Pushing the Envelope with Treatment

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Everybody knows at least one person who's had a broken collar bone. They're among the most common fractures — I've had one myself. You might end up with a bump like mine, or sometimes a bit of pain with certain activities (for me, it's swimming the breastroke). For generations, orthopedists have treated clavicle fractures with little more than a cloth support like a sling. The vast majority healed just fine. There is an operation we can do, putting a metal plate on the bone with screws, but it's not usually necessary.

Recently, America's premier orthopedic publication, The Journal of Bone and Joint Surgery, published a scholarly research paper that compared patients who have had their fresh clavicle fractures repaired surgically with patients who were treated the old way. The researchers (who seem to do a lot of operating on clavicles) found that people who had the surgery actually had less pain and less bump than those treated only with the support. So surgery as the best initial treatment is the researchers' suggestion. That's a conclusion which every orthopedist who has treated these fractures — as well as every patient, understandably nervous about being sliced open — is likely to question.

How hard should we push the envelope when it comes to medical progress? Despite what seems like an obvious answer in this case of clavicle fractures — "don't push it that hard" — the question is complex. Mainstream treatments of today were often on the dangerous fringe list 20 years ago. Aggressive advancement is the hallmark of American medicine. Yet there is, somewhere, a line to be drawn. Why? New diagnostic tests often give us more information than we can actually use or even interpret. If you do enough MRIs or blood tests, for example, you're bound to find something that's off — and that means getting still more tests. New treatments directed against minor problems, or yielding minor improvements, can be major new expenses. Wrist arthroscopy, a high-tech newcomer to my field, seems to treat problems for which few patients seemed to need more than a temporary splint and some aspirin 30 years ago.

When my father, who is also an orthopedist, was in his 30s, he kept patients in the hospital for periods that would be considered ridiculous today. Those clavicle fracture patients were kept in for a week, carpal tunnel surgery patients stayed for a few days, a bad back might get five or six days. None of these patients ever stay over even one night now; even some go home the same day, and the carpal tunnel patients are out the door in less than an hour. I lived through the change — patients and doctors both were pretty nervous as discharges moved up. Where's the line? Right now there are some docs sending total knee patients home on the day of surgery. That's too far for me — and I have lots of reasons for thinking so — but until there are reported complications I reserve judgment; I have to admit I felt the same way about many of my "same day surgeries" before they were "same day." Hospital budgeting, the driving force behind early discharges, has clearly made things better for many patients here, although lots of young mothers and some older orthopedic patients do complain of being "kicked out" too soon.

It's not just money that pushes us, however. Most surgeons love what they do and pushing the envelope, just for the sake of doing it better, faster or especially these days, smaller, has its own attraction. Surgeons who sew arteries went from repairing ones you could see across the room to ones you can barely see with the naked eye. Heart operations, in which they sawed your sternum in half and stopped your heart with ice-water, are now done with a neat little 3-in. cut under your rib while your warm ticker beats on merrily. We did our total hips and knees through smaller and smaller incisions until a couple of years ago. All that stretching led to some wound problems. So a lot of surgeons "bounced off the bottom" and went back up to a 4- or 5-in. cut. It became a little silly because after the first week there is very little, if any, difference in how the patients feel, no matter what size cut you use. But it introduced a bit of technical challenge into the field of joint replacement — which, especially when done well, can be quite routine. And it was good for marketing too.

Pushing that envelope in internal medicine often means using drugs we used to be scared of. Vancomycin (an antibiotic) and Prilosec (an antacid) were two we ruminated over like we were deciding to drop the bomb. They barely get a second thought these days. The dreaded side-effects just aren't that common. For reasons never clear to the surgeons, new drugs catch on in waves; first it was Prozac, then Zoloft, now its Lexipro. All our patients were on Lipitor, now they're on Crestor. Treating numbers like bone density and LDL cholesterol instead of treating fractures and clogged arteries is hopefully an improvement, so a new generation of patients goes to the doctor, not to get well but rather to not get sick.

The new vigilance involves lots of tests, lots of pills and lots of anxiety over nothing but numbers, however. It might mean crossing the line for some. It certainly means an expanded role — pushing the edge of what we mean by medicine, and this is the area of greatest complexity and perhaps greatest concern.

Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area