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Posts tagged with "total hip replacement"

Care Coordination, The Holy Grail of Good Medicine

Appropriate patient care revolves around a team of individuals that includes the patient, a variety of clinicians and other providers, caretakers and patient advocates. The members of this team must collaborate to ensure that the best possible decisions are made on the patient’s behalf. As clinicians, scientists and innovators develop new technologies to redesign health care to make the patient experience more efficient, effective, and better, coordination of care with the patient at the center must always take priority.  Some of the hallmarks of care coordination include:

• Is there proper communication and full information sharing going on?
• Is one provider serving as the gatekeeper, insuring that everyone who should be involved is kept informed?
• Is care well- coordinated, particularly when there are multiple providers and in pre- and post-operative situations that involve teams of clinicians:  primary care, specialists, nurse practitioners, Fellows, etc.

My recent experience at MGH represents care coordination at its best. In 2014 I had a total hip replacement.  At the end of June 2017, upon return from a trip to Japan that involved extensive climbing and walking, my hip suddenly became extremely painful. What could this be?  By the time I returned to the US I was running a fever. I contacted my primary care physician and my hip surgeon. Blood tests revealed that all of my inflammatory disease markers were significantly elevated.  Additional tests including MRIs of the hips and back and blood work that tested for metal in my system indicated that the painful hip was filled with fluid. That was drawn out by a team of radiologists.

Care coordination for all of this fell to my hip surgeon who set up an email chain that included my primary care doctor, my rheumatologist, my back surgeon, the radiology team and ultimately a specialist who performs hip revision surgery. Additionally, I was kept in the loop by the surgeon who texted me at least three times a day to check on my fever, pain level, how I was feeling and to keep me appraised of test results as they came in.

All of the tests on the fluid that was withdrawn from the hip came back negative for infection. I was presenting with a very unusual case of an individual whose hip protheses that was put in place in 2014 was deteriorating. Metal was flaking off into the muscle tissue which in turn caused the large pool of fluid to collect. This was a very rare occurrence   The hip surgeon who had done thousands of total hip replacements using the same prothesis told me that six of his patients over a period of several decades had developed this problem.

On September 8, I had surgery and am recuperating with all of the restrictions regarding mobility that hip surgery requires.  Although the underlying cause of this problem remains a puzzle to everyone on the team, I continue to be totally impressed with the quality of care that I received.

I attribute such good coordination to the fact that I get all of my healthcare in one location where my many clinicians can email each other and view the notes in a common health record, enabling them to work together for smooth coordinated care. In my situation, which was by no means clear cut, everyone was focused on what the best course would be for me, the patient, and I was kept informed and consulted at all times.

The availability of the MGH patient portal also made it easy for me to track all of my labs, tests and provider letters.  I was able to send off quick communications to my clinicians when I had questions, I was able to schedule and view appointments and find links to helpful information.

All patients want health care experiences like this. The factors that made it possible were as follows:

1. Easy to use tools that enabled quick and effective communication with my providers, including mobile apps that enabled me to enter updates and access the latest information.

2. The appropriate resources and instructions that enabled me to manage much of my own care.

3. Transparency in all aspects of my care.

In summary, coordination of care is made much more difficult when all of a patient’s providers are not under one umbrella organization.  However, it remains an essential hallmark of good medicine that needs to be given much more attention than it currently receives.  Care coordination will not happen without the active participation of the patient, and it is critical that clinicians and providers everywhere embrace that practice.  It is also essential that going forward, patients, clinicians and medical institutions work together to achieve as much transparency in care practices as possible, so that everyone is on the same page and there are no surprises.

How Do Patients Make Good Choices?




When you go to the supermarket, it is fairly easy to make a good choices about which cereal or fruit to purchase. At the paint store there are a lot of colors to choose from, but you generally can make a decision after  a bit of deliberation. When you choose a new automobile, you make an informed decision based on certain preferences such as size, color, style or brand and parameters such as price and performance.This is information that you get from research, reading articles and checking ratings.


When it comes to medical decisions, you used to leave the choice of treatment entirely in the hands of your doctors. Although these decision are often life-altering, it is now up you or your families to choose which way to treat your medical issues. This change has occurred because for many conditions: (1) There are no clear-cut parameters with proven success;  (2) The medical experts differ regarding the best way; and (3) Although there is an abundance of information about medical issues, that information is often difficult to comprehend.


A recent letter to the editor in the New York Times related the story of a patient who was undergoing cancer treatment. The doctor suggested that she have a feeding tube inserted during the treatment. The doctor explained the benefits and the risks but left the decision to the patient.  Initially she refused, but over time she realized this was a bad decision and finally after becoming too weak to continue her treatment accepted the tube and completed the treatment.   This illustration points out the difficulties we all face when forced to make choices regarding the treatment for health issues.




Let’s take Prostate Cancer as an example. How does a patient make a choice of treatment among the  three approaches, all of which are  acceptable by medical authorities, to treat early stage prostate cancer:


Active surveillance – Wait and see what develops with close monitoring by your physician, including frequent blood tests and biopsies

Surgery – Usually recommended for individuals younger than 70 who are in good health. The strategy is to remove the prostate, realizing that there may be side effects and radiation may follow.

Radiation Therapy – Recommended for  men of any age with early stage prostate cancer, particularly for  individuals who have health concerns, and therefore who are  not good candidates for surgery, and for individuals who have had surgery and need further treatment.


How about the choices patients who have  multiple coronary artery blockages have to make? There is the question of  whether stents or coronary bypass surgery is the right answer.  Although many studies have been done, there is not enough definitive evidence  that shows better survival benefit  from  coronary bypass over stents. Additionally, many patients with coronary artery disease do just as well with medication as with either procedure, both of which are invasive.


Many patients who need a hip replacement do not even realize that there are choices. These include:


Total hip replacement;  where both the thigh bone (femur) and the socket are replaced with synthetic implant materials

Partial resurfacing, the most bone-conserving approach to hip surgery, where only the femoral head (where the leg joins the hip) is reshaped and resurfaced and the hip socket (acetabulum) is left completely intact. The benefit with resurfacing is that the patient keeps most of his or her own bone, which allows for easier revisions in the future (if one becomes necessary). These differences could mean improved outcome,smaller incisions that  heal faster, less blood loss and shorter hospital stays.


Perhaps the most difficult choices are those involving medications.  Whether to take medication for  certain conditions such as diabetes and hypertension or  change your diet and lifestyle are dilemmas that many individuals face. There are also complicated choices to make when deciding with whether or not to do hormone treatment that can have severe side effects.


In all of these situations, weighing the risk/benefit is not easy.  What can patients do to help them make these decisions:


Proactively do your  research including:reading articles,  talking with friends and family, seeking reputable online communities who have similar conditions, and questioning members of the community regarding their  experiences so you understand your options;


Engage in a consultative, in-depth  discussion with your doctor.


If there is still doubt in your mind seek a second, even a third opinion from other qualified physicians.Once you have all the information you can possibly put together to make an intelligent decision create a chart listing all of the risks, benefits, side effects,  and contingencies.  If you still have questions, consult your doctor once again because in a trusting partnership with your physician, you should be able to come to the best conclusion for your particular circumstance.