Blog 2

Blog 2: Second Week 12/15/08-12/17/08

Dr. --- went to Palm Desert this week for a conference. It gave me some time to shadow another internationally-renowned surgeon from UCSF named D--- (Identity Protection). Dr. D--- is maybe the best joint replacement orthopedic surgeon in all of Northern California. He does maybe over 1000 hip and knee replacements a year, and averages about 8-10 surgeries per operating day, which is ridiculous in terms of volume. He had his own private practice and operates on all his patients in Washington Hospital. He does more joint-replacements than UCSF and Stanford combined! Because he only does joint-replacements, and nothing else, he has developed his expertise in one direction. He epitomizes a really interesting concept. If you do one thing, and one thing alone, you will become its expert. Dr. D--- knows all the intricacies of every hip and knee replacement he does; he can do these surgeries in his sleep (actually I really wouldn't be surprised if he could). In fact, he's so used to doing replacements that he can do one surgery in 45 minutes, which is amazing because it takes general orthopedic surgeons 1.5-2 hours. Watching him operate on knees and hips really showed me how experience and expertise he has in his sub-specialization. He moves at an amazingly fast pace, and operates with an extremely high level of accuracy. He's at a point in his technique in which he no longer has to think, he just subconsciously does everything as if he's a machine. Pretty much all of his operations are successful. It's really amazing to see him in action.

Dr. D--- developed his own hip replacement technique. It's minimally invasive, which required him to modify some of his surgical tools to accommodate the great reduction in cavity size. The benefit of this technique is less muscle dissection, less scarring, and a reduced incidence of infection. It's a pretty small hole, and i find it amazing that he can do a full hip replacement through it. He teaches other surgeons how to do it, and I think he might start a fellowship in the future for his technique. Pretty cool stuff.

I always wondered how Dr. D--- maintained such a high volume of surgeries. He told me that his success lies in an established system based on delegation of tasks. In the operating room he has trained physician's assistants that know every part of the surgery. They know what tools are needed every point in the progression of the operation; Dr. D--- doesn't even need to ask for what he needs next. Also, the patients are fully prepped and ready to operate on before Dr. D--- even enters the room, and after the operation is over the PA's close up the wounds. It's so efficient that after one operation is completed the next operation begins right away; another patient is already prepped by another set of PAs in another operating room. It explains how he can finish 8 or more operations in one day. His training and experience doesn't alone account for the speed of the whole process, but it does account for the speed and quality of the operation itself.

Due to his high volume of patients, Dr. D--- has his own post-operative ward, associated with --- Hospital.On Tuesdays, he makes his post-op rounds to check on how patients are doing with their rehabilitation. He addresses any complications that may result such as wound infections, joint malfunction etc. There are also a set of nurses dedicated to this department. It's pretty nice. After his post-op rounds he goes to his private office to do consults.

Dr. D--- has a state of the art office. All of his patients' records are scanned and stored on an electronic medical records system. Everything he needs is on his network. His system consists of 3 tablet PCs that he takes around with him to each consult room. The electronic charts have pre-made templates for his diagnoses. Everything is streamlined, and no time is wasted. Due to the fact that he has a finite set of procedures, all pre-operative parameters can be stored on pre-formed electronic charts. He then takes his cases (stored on the tablet PC) to a a weekly conference where his colleagues discuss upcoming cases. Everything is paperless and cutting-edge, and it's the only way he can store tons of records he has of the 100s of patients he sees. Another way Dr. D--- can keep up with the load of patients, is his usage of PA's in consult. PA's are trained to handle most long-term follow-ups; if they have any problems they call him into the room. He has a very efficient business model. And even though his practice is centered on efficiency, he's a firm believer in quality of care. In his pre-operative consults, he spends a lot of time exploring treatment options and explaining what joint-replacements are to his patients. He never tries to influence patients into choosing joint-replacements when they don't need it; he only presents it as an option among many other available treatments for arthritic hips and knees. He's a really ethical physician, and firmly believes in improving the quality of life for his patients.

By attending Dr. D---'s consults I learned about why people opt for a joint-replacement. Generally as people age, they are susceptible to arthritis due to the wearing away of the cartilage in their joints. The cartilage serves as a bearing between the bones of the joint, preventing friction and therefore bone wear. Once the cartilage is worn away, due to age and loading, it cannot regenerate. Thereafter, the bones of the joint rub against each other causing a great amount of pain. A joint replacement replaces the pieces of bone that make up the joint, with synthetic bits. These synthetic(made of metal and plastic) bits work together to restore joint-function and eliminate pain previously caused by bone friction. Replacements generally last for 20 years, and the patients can start using their new joints within a 1-3 days of the operation. People can eventually ride bikes, go dancing, and take hikes on joints they couldn't even walk on 4-6 weeks before.