Dr. Brian McGrory (Guest): That’s a great question, and I'm very happy you asked it. The logic that you need to exercise when you have an orthopedic problem and you’re thinking about elective surgery is first and foremost what’s going on. And so, my approach when I see a patient is to understand the diagnosis. That’s our medical term for what is the problem. And from that diagnosis, then you can understand the prognosis and the treatment option. So that’s the very, very first step. Now, if you think you have an orthopedic problem that is going to need attention, then you might want to ask your friends locally, you may want to ask your primary care physician who they would recommend. Once you’ve done that and once you’ve collected some names, then there are many tools that you can use today, including the Internet, to try and understand whom you should see. It can be complicated, it can be a little bit daunting, but the bottom line is when you have an elective surgery that you’re thinking about as an endpoint or even nonsurgical management, you do have choice. And if you go to a practitioner that you’re not happy with for whatever reason, you can always go to another practitioner. Don't get too caught up in finding the perfect person right out of the gate. But the more homework you do, the better chance you’ll find someone that works with your personality to get you the best treatment and outcome for your problem.
Melanie: Dr. McGrory, sometimes you see US news and health reports or the top doctors. If you’re going to use the Internet and you see this listing of the top orthopedic surgeons, is that something to believe, or how did they get on that list?
Dr. McGrory: Well, that’s a great question also. A lot of Internet information can be applied to medicine the same way it’s applied to bestselling authors or applied to other products that you’re trying to look into in research. And so there’s an array of information that you have to sort through. Some of it is actually paid for by the physician or their hospital. Some of it is objective and it’s information that comes from voluntary reviews, and then some of it is objective that comes from all the patients or all the surgeries that that physician participated in. That, in my view, is the most valuable, although you can use all three. Let’s start with the things that are paid for by the physician or their hospital. Those things are the least reliable, although they don't frankly lie when they talk about some of the accomplishments or outcomes of that surgeon or that physician. They might or might not highlight the best things. And so, it’s less objective, and I would put those to the side. The next level that you’ll see are sites that compare physicians. Healthgrade might be an example of this, or there’s some doctor compare sites. When you put in “Dr. Brian McGrory,” for example, you’ll see three or four different healthcare doctor compare sites. And those will have star ratings that patients write in, so one to five stars, and then some of them have specific questions—what’s the waiting time. And then they’ll have sometimes a place where you can do a free-form description of your experience. Those can be helpful, but I would treat them with a little bit of a grain of salt because sometimes, at least with elective surgeries, the most disgruntled or the most complimentary patients kind of have the loudest voice. Sometimes, that very loud voice tricks you into thinking that that’s the answer. And because that’s not as objective as you can get, I would go one step further. So the next step is the comparison sites where all of the surgeons’ or all of the physicians’ outcomes are mandated to be collected. We’re not perfect at doing that in the United States, but one site that you can go to is medicare.gov. And that has a hospital compare calculator. And so if you want to compare hospitals for actual outcomes of all their patients, that’s the place to go. That website is also going to, in the future, grade physicians. Right now, it doesn’t have that level of granularity, but ultimately, that’s the best site in my view because it takes into account how complicated the work that that hospital or that surgeon does. That’s important, right? You don't want to hold that against someone if they’re taking on the most complicated, sickest patient and doing a good job with them. So that site takes that into account and it looks at all of the cases for a three-year period, for example, with hip and knee replacement and allows you to look at objective outcomes. The two that they look at on medicare.gov hospital compare are in-house complications, so in-hospital complications—that’s very, very important, including death and pulmonary embolus and infection—and then it also looks at readmission, so patients that leave the hospital and come back with a problem. Those two things are areas that the government Medicare specifically is looking at grading hospitals on. That to me is the gold standard. Now, you can use those other areas like the individual doctor compare sites and you can use the paid ads that you’ll see pop up, but I would only use those as a supplement to looking at the complications and the readmissions for hip and knee replacement at your hospital.
Melanie: And yes, some of those forms are like the Trip Advisor or the Yelp for searching for surgeons, so you do have to take those with a grain of salt. And organizations like AAOS, the American Association of Orthopedic Surgeons, other organizations like that, Dr. McGrory, do we look to those organizations for a list and then go to our insurance carrier and make sure that the doctors we’re looking at are covered?
Dr. McGrory: I think that’s a reasonable way to do it. The advantage of looking at AAOS is these are board certified doctors. They might not differentiate between the specialists in sports medicine or joint replacement surgery, so there are subspecialty piece societies that are also very valuable. One for hip and knees is an association called AAHKS, American Association of Hip and Knee Surgeons. These are not only board certified surgeons but these are surgeons that have interest in hip and knee replacement. That’s very, very helpful, and they both have parts of their website where you can get a doctor locator. And so that gives you some names to work with. In the AAHKS realm, these are surgeons that do more than 50 hip or knee replacements a year, which is a relatively low standard, but I think it’s a very good standard to start at, because like any other technical thing or technical operation, the more you do, to some degree, the better you are at it. The other very valuable thing that an association like AAOS can offer is clinical practice guidelines. These are helpful not necessarily to pick a specific surgeon, but these are helpful when you have a diagnosis. So let’s say I come in the office and I’m given the diagnosis of knee arthritis, you definitely don't want to just go willy-nilly online to try and figure out what are the most effective and the least risky treatments for that. Organizations like AAOS will offer evidence-based medicine that support what treatments are effective and have low risk for both non-surgical and surgical treatment. These are called clinical practice guidelines, and these are very, very helpful once you have a diagnosis. You can use that information when you see your surgeon to ask: have we tried them enough before we consider surgery, things like weight loss, things like anti-inflammation medicine, what are the pros and cons of injection. All of this information is available in the Internet, but you have to be very careful and make sure that you go to a very well-known and objective group to get the information.
Melanie: Dr. McGrory, we don't have a lot of time left, but this is such a fascinating topic and you’re so well versed in it. Where do you put on the list, if we’ve researched everything, looking at all of these things you’ve told us to do, where do you say we do with consultations with an orthopedic surgeon? Are you docs willing to meet with us one time to see if we jive together, if we get along, if you are the surgeon for us? Is that something that you can do is maybe see one or two different surgeons to see which one you like?
Dr. McGrory: That’s a great question also. In our society, with our current milieu of health insurance, you are definitely not only allowed to do that but encouraged to do that, because a lot of outcomes—that is to say, how well does the endgame from my problem, how does it play out—depends not only on the technical expertise of the surgeon, not only on the low complication rates of the hospital but also the patient’s attitude going in and coming out of this diagnosis. And so, you really don't want to settle for, “Oh, he doesn’t have a good bedside manner,” or, “She’s an excellent surgeon, but don't ask her any questions.” That’s not appropriate anymore. Shared decision making, the new generation of doctors that understand patient expectations not only to have an excellent outcome but to also feel empowered by the process. That’s very, very important. And if that takes two or three visits before you find someone that you nailed with or are simpatico with, it’s well worth doing that homework beforehand. Because if you have a complication or a problem after, that’s when that becomes a huge problem. If everything goes perfectly, then we can all accept that it wasn’t the most touchy feely visit that we wanted, but when things don't go well, which they don't about one and a half percent of the time, even in the best of hand, you want someone that will stand by you, that will take responsibility and get you through that problem.
Melanie: In just the last minute, Dr. McGrory, if you would, please give the listeners your very best advice on finding that perfect orthopedic surgeon for them for their surgery and why they should consider coming to see you at Maine Medical Center.
Dr. McGrory: Well, we’d be thrilled to see patients that need our help and choose us, but I would say that first and foremost, there’s probably not one person. There’s probably, let’s say, 10 percent of joint replacement surgeons or the type of surgeon that you’re going to want to see. Once you get into that upper echelon, you want someone who’s compassionate, you want someone who’s knowledgeable, and you want someone with a high level of expertise. And that, in our field, is reflected by low complications, low readmissions, and to some degree, a high level of experience, a certain number of surgeries that you do a year in knee replacement, hip replacement, redo hip replacement. Those are the types of things that patients should be looking for, and they can use the Internet to set themselves up for success by looking at sites like medicare.gov for the hospital compare and looking at sites like aahks.org or aaos.org to understand through clinical practice guidelines what the best medicine advice should be and, ultimately, which members of those groups offer treatment for these problems.
Melanie: Thank you so much. It’s great information. You’re listening to MMC Radio, and for more information, you can go to mainemedicalcenter.org, that’s mainemedicalcenter.org, mmc.org. This is Melanie Cole. Thanks so much for listening.