on a global survey. We decided to include this particular source because most of the respondents were from the United States.

Finally, we looked into these top sources of information one by one and checked if we could locate insights specific to pain mitigation. Though this last strategy, we were able to learn how well-attended the Annual Future of Spine + The Spine, Orthopedic and Pain Management-Driven ASC Conference is.
Part
03
of fourteen
Part
03

General Surgeon Persona: Technology Adoption

Anecdotal evidence suggests that surgeons in the US generally study and adopt new technology in order to preserve professional readiness and with an eye to improving efficiency and safety, however, they do so cautiously and with some reluctance to adopt radical change. There is little hard data available from publicly accessible sources concerning the exact technological adoption rate among US surgeons nor enough data to tie that rate to the willingness or tendency of US surgeons to try new products.

HELPFUL FINDINGS:

General Surgeons typically adopt new technology in the US:

  • One study shows that bariatric surgeons do a lot of ongoing research because they feel they need to know what is changing in their field.
  • Bariatric surgeons strive to be up to date with what is happening in the world and regarding the new technology they use to solve their problems.
  • Per the American Society of Colon and Rectal Surgeons, there has been significant expansion of new techniques and instrumentation for advanced endoscopic procedures.
  • Colorectal surgeons are uniquely positioned to adopt with new techniques and technology to lead in the field. The adoption of new technology and techniques for surgeons in practice is challenging, but these surgeons are exposed to state-of-the-art methods and technologies.
  • Technology for breast, prostate, colorectal, esophageal, and pancreatic cancers is constantly changing.
  • Plastic surgeon Dr. Tracey Stokes observes that surgeons tend to be "...fairly set in their ways. Surgeons are used to being the captain of the ship, and we’re accustomed to getting the results we get by doing the same thing the same way, every time." He then adds the caveat, "That being said, there are many surgeons, like myself, who are early adopters of technology. If there’s something that I’m going to use differently in the OR, there has to be a reason that I’m changing from what I’m comfortable with and what I’m used to getting reliable results with. A new technology needs to be innovative, or time-saving or safety-enhancing."
  • With the adoption of new technology, the surgeons needs to be innovative, must be involved in time-saving or safety-enhancing.

Correlation between this adoption rate and their likelihood to use new products in their medical practice:

  • As per University of Iowa Hospital & Clinics, colorectal surgeries offer a minimally invasive approach to gastrointestinal surgeries, enhanced with news advanced technology which is robotic surgical technology. This new technology enhances a surgeon’s ability to perform the fine suturing required for the procedures.
  • The clinical team of hernia researchers have developed ways to use new technology, including crowdsourcing, as a platform to evaluate lay perception of prophylactic mesh placement to be used in open abdominal surgery. With the adoption of this new technology, it helps to prevent incisional hernias.
  • Healthcare organizations such as Colon & Rectal Surgical Specialists, and Doylestown Health, use advanced technology to detect and treat a range of colorectal conditions and surgeries such as colon, rectum, anus and small intestine.
  • Robotic surgery is an extension of the laparoscopic approach used in colorectal surgery. It harnesses advanced high-definition video optics and robotics technology to provide colorectal surgeons with better visualization that significantly improved precision and accuracy during dissection.

Research Strategy:

We began our research with respected market research firms such as Grandview Research, Markets & Markets, and Transparency Market Research. In the past, these sources have been helpful in providing high-quality, quantitative analyses of market trends, market sizing, and technological adoption rates. Unfortunately, none of the publicly accessible research we uncovered offered a sufficiently granular breakdown to isolate the rate of technological adaptation specifically among American general surgeons, nor were we able to gather enough information to make informed extrapolations from the available data.

Next, we turned to high-quality general media sources and those with e medical industry focus such as US News, Medical News Today and MyStrikingly.com. One of these sources produced a general analysis of technological adaptation specifically for bariatric surgeons, but that source lacked specific statistical data. We did explore that article's sources and uncover a few details and a useful insider quote. These insights might allow one to infer that technological adaptation is undertaken cautiously but actively by surgeons. That data is presented above in the Helpful Findings section.

Hoping to find more concrete data, we dove into Healthcare discussion forums and industry expert sources such as the American Society of Colon and Rectal Surgeons, University of Iowa Hospital & Clinics, and Penn Medicine. We had hoped that interviews and articles focused on high-profile medical and surgical personnel might lead us to scientific data about technological and product adoption rates, but this strategy did no bear fruit beyond a few additional helpful insights presented above.

Next, we turned to medical research sources such as Medical Design & Outsourcing and datausa.io and their peers. Although these sources generally focus on medicine and technology itself, rather than doctors and technological markets/adoption, we thought it might be possible to follow the thread of such research back to discussions of surgeons and products. Some insights emerged regarding the total workforce, average age, and salaries of US surgeons, but not enough to formulate a clear picture of those surgeons' technological or product adoption rates.

As a final strategy, we did look at combining and analyzing the data we had gathered in order to estimate or calculate some approximation of the technological or new product habits of surgeons in the US. While our research team tried combing the available information in a few ways, both deductive and inductive, none of the data that emerged rose to the level of high- or even medium-confidence estimates, so we chose to omit those calculations.

In the end, while we believe the data suggests that surgeons in the US do engage with new technology as a matter of professional readiness and out of a desire to improve efficiency and safety, they do so cautiously and with some reluctance to adopt radical changes to their tried-and-true practices. Unfortunately, we were wholly unable to gather hard data about technological adoption rates among US surgeons nor tie any such data to the willingness of US surgeons to try new products.
Part
04
of fourteen
Part
04

Orthopedic Surgeon Persona: Technology Adoption

Orthopedic surgeons are informed about new technological advancements in their field almost every single day and their technology adoption rates will continue to grow as long as the new technologies are safe, effective, and economically feasible for the patients.

TECHNOLOGY ADOPTION


HARD DATA RELATED TO THE ADOPTION OF NEW TECHNOLOGIES BY ORTHOPEDIC SURGEONS

  • The number of Orthopedic Devices with premarket approval from the US Food and Drug Administration increased by 400% from 2002 to 2012.
  • Not using computer-assisted surgery resulted in improper placement of (1) implants (30% of the time) and (2) pedicle screws during spine surgery (42% of the time).
  • As a result, adoption of CAs is increasing rapidly among surgeons with 17% surgeons currently using CAS.
  • After the launch and first use of Medtronic's Mazor X stealth edition used for spine surgery on 28th January 2019, one more hospital had installed it by 13th May 2019.
  • Surgeons are willing to adopt and spread technologies like that are safe, effective, and cost-effective.
  • Dr. Giovanini has performed more than 100 surgeries using the Mazor/Medtronic Renaissance system since its launch in 2011 and is willing to teach using the technology, in order to aid its widespread use among healthcare professionals.
  • Another study for the adoption of new knee implants showed a potential 90% adoption rate by 2025 owing to its effectiveness and cost feasibility.


COST-EFFECTIVENESS CONSIDERATIONS

  • New implants that offer a 50% decrease in long-term failures at a 50% increased cost could be considered as acceptable by Orthopedic Surgeons as an adoptable innovation technology.
  • Those that offer less than 50% decrease in long term failures at more than 50% increased cost isn't considered as a cost-effective option by WHO guidelines.


INFORMATION RELATED TO OPIOIDS AND ORTHOPEDICS


RESEARCH STRATEGY:

We began our research by searching for precompiled research reports about orthopedic surgeons' readiness to adopt new technologies. We were hoping to find studies that showed data about how they judge whether they should consider using new technology or continue the old methods, and some examples as proof for why and how they decide. We could only find data about how they would decide if new technology is ready for adoption or not. We were unable to find a study that showed hard data, numbers, or statistics for such information. We then checked for new technologies such as robotic spine surgery and knee implants in the market and the rates at which the hospitals(and by effect, orthopedic surgeons) are adopting them. We found some examples as well as studies using this strategy and we have provided our findings.
Part
05
of fourteen
Part
05

General Surgeon Persona: Pain Management Opinions

GENERAL SURGEON PERSONA: PAIN MANAGEMENT OPINIONS

Several factors influence how a general surgeon manages post-operative pain. Research suggests that while the cost is a consideration, it is not the primary consideration. Cost plays a greater role in the surgeons' decisions when they receive specific education around the costs of a particular medication. The existence and type of insurance coverage a patient has plays a role in the medication choices a surgeon makes. There is clear evidence that poorly managed post-operative pain results in a longer hospital stay. This is partly due to the types of drugs currently on the market, the mode of administration and the class of medication needed to treat moderate to severe pain. There are limited medications currently available to successfully treat moderate to severe pain outside of a hospital setting.

GENERAL OPINION AROUND PAIN IN RELATION TO COSTS

  • A 2018 study found the 3 patient-related factors that had the most influence on post-operative pain management were nausea (76.2%), constipation (67.3%) and vomiting (60.3%). It found that the practice-related factors that most influenced post-operative pain management were, the type of previous clinical experience (81.6%), type of surgery undertaken (76.2%) and analgesia onset (67.1%). The study also found 56.5% of surgeons considered the inability to prescribe certain medications due to cost as being one of the top reasons for poor post-operative pain management.
  • A 2017 study found surgeons are generally willing to try new medications in an attempt to improve the management of post-operative pain. Unfortunately, the issues around the costs of these new medications and the relationship to a surgeons' willingness to prescribe the medications were not addressed.
  • An article published in 2000 found the cost of post-operative pain management is a relevant consideration when surgeons prescribe for patients. The article qualified this by saying it must be offset against the cost of extended hospital stays if the pain is not properly managed.
  • By understanding the cost of medications, patterns of administration, patient responses to various medication types and the type of surgery performed a 2000 study found that the management of post-operative pain was improved. This suggests that the cost of the medication does play a role in the prescribing practices of surgeons.
  • A 1991 study provided a group of surgical interns with comparative medication prices, education around prescribing and feedback reports around their prescribing practices. This group was found to prescribe more inexpensive medications than the control group. This suggests that when surgeons are aware of the cost of medications and given education around this topic, the cost does become a potential influencer in prescribing practice.
  • A 2004 study found that while hospital physicians were influenced by the cost of a new medication when considering whether to prescribe it other factors such as efficacy and adverse effects were greater considerations. Pharmacists, on the other hand, were more likely to take into account the cost of a new medication when educating physicians around the use of the medication.
  • Several studies show insurance coverage impacts on the type and amount of medication a patient is prescribed. Patients with poor or no insurance are likely to have poorer health outcomes than patients with insurance coverage. This suggests the extent of the healthcare provided, including the medications prescribed are impacted by insurance coverage.
  • Medication costs account for a significant portion of healthcare spending. This has resulted in insurance companies restricting the use of some more expensive medications. Some insurance companies also limit the number of medications able to be prescribed. Research suggests that in the future a pharmaceutical company will need to prove that the cost of a new medication is justified by the reduced costs in other areas as a result of a patient taking that medication. In a surgical context, this could mean the use of the new drug results in shorter hospital stays.
  • Given this information, it is clear that the cost of medication and a patient's insurance coverage do have a role to play when a surgeon is formulating a post-operative pain management plan for a patient. However, there is insufficient evidence available to suggest the weight given to this factor by surgeons and previous research suggest other factors carry greater weight in prescribing practices.

GENERAL OPINION AROUND PAIN IN REALTION TO HOSPITAL DISCHARGE

  • A 2018 study found discharge from hospital was likely to be delayed if post-operative pain could not be managed effectively. The survey participants were asked to rank the top 3 challenges in post-operative pain management. 40.5% of those surveyed considered the resulting delay to hospital discharge as 1 of the top 3 challenges. The risk of readmission was also considered to be a significant issue for surgeons if post-operative pain management was not appropriately managed before discharge.
  • In 2018 a Singapore study found that poorly controlled pain resulted in longer stays in the post-anesthetic care unit. Although it does not relate directly to hospital discharge it does allow some broad conclusions to be made and confirms the results of other studies regarding the inability to manage post-operative pain and extended hospital stay.
  • A 2017 article found that poorly controlled post-operative pain is likely to impact on both the length of stay in the hospital, with discharge being delayed and patient readmission rates. It also noted the increased financial cost of longer hospital stays and readmission.
  • A 2002 study found post-operative pain as the primary reason for extended hospital stays and patient readmission to hospital following discharge.
  • A 2000 article observed the relationship between poorly controlled post-operative pain and prolonged hospital stays.
  • Although there is little direct evidence regarding what level of post-operative pain can be managed outside of a hospital setting the consensus of the studies to date suggests a patient needs to remain in the hospital if they are experiencing moderate to severe pain.
  • One of the primary reasons for extended hospital stays as a result of ineffective post-operative pain management is the mode of administration around medications for moderate to severe pain. Most of these medications are administered intravenously which means the patient must remain in hospital while these types of medications are being prescribed.
  • Transdermal Fentanyl patches could allow for moderate to severe pain to be managed in a community setting, given they do not require an intravenous line. Unfortunately, at the current time, the prescription of these patches is limited to opioid resistant patients. This means generally they should not be used for post-operative pain management due to the potentially life-threatening side effects associated with there use.
  • Even if a moderate to severe pain can be managed through oral opioids various legislative and policy changes as a result of the opioid epidemic limit the amount of these types of drugs that can be prescribed outside a hospital setting. There are limited non-opioid options available that can manage moderate to severe pain.
  • The primary reasons for extended hospital stays due to moderate to severe pain relate to the mode of administration, the class of medication required to manage this type of pain and recent legislative and policy changes around the ability to prescribe this class of medication in a community setting. The conclusion that can be drawn from this information is that until there are new medications, that can be safely prescribed in the community and effectively manage moderate to severe pain, a surgeon has limited options in terms of discharging the patient from the hospital.

RESEARCH STRATEGY

Despite an extensive search of the evidence-based research, we found no studies that dealt specifically with the impact of cost on a surgeons' willingness to prescribe a new medication. We then considered the impact cost has on the prescription of medications that are currently available on the market as we felt this information had the potential to be applied to new medications and conclusions could be reached on this basis. 

We searched professional journals and other scholarly articles to determine if the cost of a medication influenced a general surgeon's decision to prescribe it. There was limited research around this topic although we did find several articles that considered all the factors that influenced prescribing practices. We included the results of a Singapore study because we felt it replicated the results of studies carried out in the US and as a result carried some weight. Several of these articles were useful as they considered the cost of medication. We also found several articles that dealt with the impact of cost as a peripheral issue and found them useful in providing background on the issue. By cross-referencing various aspects of different studies around prescribing practices we were able to draw some conclusions regarding the impact cost has when surgeons prescribe medications.  

We also considered the impact insurance has on general surgeons prescribing practices. Unfortunately despite searching a range of medical journals and practice guidelines we were unable to find any information that addressed this issue directly. As a result, we expanded our research to include different medical specialties and similar overseas countries. An English study was discarded, despite the cultural similarities between the two countries, due to the different healthcare structure in the United Kingdom. A study around physician prescribing practices based on cost was included because a number of the findings could be applied to a surgical setting.

A literature search of scholarly research found several articles that dealt directly with the issue of post-operative pain management and discharge from hospital. Given the clear relationship between poor post-operative pain management and extended hospital stays we expanded our search to consider the reasons for this and found several relevant articles that addressed this issue.
Part
06
of fourteen
Part
06

Orthopedic Surgeon Persona: Pain Management Opinions

We were unable to find information from primary sources for either a relationship between pain management and cost or pain management and discharge. Articles, presentations and conference transcripts provided insights into what orthopedic surgeons learn during their professional continuing education. That information is provided below.

Cost of Pain Management.

  • When discussing costs of pain management, orthopedic surgeons tend to think not just in terms of dollars, but also of health outcomes for the patient.
  • The comments found most consistently when evaluating new pain management treatments were "improved pain management, shorter hospital stays, and reduced costs."
  • That statement indicates that orthopedic surgeons are aware of the fact that orthopedic surgery is the most painful type of surgery.
  • It also indicates that surgeons make pain management decisions based on what is best for the patient, not the cost of the treatment.

Common themes

  • Comments found from articles about pain management echoed a common theme. Not surprisingly, given the current opioid academic crisis in the US, much of the ongoing discussion in orthopedic literature focuses on stopping the use of opioids.
  • In discussing the importance of physical therapy after surgery a presenter said, "We need technologies that facilitate early discharge and then minimize the side effects. One of the most distressing components of pain management in many patients is the opiate-related side effects. We need to have protocols to minimize the unpleasantness associated with some of the systems that we use."
  • The presenter went on to say, "In my practice, we definitely see patients who are probably over managing their pain perioperatively in terms of taking large doses of narcotics. That's certainly something that we have to deal with."

Discharge and the Responsibilities of Orthopedic Surgeons

  • Pain management after discharge is the one area where there is a disagreement between surgeons. Some saw their responsibility for pain management extended after discharge. "We need to manage their pain in the hospital as well as after discharge and do so with minimal side effects such as nausea and vomiting."
  • A second opinion from another surgeon stated that "Although narcotics play a role in acute pain management after surgery or injury, the chronic management of pain is not typically in the orthopedic surgeon's "wheelhouse."
  • During and after discharge, there is a recognition of the importance of pain management postoperatively. "You do need to work with your discharge planners to make sure that your patients are getting the postoperative care that you want them to have."
  • While doctors are not considering costs in pain management treatments, they are taking them into account in discharge. "A group of surgeons from Missouri explained that innovations in pain control, regional anesthesia and rehabilitation, among other advances, now allow patients to return home sooner. Surgeons, practice administrators, anesthesiologists, nurses, physical and occupational therapists, case managers, and post-acute care providers all have roles to play."
  • Some surgeons are aiming for reducing hospital stays. Others are going even further and recommending knee replacements as day surgery. "Researchers at an Ottawa Hospital found that outpatient care for patients who had undergone total knee replacement was about 30% cheaper than inpatient care.
  • At the same time, there was no difference in the quality of care noted within a year of surgery."

Research strategy

We began our search for what drives orthopedic surgeons in making decisions about pain management by searching the medical research sites such as PubMed, NIH, Researchgate and Medscape. Our goal was to find information on orthopedic surgeons' opinions of pain management and patient discharge. We were looking for surveys from which we could get primary source data from the surgeons, but found no relevant research published.

We then went directly to the site for professional information at the American Association of Orthopedic Surgeons. There we hoped to find some information directly targeted to the orthopedic surgeon on costs of pain management and managing pain after patient discharge. We found several articles about pain management, but the only reference to costs a new addressed new technologies when the positives were listed as "improved pain management, shorter hospital stays, and reduced costs," almost always in that order.

We then looked through medical insurance sites looking for pain management directives that doctors must follow. The only thing we found was a list of codes for pain treatments for which prior approval had to be obtained. Unfortunately, the actual code meanings were behind a membership login.

We then found a website called healio.com whose mission is to provide personalized news and education to health care professionals. It was there we found an article on the responsibilities of orthopedic surgeons in pain management. It was from that site we realized there was a strategy we could use.

The information we were looking for was necessarily qualitative in substance, and therefore, there was no mathematical way to extrapolate data. We did, however, come up with a way to extrapolate subjective data for this research. We assumed that the surgeons' opinions would be driven, at least in part, by the CME courses they took, the conferences they attended and the research and articles they read in medical journals. We, therefore, went back and reviewed the available information from the perspective of what orthopedic surgeons are being told about pain management. From there we were able to gather information of surgeons' thoughts on pain management as it related to costs and discharge. Unfortunately, we still found no mention of insurance driving medical decisions.
Part
07
of fourteen
Part
07

General Surgeon Persona: Pain Management Confidence

To become a certified general surgeon, a person is required to undergo extensive training and obtain significant experience in the area. A key component of this training and experience is the management of post-operative pain. Once qualified, a general surgeon is required to enter an annual re-certification program so they remain up to date with new treatments and developments in the field. This suggests that general surgeons have a high level of confidence when managing post-operative pain. The management of post-operative pain is not the sole responsibility of the general surgeon. A management plan is developed not only in collaboration with the patient but other medical professionals involved in the patient's care as well.

UNDERSTANDING PAIN — CONFIDENCE LEVEL

  • Considerable training is undertaken to become a board-certified general surgeon in the US. This includes the completion of a 4-year undergraduate degree and a further 4 years at medical school. Following graduation, a candidate for general surgical certification must complete a minimum of 5 years in progressive residency education.
  • Upon completion of the residency, a candidate for certification undertakes an 8 hour written examination and 3x30 minute oral examinations. These examinations evaluate the understanding of the practice of general surgery. One of the key areas assessed is surgical critical care. Surgical critical care includes pain management.
  • Upon becoming board certified a general surgeon is required to engage in the continuous certification program to illustrate their ongoing commitment to maintaining their education and staying abreast of current developments in the specialty.
  • There are several policy statements and resources on the website of the American College of Surgeons (ACS) illustrating the commitment to staying up to date in respect of post-operative pain management.
  • The available resources encompass recent developments, issues, and policy statements. This is illustrated by the resources which address the recent opioid epidemic in the US.
  • A study in 2016 evaluated the evidence around the management of post-operative pain and made some recommendations as to how it could be managed. This study reviewed the evidence around different pain management strategies and recent developments in the area. This study was subsequently approved and the recommendations adopted by the American Surgical Association (ASA), one of the professional bodies that oversee general surgeons in the US and their ongoing education.
  • There are several reputable medical journals and publications relating to the practice of general surgery. Part of the focus of these publications is the dissemination of information regarding new developments and studies as to the efficacy of these developments. It is not unreasonable to assume that the general surgeons are aware of these articles and use the information in their practices.
  • There are a number of medical conferences worldwide concerning general surgery. Part of the program for a number of these conferences deals with new developments in the specialty, including developments in the area of post-operative pain management. General Surgeons in the US have the opportunity to attend these conferences. They are a good way to maintain education and keep abreast of new treatment options.
  • In addition to the conferences that focus on general surgery, there several conferences both internationally and domestically that discuss issues around pain management. Although these deal with pain management in a broader sense they also encompass workshops and seminars that equally apply to general surgeons. General Surgeons can attend these conferences. An example of a conference of this nature is PAINweek 2019.

VIEW OF PAIN MANAGEMENT

  • Due to their education and training, general surgeons have very clear guidelines to base their approach to post-operative pain management. The variable in the equation is the patient and it is only through using their education and training in collaboration with the patient that post-operative pain can be managed effectively.
  • The ACS has many resources on its website relating to the management of post-operative pain including a patient education pamphlet. This pamphlet illustrates that the management of pain involves a collaboration between the surgeon and the patient. There are several worksheets contained in the pamphlet for the patient to complete illustrating this collaborative approach.
  • A 2016 article that made a number of recommendations regarding the management of post-operative pain emphasizes the importance of a collaborative approach between the surgeon and the patient. These recommendations were adopted by the ASA and form part of the best practice guidelines for general surgeons.
  • A 2000 article addresses the importance of a collaborative approach between the surgeon and patient to optimize the efficacy of the pain management plan for a particular patient.
  • In addition to collaborating with the patient, General Surgeons work in collaboration with anesthetists, both during the surgery and during the immediate post-operative period. The approach to pain management is generally a collaborative effort between these 2 professionals with the anesthetist having primary responsibility during the surgery and the immediate post-operative period, and the surgeon taking primary responsibility once the patient leaves' recovery.
  • A 2016 article reviewed literature and studies in both the US and Europe regarding the management of post-operative pain. This article concluded that it is essential that surgical ward nurses be involved in post-operative pain management to enable the best outcomes for the patient.

RESEARCH STRATEGY

We completed an extensive search of medical publications and professional qualification and certification documents to ascertain the training and experience required to become a general surgeon. The focus of this search was the amount of education a general surgeon receives concerning post-operative pain management in the US. Once we had determined the baseline for new general surgeons we considered the requirements that a surgeon must meet to maintain their certification and illustrate knowledge of treatment advancements in this area. We then considered the methods and opportunities that are available to a surgeon to meet these ongoing professional obligations. After, reviewing the literature we felt confident concluding that general surgeons have a high confidence level when managing post-operative pain.

We reviewed the professional literature regarding the best strategies to optimize post-operative pain. This search revealed the professionals that should be involved in formulating this management plan and the importance of a collaborative approach between these professionals. To ascertain the level of patient involvement in the management of post-operative we reviewed the articles in professional journals and the best practice guidelines for general surgeons. We looked for evidence from studies and resources published by the professional bodies to determine whether these best practice guidelines and recommendations were being implemented by the surgeons or whether they considered post-operative pain management to be their sole responsibility.

Part
08
of fourteen
Part
08

General Surgeon Persona: Procedure Follow Up Appointments

Several research studies specifically address the issue of poorly managed post-operative pain and the impact it has on patient satisfaction. Despite poorly managed post-operative pain being an ongoing source of patient dissatisfaction over the last two decades it has not been adequately addressed by general surgeons. There is relatively little direct information on this topic beyond academic studies recording patient satisfaction levels so it is difficult to gauge how this information has impacted the practice of a general surgeon.

Post-operative pain Management

  • Recent concerns regarding the opioid addiction rates in the US have resulted in several changes in the way medication is prescribed to manage post-operative pain suggesting there is potential for the development of alternative treatments.

PATIENT VIEWPOINT

  • A 2013 journal article recorded the results of a US national survey investigating how patient perceptions on pain post-operatively was managed. The survey has some limitations due to the small sample size and the need to rely on patient recollections, on average 14 months after the surgery.
  • The survey found 86% of those surveyed experienced post-operative pain. Of those that experienced post-operative pain, 75% described the pain as moderate or extreme. Pain at the same level continued for 74% of the survey participants post-discharge.
  • Although the survey does not address patient satisfaction levels directly, assumptions can be made based on the patient's responses to pre-surgical concerns. The most common concern was post-surgical pain with over 50% of the participants expressing anxiety in this regard. Given the patient concerns were not adequately addressed it can be concluded that patient satisfaction levels in respect of pain management were low.
  • The survey recorded that 88% of patients were given analgesic medications to control pain. However, 80% of those patients "experienced adverse effects" and 39% continued to experience moderate to severe pain after receiving the medications.
  • The survey was carried out because previous surveys over the last 20 years had indicated poor patient satisfaction levels with post-operative pain management.
  • The article concluded that although there have been advances in the field of pain management and there is an increased awareness among surgeons little improvement had been seen in area.
  • A 2009 journal article recorded the results of a patient survey into satisfaction levels post day surgery. The article considered the satisfaction levels at discharge and again 30 days post-discharge. 95% of the participants were satisfied with their care in both instances. Of the patients satisfied with their care, 74.5% were completely satisfied at the time of discharge. This figure fell to 62% when they were surveyed 30 days post-surgery. The primary reason for the decrease in satisfaction levels related to pain management.
  • A 2004 Canadian journal article records 30% of patients continued to have moderate to severe pain 24 hours post-surgery. Unfortunately, the article includes orthopedic patients as well as those under the care of general surgeons but it has some applicability to the current topic. The study found that as a result of ongoing pain 13.2% required telephone advice, 1.4% needed to visit a doctor and 0.08% needed to be readmitted to the hospital.
  • The study determined which procedures were likely to cause patients the most pain and those completed by general surgeons made up 50% of the procedures. Unfortunately, the information available in the abstract does not indicate the actual number of procedures carried out by each specialty.
  • A 2017 US study found post-operative pain is not managed well in over 80% of patients. The study did not directly address the impact on patient satisfaction scores. It did list the issues that resulted from poorly managed pain. They included increased morbidity, functional impairment, decreased quality of life and longer recovery times. Given the seriousness of the consequences of poorly managed pain, it is fair to conclude that it results in decreased patient satisfaction.
  • No studies were found identifying the over-prescription of pain management medications as an issue impacting on patient satisfaction in post-operative patients.

PHYSICIAN VIEWPOINT

  • There is little information available on the feedback that general surgeons receive on a personal level. No information of this nature is available in the public forum.
  • The aforementioned studies all indicate that poor pain management post-surgery results in lower patient satisfaction. This is significant feedback that general surgeons are aware of and as a consequence, they must be aware that post-operative pain management is an ongoing issue.
  • Clinical Guidelines or Best Practice recommendations are readily available in all areas of medicine. There are several guidelines regarding the management of post-operative pain following general surgery.
  • A study in 2016 evaluated the evidence around the management of post-operative pain and made some recommendations as to how it could be managed. The study observed 80% of surgical patients experience post-operative pain with 75% of these patients describing the pain as moderate to severe.
  • This study was subsequently approved and the recommendations adopted by the American Surgical Association (ASA), one of the professional bodies that oversee general surgeons in the US. As a result, they carry significant weight in influencing the practices of general surgeons when managing post-operative pain.
  • The current opioid epidemic in the US was identified as a significant factor in changes to post-operative pain management prescribing. This has resulted in legislative changes in an attempt to combat the problem. Among these legislative changes are restrictions on the number of opioids prescribed post-surgery. An emphasis has also been placed on reduced opioid consumption in a number of surgical protocols.
  • Historically opioids have been a primary medication used in the management of moderate to severe post-operative pain. Given the poor patient satisfaction levels which result from poor pain management and the failure to improve these levels in the last two decades, it seems there is a gap in the market for post-operative pain medications.

RESEARCH STRATEGY

To assess typical post-surgery satisfaction rates for patients under the care of a general surgeon, we searched through scholarly articles and medical journals for studies and surveys that addressed this issue. The focus of this search was post-operative pain management and prevention in the US. We found four studies that were of use. The first specifically dealt with general surgery patients. Two of the other studies dealt with ambulatory or day surgery with a mixture of patients under general surgery and orthopedic surgery. After considering the information regarding the type of procedures being undertaken and observing a relatively equal division between the specialties we felt these studies were useful in answering the research question. One of these studies was based on Canadian research however given the proximity and cultural similarities between the two countries we felt the results could be applied to the US.

In an attempt to gauge whether poor pain management is the primary source of patient dissatisfaction we searched general surgeons on rate my MD. We hoped this would assist in addressing the type of feedback doctors receive on this issue. We read the reviews of those rated at the lower end of the scale in the hope it would identify the source of the patient's dissatisfaction. Unfortunately, this was largely unhelpful with very limited reviews of the majority of the general surgeons listed on the site. We did not consider this information added value to the research.

An extensive search of medical publications, various general surgeons web pages and blogs, and various media publications yielded no results regarding direct feedback general surgeons report from patients post-operatively. The results of the aforementioned articles are all widely available in reputable medical publications and it is not unreasonable to assume that the general surgeons are aware of these articles and use the information in their practices.

Given the lack of direct feedback available to general surgeons, we searched for scholarly articles and publications that indicated that the studies around post-operative management and patient satisfaction had been noted by general surgeons and influenced their future management decisions. We were able to find a study that used not only the studies relating to the US but several international studies of a similar nature to make recommendations. These recommendations were subsequently adopted in the US. On this basis, we felt confident concluding that patient feedback provided in the aforementioned studies is readily available to general surgeons. Given this, we were able to draw conclusions regarding the impact this information has on prescribing practices.

There was no information available publicly that indicated whether general surgeons felt there is a gap in the type of pain management options available. We considered other factors that have impacted on a general surgeon's management of post-operative pain and compared this to the current management guidelines. By doing this we were able to identify a potential gap in the treatment options available to post-operative patients.





Part
09
of fourteen
Part
09

Orthopedic Surgeon Persona: Procedure Follow Up Appointments

Top issues being faced by surgeons and pain management teams are customizing the pain management for individual patients, and minimizing side effects, ensuring safety, and providing ease of use.

Orthopedic Surgery Patients' Procedure Follow Up Appointment Sentiments/General Opinion

  • According to an article from Orthopedic Proceedings, regional anesthesia along with multi-modal pain therapy minimizes the pain and maximizes patient satisfaction.
  • Top issues being faced by surgeons and pain management teams are customizing the pain management for individual patients, and minimizing side effects, ensuring safety, and providing ease of use.
  • According to a MedScape article, "75% of patients believe it is 'necessary' to feel pain following surgery, and 59% of patients cite pain as their most common concern when contemplating surgery".
  • Patient satisfaction is beneficial for surgeons too, as it increases their self-esteem, pride in profession, and provides them with referrals.
  • An efficient pain management process starts with the orthopedic surgeon being acquainted with anesthesiologists and work as a team.

RESEARCH STRATEGY

We began our research by looking into patient surveys after a surgery to recognize sentiments and general opinion on orthopedic surgeon's pain management and patient satisfaction. We looked into various surveys conducted on the subject by Medicare, Televox, NCBI, and NEJM Catalyst. We did find a few patient satisfaction surveys on pain management, however, the data was specific to India and compared the 'worst pain' rankings by American and European patients.

Next, we examined medical research databases to find information on general opinion of patients on satisfaction from pain management post surgery. We searched credible databases such as the World Health Organization (WHO), American Surgical Association (ASA), Association of Academic Surgery (AAS), American Association of Nurse Anesthetists, American College of Surgeons (ACS), Institute for Healthcare Improvement, Society of University Surgeons (SUS), and The Consortium Pain Task Force. However, even after a deep search, we couldn't locate a research report directly or indirectly relating to what we were seeking.

Subsequently, we scanned medical news and media websites like Mayo Clinic, Medscape, Healthline and Medline, in order to see if there was any data available on patient satisfaction post surgery in relation to pain management. We found many articles on what to do to lessen the pain, but none on the topic we were dealing with.

After this, we focused on surgeon perspectives. For this, we searched credible and regulated forums where orthopedic surgeons usually convene and discuss on various topics — Reddit, General Surgery News Forum, and the Surgery and Surgical Subspecialties forum on the Student Doctor Network. We hoped to find opinion polls and thread from where we could derive some well-informed conclusions. Nevertheless, we could not locate any such thread even after doing a scan search of these forums.

Since the data required was qualitative and research based in nature, we couldn't go through triangulation or extrapolation neither could we identify paywalled studies on patients' pain perception and orthopedic surgeons' pain mitigation techniques. Also, due to the data being related to medical science, using arbitrary approximate approaches like combined analysis and logical inference would require some definite amount of background data on the subject, which was not found during our research.

As our last resort, we decided to expand the scope by looking for data that was older than two years. After redoing the entire research with this new time scope, we were still unable to find any information or insight which directly or indirectly informed us on orthopedic surgery patients' satisfaction concerning pain management and/or orthopedic surgeons' general opinion on patient satisfaction regarding pain management.

To conclude, there is no research available on the public domain regarding the said subject.
Part
10
of fourteen
Part
10

Orthopedic Surgeon Persona: Pain Management Confidence

After an extensive search through industry-related websites, interviews, and orthopedic industry publications, details about the confidence level of orthopedic surgeons, in general, when it comes to their understanding of how pain works in the human body do not appear to be available in the public domain. However, the research team was able to gather valuable insights about the changes in approach by orthopedic surgeons as well as a recent campaign by the American Academy of Orthopedic Surgeons on the prescription and misuse of opioids as pain management options.

HELPFUL INSIGHTS

  • When it comes to post-procedure pain, analgesic approaches have changed in recent years, in part, due to patient expectations, the shift towards ambulatory surgery, and shorter hospital stays. Some improvements in this space is based on a "greater understanding of the neural pathways and mechanisms involved in the stages of acute pain."
  • As a profession, orthopedic surgeons have developed good short-term acute pain management programs but their role in the long-term prevention and management of chronic pain needs to be defined better. "Chronic pain management should be more than filling opioid prescriptions and extending the patient’s disability claim. We need to consider different approaches when the musculoskeletal condition producing the original pain has not resolved."
  • In the United States, orthopedic surgeons treat a small percentage of chronic pain patients.
  • The orthopedic surgeon’s job is to determine whether there is an objective, musculoskeletal cause for a patient’s chronic pain. Once that cause is determined, the next goal is to initiate either nonoperative or operative treatment focused on the pain generator.
  • The American Academy of Orthopedic Surgeons initiated a public service campaign to engage orthopedic surgeons in the process of decreasing the prescription and misuse of opioids as pain management options. They developed a pain relief toolkit aimed at orthopedic surgeons which provides them with information about postoperative pain relief, prescribing guidelines for common pain relief situations, and strategies for establishing an opioid prescribing policy.

Research Strategy:

We commenced our research by searching for interviews and surveys with orthopedic surgeons that focused on or were related to the topic of orthopedic surgeons' level of confidence when it comes to the understanding of how pain works, and their attitude towards who should manage the pain. We reckoned that seeking information directly from orthopedic surgeons could provide primary insights, given that they would be more familiar with the industry. To find interviews, we looked through various industry-specific publications, such as the American Orthopaedic Association's website and the American Academy of Orthopedic Surgeons' website. This research path did not yield any tangible result regarding surgeons' attitudes and level of confidence when it comes to the understanding of pain and management in patients, except interviews focused on orthopedic surgeons personal experiences with pain.

Our next approach was to search orthopedic industry publications, looking to find reports on the topics of orthopedics understanding of how pain works, and how they view pain management. To find reports on these topics, we searched sites, such as ORTHOWORLD® and Orchid. Regrettably, our research showed that existing reports focus do not focus on the desired subject matter under investigation. The closest insights we found using this strategy was a report on orthopedic patients' pain management strategies, no insights were available regarding surgeons views on pain management or how they understand pain.

Lastly, we decided to turn to academic research articles hoping to find articles that focus on the general confidence level of orthopedic surgeons when it comes to how pain works, or how they view pain management in terms of who should manage pain or at least locate any relevant insights into this topic. This strategy failed because no relevant insights were found. Although there were publications with insights and information on pain management in the orthopedic industry, these publications focus on the patient's point of view instead of the surgeon's point of view. As such none had any insights that could answer any part of the research query — either the orthopedic surgeons attitudes towards pain management or how familiar they are with how pain works.

Therefore, after following the above strategies, we have concluded that there is not enough information available publicly to reliably determine the answer to the query. However, we have provided helpful insights as available in the public domain.
Part
11
of fourteen
Part
11

General Surgeon Persona: Pain Perceptions

Information regarding the relationship between patient perception of pain and surgeon's use of pain management or prevention techniques is not available in the public domain. Some related findings and a detailed overview of our research strategy are below.

Patient's pain perception and management techniques used by general surgeons to mitigate them —

  • According to an article published in official bulletin of American College of Surgeons, the usual path for surgeons to take pre- or post- surgery for pain mitigation is to prescribe opioid-based drugs.
  • The patient's pain perception plays no role in this mitigation process. However, the intensity of pain decides the dosage.
  • Surgeons usually don't educate families of patients or patients themselves about pain, pain treatments, and associated risks.
  • Efforts are being made by various healthcare organizations to push for a standardized prescription program for opioid prescriptions post-surgery.
  • One research study mentions that not many studies have been done to pinpoint the relation between pre- and post- operative pain and pain management.
  • The patterns of prescription for pre- and post- operative surgery do not differ much between different types of surgeons.
  • According to a thread on the Surgery and Surgical Subspecialties forum of The Student Doctor Network, there is a divided opinion among surgeons on whether to give a TAP nerve block to patients without consent. Many surgeons found the act a violation of choice and a potential professional hazard, some considered it a viable and necessary option as the surgery demands.
  • The same thread also shows that generally surgeons consult their patients on what kind of pain blockers and anesthesia they are going to employ.

Research Strategy:

To find information on whether patients' perception of pain impacts the pain management or prevention techniques of surgeons, our research team started by looking into research repositories like ResearchGate, MedPub, Academia, NCBI, National Library of Medicine and Online Pain Reports. While some research on opioid use for pain management and surgeon prescription habits were found, we were unable to find data specific to the impact of patient perception on pain management or prevention techniques chosen by surgeons.

Our second strategy was to look into specialized medical databases and organizations, directly or indirectly related to general surgery. We hoped to find general opinion as well as qualitative studies or surveys by these organizations on patients' pain perception and/or pain mitigation procedures applied by surgeons. After searching through credible databases such as the World Health Organization (WHO), American Surgical Association (ASA), Association of Academic Surgery (AAS), American Association of Nurse Anesthetists, American College of Surgeons (ACS), Institute for Healthcare Improvement, Society of University Surgeons (SUS), and The Consortium Pain Task Force, we found some studies on rising opioid use and related deaths, but no information on the relationship between patient perception and pain management or prevention techniques used.

Next, we searched through published articles on websites like Mayo Clinic, Medscape, Healthline and Medline in order to find information on general surgeons' pain mitigation strategies being affected by patients' pain perception. Information that we found here was mostly related to best practices for patients pre- and post- surgery, and some articles on how surgeons can regulate the opioid intake and abuse using controlled prescriptions. However, none of this information was related to our purpose.

As our next strategy, we tried to look for information on general surgeons' opinions on how to mitigate pain and the procedures used by them on online forums like Reddit, General Surgery News Forum, and the Surgery and Surgical Subspecialties forum on the Student Doctor Network. Our hope was to retrieve opinion from general surgeons on pain mitigation and any relation that has with patient's pain perception. Although we couldn't find any relevant forum discussions, we did find one discussion on TAP block consent, where general sentiment was divided between giving an uninitiated TAP block without patient's consent or giving it spontaneously in an emergency.

As a last approach, we expanded the scope of research to more than two years, and later to entire North America. However, both these approaches failed to fetch any reliable data point on patients' pain perception pre- and post- surgery, and general surgeons' pain mitigation strategies being affected by them. We did find older studies on opioid intake post surgery but they were not related to our request.
Part
12
of fourteen
Part
12

Orthopedic Surgeon Persona: Pain Perceptions

While no information was found on patient's pain perception and management techniques used by orthopedic surgeons to mitigate them, available data has been used to put together some related information. Our research revealed that the patient's pain perception in terms of pain intensity can influence the surgeon's decision on the dosage opioid to be prescribed pre and post surgery.

Helpful findings

  • According to an article published in the official bulletin of American College of Surgeons, the usual path taken by surgeons pre or post-surgery for pain mitigation is to prescribe opioid-based drugs.
  • The patient's pain perception in terms of pain intensity can influence the surgeon's decision on the dosage of opioid to be prescribed.
  • Surgeons usually don't educate families of patient and patient themselves, about pain, pain treatments, and associated risks.
  • Various healthcare organizations are making efforts to push for a standardized prescription program for opioid prescriptions post-surgery.
  • There is a paucity of published studies or articles on the relationship between pre and post-operative pain and surgeons' decision-making on pain management.
  • The patterns of prescription for pre and post-operative surgery pain medications do not differ much between different types of surgeons.

Research Strategy

We commenced our research by first looking into research repositories like ResearchGate, MedPub, Academia, NCBI, National Library of Medicine, Online Pain Reports, among others, to seek for relevant studies to track required data points about orthopedic surgeon's procedures, patients' pain perception, and any correlation between them. However, we couldn't find any such information. What we found were studies on "increasing opioid abuse" and "surgeons' prescription habits" which were not related to the information we needed.

Next, we searched through specialized medical databases and organizations website, directly or indirectly related to orthopedic surgery. We hoped to find general opinion, as well as qualitative studies or surveys by these organizations on patients' pain perception and/or pain mitigation procedures applied by surgeons. Even after scan searching through credible databases of World Health Organization (WHO), American Surgical Association (ASA), Association of Academic Surgery (AAS), American Association of Nurse Anesthetists, American College of Surgeons (ACS), Institute for Healthcare Improvement, Society of University Surgeons (SUS), and The Consortium Pain Task Force, we were unable to find any such data points. Once again, though, we found unrelated research studies on rising opioid abuse and related deaths.

Going forward, we searched through established and published researches in websites like Mayo Clinic, Medscape, Healthline, Medline, among others, to find any article or reports on orthopedic surgeons' pain mitigation strategies being affected by patients' pain perception. Information that we found here was mostly related to best practices for patients pre and post-surgery pain management, and some articles on how surgeons can regulate the opioid intake and abuse using controlled prescription. However, none of this information was related to the purpose of the research.

Since the data required for our purpose was qualitative and research-based in nature, we couldn't go through triangulation or extrapolation approach. Neither could we identify any paywalled studies on patients' pain perception and orthopedic surgeons' pain mitigation techniques. Also, due to the data being related to medical science, using arbitrary approximate approaches like combined analysis and logical inference would require some definite amount of background data on the subject, which was not found during our research.

As a last resort, we expanded the scope of research to more than two years and later to entire North America. However, both these approaches failed to fetch any reliable data on patients' pain perception pre and post-surgery, and orthopedic surgeons' pain mitigation strategies being affected by them. However, we did find older studies on opioid intake post-surgery, but they were not related to our request.

The unavailability of data regarding the patient's perception of pain and orthopedic surgeon's pain management approach can be due to a lack of research on the topic, or there being no correlation between the two. It could also be that there are studies on the topic, but are yet to be published in the public domain.
Part
13
of fourteen
Part
13

General Surgeon Persona: Pain and Caregivers

In the United States, general surgeons work with a patient's caregiver, or parents in case of minor patients, when it comes to pain management/prevention by having pre and post-surgery conversations with them on opioid pain treatment, which is most commonly prescribed by the surgeons, along with being educated and taking consent from them on drug intake and the disposal of leftover pills.

ROLE OF CAREGIVER IN PAIN MANAGEMENT

  •  According to the 2017 Bulletin published by the American College of Surgeons (ACS), over 40% of prescriptions issued for outpatients by surgeons are opioids for pain management. This is found to be a common practice to curtail the pain that patients feel after undergoing severe surgical procedures.
  • According to the guidelines placed by the FDA and the American Academy of Pain Medicine, the patients' caregivers or parents in case of minor patients play a vital role in ensuring safety and the proper intake of opioids during pain management. It is necessary for them to follow the guidelines and instructions of opioid safety principles for patients and caregivers to reduce drug abuse.
  •  In multiple states within the country, such as Pennsylvania and Ohio, the parents of minor patients are required to provide their consent by signing a form for the prescription of opioids in non-emergency circumstances for medical treatment and pain management.
  • According to numerous studies, it was found that the role of a caregiver/parents, whose children were prescribed with opioids after inpatient surgery, are required to ensure the proper disposal of any leftover medication to prevent the risk of drug abuse.
  • Experienced caregivers follow a specific protocol, or system, when helping adults and children manage pain. When working on “pain psychology,” caregivers/parents look for changes in body positions, gestures, and facial expressions to identify and understand their loved ones' pain levels. This will further help them effectively handle the pain medication course prescribed for the patients.
  • Competent caregivers use a variety of options such as biofeedback, massage therapy, reflexology, and other non-medication alternatives to avoid situations of acute pain and pain killer dependency of patients.

GENERAL SURGEONS: CONVERSATION WITH THE CAREGIVER

  • The American College of Surgeons has guidelines in place for surgeons to reduce the wide gap in knowledge and are encouraged to have more conversations with caregivers and patients' families in case of preoperative pain management. Resources and education are provided to surgeons in the use of opioids for individuals undergoing surgery.
  • The surgeon is required to share proper instructions and guidance to the caregiver/parent of the patient, especially in the case of minor patients, on proper opioid intake and the proper disposal of leftover pills.
  • To curb the risk of opioid abuse, the United States Department of Health and Human Services has issued a public health advisory to generate awareness for caregivers before and after surgeries on the "lifesaving medication that can reverse the effects of an opioid overdose". It was found that police officers and EMTs are already carrying such medications like naloxone.
  • Preoperative pain management medications: Generally before surgery, the surgeon is required to have a detailed discussion with family members, caregivers, partners, or parents about the patient's medical history, allergies, supplements, reaction to anesthesia, and the general pain holding intensity. The surgeons also discuss the after-effects, recovery, and pain management journey that patients would have to go through.
  • Post-operative pain management medications: Surgeons also have particular instructions for the surgical incision site such as testing for signs of bleeding and infection. Along with providing aftercare instructions to caregivers, surgeons also provide medications such as pain relievers and other symptom-reducing medications to relieve patients from any discomfort associated with having surgeries or with pain medications.

SURGEONS' DECISIONS AROUND PAIN MANAGEMENT/PREVENTION

  • The American College of Surgeons journal states that the education provided to patients and caregivers are exercised more often, particularly resources around the specific procedure, the extent and degree of the preoperative pain recovery time, and the expectations for pain management during his/her recovery.
  • According to a survey conducted by the American Society of Anesthesiologists, parents and caregivers of minor patients, usually, have conflicting thoughts about the use of opioids to treat their children's pain. The survey reveals that "more than half of parents said they are concerned their child may be at risk for opioid addiction". It was also found that parents do believe that opioids are more effective at managing pain after surgery.
  • The report reveals that the patient's pain treatment can be altered based on the details of the patient’s pain tolerance, personal and family history of a substance use disorder (SUD), and other concerns on pain medications/opioids, influencing the general surgeon's thoughts on pain medication and pain management.
  • Surgeons are also provided with feedback and inputs from experienced caregivers after closely monitoring their patients' pain tolerance. By doing so, surgeons will be able to make alterations and take necessary steps in the patient's medication course.

TRYING NEW PRODUCTS

  • The national survey conducted by the American Society of Anesthesiologists highlights that 59% of parents whose children were prescribed with opioids asked their surgeons about pain management alternatives. Over 88% of parents were able to recognize a non-opioid over-the-counter medication, like acetaminophen, to be effective in treating pain.
  • The survey also revealed that only a few parents were aware of the range of options available under non-opioid pain treatment, pain therapy, and other alternative medications for children.
  • ACS states that more than 70% of pills prescribed to patients during the acute postoperative period are not used. It was also stated that by educating patients on the multi-modal pain control plan, that generally includes non-opioid medications, often helps in effective and better pain management.
  • An experienced caregiver can urge surgeons to provide alternative pain management therapies such as massage therapy, breathing control, reflexology, and others to the patients during post-surgery to avoid instances of pain medication addiction.

GENERAL AND TRAUMA SURGEONS

  • DIFFERENCE: In the treatment of pain management for surgery patients, it is found that the deliberation to provide opioid for pain management to surgery patients is about 40% by the general surgeons as compared to 49% of pain specialist surgeons.
  • ADDITIONAL INFORMATION: According to the American Board of Surgery, a certified general surgeon would demonstrate a broad knowledge and have vital experience in various conditions including trauma.

Research Strategy:

In order to identify the required information on how the general surgeons work with a patient's caregiver/parent and family members when it comes to pain management and pain prevention of a general surgery patient, we searched through industry-specific websites, medical and government databases related to general surgery such as American College of Surgeons, American Society of Anesthesiologists, National Center for Biotechnology Information, and the Department of Health and Human Services; research publications from Pubmed, and Crossref; and media websites such as HealthLine and WebMed.

Through our search, we were able to locate insights on the surgeons' conversations with caregivers/parents and family members, along with their role, possibilities to influence and contradict the pain management treatment/course, especially when related to opioid medication. A thorough search through the various surgeons' organizations/associations revealed no major differences between general and trauma surgeons course of treatment for general surgery practice. It was found that general surgeons and trauma surgeons usually work as part of one team. However, the only difference found was related to the deliberation of prescribing opioids for pain management for surgery patients.

Part
14
of fourteen
Part
14

Orthopedic Surgeon Persona: Pain and Caregivers

There is insufficient information available to the public regarding the contribution of a caregiver, e.g., parent or spouse in pain management following orthopedic surgery in a patient. Orthopedic doctors administer preemptive analgesics (neuraxial anesthetics) such as celecoxib and try to avoid narcotics to manage pain that results from orthopedic surgeries.

1.0 ROLE A CAREGIVER, PARENT, SPOUSE & PHYSICIANS

1.1 PHYSICIAN'S/CAREGIVER DECISIONS AROUND PAIN MANAGEMENT

  • According to Dr. Craig Della Valle's publication hosted on Medscape web, (screen capture available here), an orthopedic surgeon in the Chicago area, preemptive analgesics are administered carefully and monitored by orthopedic surgeons during surgery. Surgeons often prescribe "celecoxib or another pre-emptive analgesic." the patient's renal activity is monitored pre-operatively.
  • Dr. Craig Della Valle is an orthopedic surgeon in Chicago, Illinois and also affiliated with the Rush University Medical Center.
  • Additionally, orthopedic surgeons need the close collaboration of their anesthesiology colleagues to develop pain protocols, critical for the success of orthopedic procedures.
  • Advanced countries now use a "patient-centered biopsychosocial model," which permits patients and family members to determine some treatment options. This process is known as shared decision-making (SDM) for patients with new hemophilia. "People with hemophilia" have pain management procedures that are specific to orthopedic operations.

2.0 PREVENTION OF PAIN IN ORTHOPEDIC SURGERIES:

2.1 TYPE OF MEDICATION PRESCRIBED

  • To manage pain, orthopedic doctors recommend the use of a multi-modal approach. Several doctors, including Dr. Della Valle, have used the multi-modal approach very effectively.
  • Orthopedic surgeons have a strong preference for the use of neuraxial anesthetics (anesthetics placed around the nerves). However, most doctors try to avoid narcotics. They aggressively hydrate (drip) their patients with crystalloid and colloid substances to revive them (wake them up) after surgery.
  • A perioperative infiltration mixture containing ropivacaine, combined with self-administered morphine, is often used by doctors to control pain resulting from orthopedic surgery.

3.0 HOW THEY INFLUENCE A PHYSICIAN TO TRY A NEW PRODUCT

  • According to Dr. Della Valle, all his patients relate with nurses and other office staff during "pre-operative medical evaluation," which is highly required. A teaching class which is also critical helps in identifying significant parts of patients past medical history, which may influence the medications to administer during surgery.

METHODOLOGY

Our team commenced by researching through international health agency guidelines such as WHO guidelines for insights on the role of a caregiver (e.g., parent, spouse) in the pain management process of an orthopedic surgery patient. Unfortunately, the WHO article does not reveal how caregivers influence pain management in patients. We also researched for how caregivers manage trauma in orthopedic patients with limb-threatening injuries, which result in surgeries. No such detailed information is in the WHO guide. The guide revealed that trauma care is one of the most challenging decisions which clinician's face.

We researched the websites of health solution service organizations such as RTI International. We researched for clinical-based decision support tools that orthopedic patients already consuming opioids rely on to influence their choice of painkillers during an orthopedic operation. This information was not published. We researched how caregivers, such as parents, spouses, siblings, etc., use patient-centered tools to influence the choice of pain killers in orthopedic surgery patients. This information was also not available to the public. RTI International revealed tools that opioid consuming patients rely on to influence their choice of drugs in American communities such as Patient-Centered Clinical Decision Support (PCCDS). There were no insights into any tool specific to orthopedic patients or their caregivers.

We studied Pain Research and Management institution journals such as Hindawi for research conducted by American Universities on the types of pains experienced by adult patients across America following orthopedic surgeries. We also searched for breakdown statistics on how many people are affected by post-surgical pain and how the pain gets managed by various groups of persons such as children and adults. We researched for any assistance offered by caregivers of the different groups and doctor influence. Unfortunately, there were no such details unearthed. A Hindawi research study revealed that about 80% of American patients are affected by acute pain due to surgery. The study revealed that "Postoperative pain" is under managed in America. The article failed to classify postoperative pain based on various types of surgeries such as orthopedic, etc.

We researched academic and scholarly publications such as the United States National Library of Medicine, National Institutes of Health. We studied for insights on stakeholders that are involved in shared decision-making (SDM) for orthopedic pain management processes. Insights obtained from this strategy revealed that new hemophilia treatments in developed countries no longer depend on clinician-based decisions, as physicians take decisions for their patients. These countries now use a "patient-centered biopsychosocial model," which allows patients and family members to contribute to treatment options. The shared decision-making (SDM) process referred to the treatment of new hemophilia patients. We have assumed it is relevant since there are pain management procedures specific to orthopedic surgery and "people with hemophilia."

We also examined medical news service provider websites such as Medscape for a detailed analysis of what orthopedic surgery service providers are doing to combat pain that results from surgery. We focused on the drugs they are using, the processes designed to carry the patients and their caregivers along, etc. A report by Dr. Craig Della Valle's and his team of doctors hosted on Medscape web, (screen capture available here), revealed useful findings. The report revealed that orthopedic doctors are administering pre-emptive analgesics (neuraxial anesthetics). Such analgesics include celecoxib. They try to avoid narcotics while managing pain that results from orthopedic surgeries. The publication also revealed that a teaching class which is also critical helps in identifying significant parts of patients past medical history, which may influence the medications to administer during surgery. There were no specifics regarding the contribution of caregivers such as parents, siblings, spouses, etc., uncovered with this strategy.

Sources
Sources

From Part 03
Quotes
  • "The surgeons should always be up to date with what is happening in the world and they should be able to use the new technology to solve their problems at all times."
Quotes
  • "There has been significant expansion of new techniques and instrumentation for advanced endoscopic procedures. These techniques broaden our ability to perform more complex procedures in a much less invasive way. As colorectal surgeons, we are uniquely positioned to adopt these techniques and to lead in this field."
  • "The adoption of new technology and techniques for surgeons in practice is challenging. There is often insufficient opportunity for the practicing surgeon to be exposed to the most state-of-the-art methods"
  • "Surgeons should be able to define and identify disruptive technology, and thus better understand how it can affect their lives. This will also allow them to anticipate changes in their practice and stay ahead of the curve as their profession evolves. "
Quotes
  • "Technology for breast, prostate, colorectal, esophageal and pancreatic cancers is changing. "
  • "Lumicell is pursuing the combination product pathway for its technology with the FDA and expects to file a premarket approval application by the start of 2019."
  • "Lumicell’s team is positioning its technology as a way to move the mark of success from a pathologist’s slides into the patient’s body"
  • "Lumicell’s technology could help inform them when they’ve removed just enough tissue to rid the patient of cancer, noted longtime medtech design veteran Bill Evans."
  • "Surgeons are fairly set in their ways. Surgeons are used to being the captain of the ship, and we’re accustomed to getting the results we get by doing the same thing the same way, every time,” Stokes told us. “That being said, there are many surgeons, like myself, who are early adopters of technology. If there’s something that I’m going to use differently in the OR, there has to be a reason that I’m changing from what I’m comfortable with and what I’m used to getting reliable results with. "
  • "A new technology needs to be innovative, or time-saving or safety-enhancing"
Quotes
  • "The clinical team of Hernia research have also developed ways to use new technology, including crowdsourcing, as a platform to evaluate lay perception of prophylactic mesh placement. The researchers wanted to gauge public perceptions of prophylatic mesh placement in open abdominal surgery, because another Hernia Program study demonstrated that mesh helps prevent incisional hernias."
Quotes
  • "Robotic surgery is an extension of the laparoscopic approach. It harnesses advanced high-definition video optics and robotics technology to provide colorectal surgeons with better visualisation and significantly improved precision and accuracy during dissection."
  • ""
From Part 04
Quotes
  • "Orthopedic surgeons are barraged, virtually on a daily basis, with information concerning new technologies; this may include different implants, instrumentation and surgical techniques, local and systemic biological therapies, and other devices. This information originates from numerous sources and stakeholders, including journal and media advertisements, device manufacturers, conferences, medical associations, payers, government agencies, hospitals, colleagues, and patients."
  • "Indeed, direct-to-patient advertising has already altered the conversation between surgeons and patients. Patients commonly arrive in clinic with preconceived ideas (and comments such as, “I have done my research and . . . .”) regarding what they want done at surgery, the surgical approach, and their specific choice of implant. Whereas a robust conversation between surgeon and patient may foster an engaging two-way decision-making process, patients often are confused and misinformed by material they have seen or gathered.2,3 Furthermore, to remain relevant and viable in a highly competitive marketplace, surgeons may feel pressured into adopting new technologies requested by patients or presented by implant representatives."
  • "Several research groups and committees have provided sage insight into how we should think of introducing new technologies into surgical specialties and into orthopedics in particular.5,20,21 The “innovation cycle” has many stakeholders with a vested interest in the safety, efficacy, and cost-effectiveness of introducing a new product into surgical practice."
  • "Almost 25 years ago, Professor Rik Huiskes23 emphasized that it is the surgeon who should take a clear leadership role and responsibility to systematically review the preclinical data (biomechanical, computational, biological, animal studies, and so on) and clinical trials prior to introducing any new technology for use in patients. Once the preclinical and regulatory criteria are met, a stepwise introduction of new technologies, on a limited basis, to high-volume clinical centers with the appropriate infrastructure for detailed analysis of outcomes follows logically."
Quotes
  • " For instance, in 2002, less than 20 orthopedic devices received premarket approval through the US Food and Drug Administration. However, by 2012, this number had risen nearly 400% [1]. Similarly, Medicare payments for outpatient orthopedic procedures (including fees for physician services, surgeon fees, and all payments made on behalf of Medicare patients for outpatient services) increased 64% from 2000 to 2010. "
  • "Another study analyzed the cost-effectiveness of hypothetical innovation in traditional total knee arthroplasty. Using a validated computer model and Medicare claim data, the authors reported that new implants offering at least a 50% decrease in long-term failure rates at less than or equal to 50% increased costs resulted in incremental costs of less than $100,000 per QALY. However, innovations resulting in less than a 50% decrease in long-term failure rates were not considered cost-effective according to World Health Organization guidelines."
Quotes
  • " In 2017 alone, there were more than 47,000 opioid-related deaths nationwide. Of these, 40 percent involved a prescription. While opioids are an important part of pain management, improper prescription and use—by physicians, patients and others with access—places patients at risk of poor outcomes, overdose, addiction and death."
  • "Orthopedic surgeons are the third-highest prescribers of opioid medications in the U.S., yet postoperative prescriptions vary widely between providers. For example, in studies around total hip arthroplasty (THA) and total knee arthroplasty (TKA), the median number of opioid pills prescribed was 90, but ranged from 10 to 330. Further, most patients do not take all the pills they are prescribed. In fact, for upper extremity surgery, up to two-thirds of prescribed pills are not consumed. Another major cause for concern is the fact that more than 90 percent of patients do not properly dispose of excess pills."
  • "Use of CAS is increasing rapidly, with 17 percent of surgeons practicing some form currently, according to a statewide database study."
  • "In non-CAS TKA procedures, 30 percent of implants are placed in an improper position. In spine surgery, where placement of pedicle screws is crucial for avoiding nerve injury, up to 42 percent of screws are improperly placed in cases which do not use CAS."
Quotes
  • "The first U.S. procedures using Medtronic's Mazor X Stealth Edition were performed at Louisville, Ky.-based Norton Healthcare and Reston (Va.) Hospital Center."
  • "UnityPoint Health-Methodist Medical Center in Peoria, Ill., installed the Mazor X Stealth Edition Spinal Robot."
  • "Dunes Surgical Hospital in Dakota Dunes, S.D., installed Medtronic's Mazor X for spine surgery."
Quotes
  • "January 28, 2019 - Medtronic plc (NYSE:MDT) today announced the first U.S. patients treated with the Mazor X Stealth(TM) Edition for spine surgery following its recent commercial launch. The Mazor X Stealth Edition offers a fully-integrated procedural solution for surgical planning, workflow, execution and confirmation. The system was first used at Norton Healthcare in Louisville, Ky., and Reston Hospital Center in Reston, Va."
Quotes
  • "Dr. Giovanini employs the Mazor/Medtronic Renaissance system in the outpatient space due to its low cost and size. The Renaissance system is efficient and cost effective for surgery centers and is time proven highly accurate. He employs the Mazor X for cases at the hospital requiring more complex procedures or for medical necessity."
  • "From a financial standpoint robotic SI fusion is a very successful procedure for SI joint dysfunction and is extremely beneficial to the ASC both financially and from an outcome and complication prospective."
  • "The learning curve for this technology is super-fast," said Dr. Giovanini. "Everyone knows orthopedics and spine are moving into the outpatient space and surgeons will want a navigation or robotic system to improve outcomes. But it has to be economically feasible. The Renaissance system is feasible to use in the ASC."
Quotes
  • "The simulation results indicate that, by 2025, an adoption rate of 90% for CIM implants will reduce the number of readmissions and revision surgeries by 62% and 39%, respectively, and save hospitals and surgeons 6% on procedure time, resulting in cumulative savings of approximately $40 billion in healthcare costs. Conclusions: CIM implants have the potential to deliver high-quality care while decreasing total costs, but their adoption requires the expansion of current insurance coverage."
From Part 10
Quotes
  • "Acute pain after orthopedic surgery should be anticipated and its treatment should be a part of every anesthetic plan. "
  • "Analgesic approaches have changed in recent years in part due to patient expectations, the shift toward ambulatory surgery, and shorter hospital stays. Further, analgesic options have increased with new drugs and modes of delivery. Some of the improvement in management of acute pain is based on a greater understanding of the neural pathways and mechanisms involved in the stages of acute pain. "
  • "Management of acute pain after orthopedic surgery has changed significantly during the last decade. Formerly a task relegated to residents and ward nurses, analgesia is now being managed by increasingly large numbers of Anesthesiologists and members of surgical teams. This change is driven, in part, by increasing expectations from patients who hear from the lay press that excellent control of pain is possible and should be considered in selecting physicians and health care facilities."
  • "The development of devices such as patient controlled analgesia (PCA) pumps have increased options for effectively treating acute pain. The traditional, on-demand parenteral opiate strategy accomplishes analgesia but has some limitations. Severe pain motivates the patient to request analgesia."
  • "Acute pain after orthopedic surgery is the result of tissue injury from the procedure. The link between a surgical incision and the pain experienced by the patient is mediated by distinct neural pathways."
  • "The signals from the dorsal horn synapse with receptor cells and inter-neuron linkages enter the lateral spinothalamic tract at the same spinal level as they entered and few segments rostral and caudal. They ascend into the thalamus, where some synapse directly with the somatosensory cortex to produce acute sensation and some synapse in the brainstem reticular formation, where they participate in the downward pathways that modify nociceptive transmission. These synapses also project to the frontal cortex in non-somatosensory areas and are responsible for some of the emotional aspects of pain perception."
  • "The origin of pain in orthopedic patients begins with an injury or a painful, degenerative process that requires reconstruction or palliation. The surgical incision creates an additional nociceptive stimulus, as does manipulation of soft tissues and bone, whose periosteum is richly innervated with mechanical nociceptors. A unique aspect of orthopedic surgery is that large amounts of tissue injury messengers are released. Exposure of fractures, osteotomy, or the reaming of long bones liberates copious amounts of histamine, bradykinin, serotonin, prosta-glandins, and substance P."
Quotes
  • "Becoming an orthopedic surgeon typically requires eight years of schooling, although some schools offer accelerated programs. The first four years are spent in earning a pre-medical degree. These are bachelor of science programs designed to meet the prerequisites for admission into a medical or osteopathic college. A typical pre-med curriculum includes basic courses in physics, chemistry and biology, as well as more advanced work in organic chemistry and microbiology. The second four-year degree is a doctorate from a medical or osteopathic college, consisting of two years' classroom instruction and two years primarily spent in clinical rotations. Graduation from college makes the student a doctor, but not yet an orthopedic surgeon."
  • "Within the field of orthopedic surgery, several subspecialties require further training. These include disciplines such as pediatric orthopedics, spinal surgery, hand and wrist surgery, foot and ankle surgery, orthopedic sports surgery and trauma surgery. Each of these requires the surgeon to complete a one-year fellowship to learn its intricacies in a suitable clinical setting under the mentorship of experienced practitioners. Surgeons must first pass their board exams as general orthopedic surgeons before going on to write a second certification exam in a subspecialty."
Quotes
  • "In order to become an orthopedic surgeon, you would first need to complete a four-year bachelor's degree program comprised of one year of biology, two years of chemistry, and one year of physics. This would be followed by four years in medical school. The first two years would be classroom-based, while the final two are predominantly hospital-based. During this time, you would need to pass the National Board exams which are taken in two parts: one after the second year of medical school and the other after the third."
  • "You would next need to apply for and begin a residency program. The program would consist of four years of focused study on the fundamentals of orthopedic surgery. During this time, you would rotate through the major subspecialties in different hospitals to get practical exposure to the various surgical techniques and technologies."
  • "Once certification is granted, orthopedic surgeons must undergo a rigorous recertification every 10 years. So, in addition to running a practice, you would need to devote time to studying and attending continuing medical education courses to ensure that your knowledge is updated and in line with current practices."
Quotes
  • "One of the difficulties of chronic pain management is that there are no diagnostic tests to consistently differentiate “real chronic pain” from the symptoms rooted in secondary gains and emotional overlays. Scales, psychological tests, pain drawings and selective blocks can be helpful. However, orthopedic surgeons often find it challenging to differentiate patients who can be helped from those who are malingers, drug dependent or are working their disability situation. "
  • "As a profession, orthopedic surgeons have developed good short-term acute pain management programs. However, our role must be better defined in the long-term prevention and management of chronic pain. Chronic pain management should be more than filling more opioid prescriptions and extending the patient’s disability claim. We need to consider different approaches when the musculoskeletal condition producing the original pain has not resolved."
  • "Orthopedic surgeons treat a small percentage of the chronic pain patients in the United States. Most of these patients are treated by non-MDs (chiropractors, podiatrists, physical therapists, massage therapists, trainers, nurse practitioners, physician assistants, etc.) and by other health care specialties. The cost for all the combined treatments, medications and associated lost wages in the United States is staggering. "
  • "Most orthopedic surgeons have developed their own individual approaches to the refractory chronic pain patient. However, there is a great deal of variation in our approaches. Some orthopedic surgeons do not attempt to manage chronic pain patients while others surgeons refill medications and follow their patients for years. At some point in long-term pain management, the patient should be evaluated in a multidisciplinary pain management program with ongoing medical supervision and monitoring. "
  • "Over the years, I have read very little clinical research that has assisted me as an orthopedic surgeon to successfully treat refractory chronic pain patients. My preference was to tell chronic pain patients in a very straight-forward manner if I believed I could not make a difference in their chronic pain. When I could not help them, I would refer them for another opinion. That is to say this was for the patients where I recognized the chronic pain issues. I would occasionally learn that one of my patients was also getting pain medications from more than one physician or forged my signature. "
Quotes
  • "Despite the paradigm shift, the role of the orthopedic surgeon in the management of a patient’s persistent pain has not changed, in my opinion. The orthopedic surgeon’s job is to determine whether there is an objective, musculoskeletal cause for a patient’s persisting pain. Once that cause is determined, the next goal is to initiate either nonoperative or operative treatment focused on the pain generator."
  • "In general, our training is geared toward the identification and treatment of mechanical causes of pain and dysfunction. For example, if a patient has shoulder pain, stiffness and radiographic signs of end-stage glenohumeral arthritis, the orthopedic surgeon’s role is to offer treatment options including activity modification, anti-inflammatory medication, gentle stretching, cortisone injection or joint replacement. Although narcotics play a role in acute pain management after surgery or injury, the chronic management of pain is not typically in the orthopedic surgeon’s “wheelhouse."
Quotes
  • "To engage orthopedic surgeons in the process of decreasing the prescribing and misuse of opioids, the American Academy of Orthopaedic Surgeons initiated a public service campaign that includes advertisements. It developed a pain relief toolkit aimed at orthopedic surgeons, which provides them with information about postoperative pain relief, prescribing guidelines for common pain relief situations and strategies for establishing an opioid prescribing policy."
  • "Orthopedic surgeons are among the highest prescribers of opioids, in general. Although we are not involved necessarily in treating patients when they have opioid problems, we can be more involved in making sure that we are not inadvertently prescribing excess opioids and putting more unnecessary opioids out in the community,” Asif M. Ilyas, MD, program director of hand surgery fellowship at the Rothman Institute and associate professor of orthopedic surgery at Thomas Jefferson University, told Orthopedics Today"
From Part 14
Quotes
  • "Key roles of the patient and HCP revolve around medical decision making. The respective decision-making roles of patients and HCPs have evolved as the practice of modern medicine has developed over the past century. Over the past 20 years, there has been a shift in medical decision making, from a clinician-based biomedical model, where physicians make decisions on behalf of the patient, to a patient-centered biopsychosocial model.4 Patient- and family-centered care may be facilitated through SDM"
Quotes
  • "The life- and limb-threatening injuries that are daily parts of trauma care present some of the most difficult decisions that any clinician can face."
Quotes
  • "‘worst pain’ [US 7.6 (2.2) vs international 6.0 (3.0)], and ‘extent of participation in decisions about pain treatments [US 8.2 (2.7) vs international 6.1 (4.0)]"
Quotes
  • "In fact, results from a national survey conducted among adult patients who had undergone surgical procedures in the United States suggest that 80% of patients experienced acute pain after surgery and state that postoperative pain continues to be undermanaged"
Quotes
  • "Opioid analgesic agents During surgery, the patient’s anesthesia provider will use several analgesic agents, including opioids and non-opioids. Commonly used opioids include fentanyl, morphine, and hydromorphone; less commonly used are remifentanil, alfentanil, sufentanil, and meperidine. Historically, surgical pain has been treated with opioids. However, both the American Association of Nurse Anesthetists and the American Society of Anesthesiologists recommend a multimodal approach to pain management. (See Multimodal analgesia explained.)"
Quotes
  • "Finally," said Dr. Della Valle, "you need to ensure that the patient is ready for surgery. I know this sounds very obvious, but I can't tell you how many patients come in and their son is ready for them to have surgery, or their wife is ready for them to have surgery, but the patient is not. You need to make sure that this is a patient-derived decision -- that someone else isn't making this decision for your patient."
  • "Dr. Della Valle continued by remarking that all of his patients meet with the nurses as well as the office staff. "We arrange for pre-operative medical evaluation, which is critical. We also arrange for a teaching class, again critical. At that point, we really want to identify significant parts of their past medical history, which can lead to a cancellation at the time of surgery. "
  • "We do also recommend the multimodal approach, and I've used that very effectively," remarked Dr. Della Valle"
  • "Our strong preference is to use neuraxial anesthetic, but we try to avoid narcotics. We aggressively hydrate these patients with both crystalloids and colloids that will make them get up after surgery; they don't feel dizzy. We replace blood when appropriate, and normothermia has been found to be very important.""
  • "In another study, patients undergoing TKA were randomized to receive either a perioperative infiltration mixture, consisting principally of ropivacaine, along with self-administered morphine (local analgesia group) or self-administered morphine only (control group). The results showed that although both groups had high satisfaction and good pain control, morphine consumption was significantly lower in the local analgesia group than in the control group. Both groups achieved a similar amount of knee flexion on the fifth postoperative day, and patients in the local analgesia group experienced less nausea over the first 5 postoperative days compared with the control group.[12]"
  • "We do utilize a pain service and have found having anesthesiologists and physicians who are specifically directed toward managing our patients"
  • "If they still need large doses of narcotics, we send them to a pain management specialist at that 3-week visit so that there's someone who's specifically focused on their pain management postoperatively. We discontinue narcotics as soon as they're not necessary and liberally use a combination of tramodol and acetaminophen as well as COX-2 inhibitors. We intervene if there's a problem."
  • "What can we do as orthopedic surgeons to reduce pain?" pondered Dr. Parvizi. One of the most important factors is the selection of the surgical procedure. "There are some parameters that we can control in the operating room, which will lead to less pain following this orthopedic procedure, but we also need to realize that anesthesiologists play a critical role in control of pain in these patients." Therefore, communication between the anesthesiologist and the surgeon on multiple aspects is an important step to manage patients "
  • "Anesthesia. Anesthesia does not start at the time a patient enters the operating room; it starts pre-operatively. Therefore, administration of pre-emptive analgesics needs to be carefully monitored. When surgeons prescribe celecoxib or another pre-emptive analgesic, the patient's renal function needs to be monitored pre-operatively. In addition, said Dr. Parvizi, "We need the close collaboration of our anesthesiology colleagues to develop pain protocols, which are so critical for the success of our procedures"
  • "Orthopedic Surgical Pain: Emerging Technologies in Analgesia Analgesic Considerations. "What is it that we need to accomplish when designing an analgesic program or protocol?" asked Eugene R. Viscusi, MD, to begin his presentation (Slide 14). "Perhaps more than in any other surgical discipline, orthopedic patients have this composite of rest pain and dynamic pain. If we do not resolve those components, our patients will not do well; yet not all analgesic techniques equally work with rest pain and dynamic pain. Dynamic pain is never well controlled by opioids alone. You need to consider both components.""
  • "Patients typically report unpleasantness related to pain following surgery," continued Dr. Viscusi. "This is still a significant unmet need. Orthopedic surgery is a major component of ambulatory surgery, and it is one of the most painful. Pain consistently remains one of the reasons why patients are readmitted after ambulatory procedures"
  • "There are many reasons why patients have unhappy experiences with their pain control," said Dr. Viscusi. "I think 80% of pain management is really just showing up and talking to your patients pre-operatively, confronting their fears about their postoperative pain, having protocols and plans so that you'll all have tools and instruments for working with them in terms of how their pain's going to be managed." Analgesic Gaps. Dr. Viscusi explained that before multimodal therapy, patients were given an opioid for pain, and if the pain persisted, more opioids were administered. "This is what we grew up with 10 years ago, but it is not the way we practice today. Today, our approach to pain management is clearly multimodal." Pain is an analgesic gap, a period during an otherwise appropriate plan when patients experience unrelieved pain"
Quotes
  • "The key to successful pain management of such procedures requires individually tailored education to patient or caregivers including information on treatment options for postoperative pain and use of multimodal analgesia. Effective pain control aims at patient safety and comfort with simultaneously decreasing complications and providing early rehabilitation. Regional anesthesia techniques, especially peripheral nerve blocks, are an emerging and promising concept in the field of day care surgery."