What Does a Community Based Joint Replacement Specialist Do?

Session 62

Dr. Brock Howell is a community-based joint replacement trained Orthopedic Surgeon. We dive in and talk about his path and what you need to know about joints. Brock has been out of Fellowship now for two and a half years.

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[02:00] Interest in Being a Joint Specialist

Throughout his third year of clinical training, Brock had no clue as to what he wanted to do. Although he found himself in between medicine and surgery. He knew wanted to go into surgery, just not what exactly in surgery he wanted to do.

What he gravitated him towards orthopedics is that it’s very tangible when for instance, you see a broken bone. And then it gets fixed. As opposed to things in medicine or GI where you tinker a bit and still have to wait for a result. Hence, there is that sense of instant gratification.

As to why he chose joint replacement surgery, he liked that it’s not a small surgery so you get to walk away and look at an x-ray and be able to change someone’s life. Plus, you can do it in an hour or less. It’s not a scope procedure where you just look at the sutures. And seeing patients before and after the clinic makes him happy.

[05:05] Traits that Lead to Being a Good Joint Replacement Doc

Brock says you have to be comfortable around older population. In some instances, you have to be real patient when it comes to those kinds of your patients. They would usually try conservative therapy for a long period of time before the surgery.

That said, you have to be willing to go in and just make things work. You have to be able to adlib and be comfortable at times.

Revision surgery is where patient has already had a joint replacement. But for whatever reason, the joint replacement has failed. It could be that it’s gotten infected or that the parts have come loose. A lot of times, you have to go in and deal with something someone else has been before. You may also have to get implants out of the bone whether they’re grown into the bone like most hip surgeries or whether cemented in place. So you have to get implants out and deal with extensive bone loss. You’d have to get new implants in and use different types of implants into your normal primary or first time having a joint replacement surgery. So this is a big surgery and this can be tough.

[07:33] Situations Patients Need a Replacement

Patients who undergo joint replacement would usually have undergone arthritis in the joint, whether primary degenerative osteoarthritis or something post traumatic for whatever reason.

Brock often tells patients that it’s not heart disease or cancer so it’s not going to kill them. If they didn’t have a joint replacement, they’re not going to die. So he really doesn’t rush anybody into it. He sees no reason to push someone into the replacement if they’re not ready for it.

Most patients coming in complain that they’re not able to do the activities they want to do. They can’t walk anymore or play tennis. So he leaves it up to the patient to assess their quality of life and if they’re not able to handle it, then they could have the surgery done.

[08:45] Community versus Academic

As to why he chose community versus academic, the major factor was proximity to his family. He’s in his hometown that he grew up in and his wife’s family is less than two hours away. Also, you’re an employee in most university setting practices so he wanted more of the private practice model where he could control things more on a day to day basis.

Brock also cites the difference in the private practice as a joint replacement surgeon. You’d do a lot of primary joint replacements. You’d also be doing revision surgery but majority of the cases consist of primary.

A lot of times, academic joint replacement surgeons do a higher percentage of revision cases than they do primary cases. This is mostly due to the fact that they’re paid differently than what a private practice surgeon would be. Plus, revision cases take more time. In some instances, he can get three primary surgeries done in the same amount of time it would take to do a big revision. And you’re not going to be paid significantly more for a revision surgery than a primary surgery.

[10:22] A Typical Day and Percentage of Surgeries

Brock would usually get up between 5 and 5:30 am. He’d go to the hospital to round if there are any patients. Mondays and Tuesdays will be his office days, seeing between 25 and 35 patients in the morning. He will do elective cases even at the surgery center or he’ll have time to do one or two joints on a Tuesday afternoon. Wednesdays would be his big surgery day. He’d do 5-6 total joints. And every other Wednesday, he’d take calls so he’d leave his Thursday mornings open to do call cases versus other elective or non-urgent trauma cases like ankle fractures. Fridays, he does an all-day session of office.

Brock says he’s dealing with joints in 60-70% of cases while the rest of it would be dealing with issues like knee pain. It doesn’t necessarily end up in a joint replacement but it could end up in any scope. He’d also take a lot of call cases as well as carpal tunnel issues.

So his main surgeries are joint replacement (70%), arthroscopy of the knee (5%), and the rest would be trauma cases.

For joint replacement, most of the patients that show up in the office with arthritis end up with the joint replacement but it’s just a matter of when. Some may want to do it immediately while others would try not to getting surgery done. So you’d be injecting them for two years before they finally decide to do a surgery.

[13:10] Work-Life Balance

Brock says having a work-life balance. He is married to an optometrist that works part-time and they have three boys. Although a lot of times, it is tough. There are some busy weeks but most of the time, he has plenty of time to do everything he needs to do.

[14:05] The Training Path to Become a Joint Specialist

Most orthopedic surgeons do five years of residency followed by a Joint Replacement Fellowship which is another year, for a total of six years of postgraduate training after medical school.

As to competitiveness, Brock describes it as being average. And that most who go through it usually matches but it just depends on where they match and whether it’s high up on their list or not.

If you’re interested in getting into joint surgery, Brock recommends trying to get some research done and try to do as much as you can joint replacement-wise. More than anything, you have to figure out Fellowship as to where you want to match.

This said, see if there are connections in your residency program to certain places you want to go. All it takes is picking up the phone and calling in a buddy or your fellowship director or a program director and that could get you a spot.

Again, do your research. Do well in all of the services you work on. Don’t just focus only on joint nor be a bad resident when you’re in trauma. Just be a great resident and do some research. Figure out a way to make the connection you need to make.

[16:25] Working with DOs and Special Opportunities

Brock says he has been around plenty of DOs that were great orthopedic surgeons. In fact, he knows some very prominent orthopedic surgeons in the joint replacement field that are DOs. Hence, it doesn’t really matter to him. Although admittedly, there is some bias out there. And it’s harder for DOs to sometimes into competitive fields of fellowships. At the same time, there are also some very friendly DO programs out there in orthopedics. Just get out there with anybody else and do well. So Brock says DOs should not be discouraged and just go for it. In the Fellowship he did, he had met some DOs that went through it as well.

As other further subspecialties for joint replacement, Brock mentions the Joint Hip Preservation Fellowship. This gets you into the realm of doing hip sculpts or hip resurfacing. Some joint fellowships like WashU and University of Salt Lake City, Utah, they specialize in patients with hip dysplasia and other hip scopes.

[19:00] Other Body Replacement Options

Brock solely does hip and knee replacement but as far as joints that can get replaced include ankles, hips, knees, joint replacement in the spine, cervical discs, shoulders (three different types), elbows, wrists, and almost every joint out there can be replaced.

[20:10] Working with Primary Care Doctors and Other Specialties

What Brock wishes to tell primary care physicians out there is to not be afraid to treat the joint replacement patient conservatively. Moreover, understand that joint replacement patients can be totally normalized after joint replacements. No restrictions are needed and they could go back to doing whatever they can do and want to do.

Brock’s practice is built up mainly of general orthopedic surgeons but usually they deal with a large amount of trauma they do at their facility. So he deals a lot with the anesthesiologists and general surgery trauma doctors.

[22:10] Special Opportunities Outside of Clinical Medicine

Being a joint specialist, there’s a plethora of different companies to use and each company has different implants to use. They’re always looking for joint surgeons who deal with a lot of joints and have a lot of experience doing joints to help them design better implants and design better instruments to put the implants in with. Or help and teach surgeons who may not have done joint replacement fellowship as to how to use their products better and what opportunities the products present to patients.

[23:06] What He Wished He Knew that He Knows Now

He wished he knew that not everybody does great. Even with the best of intentions, you can go in and do a joint replacement surgery and for whatever reason, a patient may not be happy with it.

There are some studies done that show characteristics in patients that they won’t do well after joint replacement surgery no matter what. There are a couple of studies done like if you look at the patient’s allergy list and the higher number of allergies the patient listed, lower patient satisfaction scores and other scores post-surgery. ¬†Another study done where they put a blood pressure cuff on a patient’s arm and it would blow up to 200 mmHG and have the patient rate their pain on a scale of 1-10. The patients who recorded higher pain with blood pressure cuff on actually had some of the poor outcomes after surgery.

[24:50] The Most and Least Liked Things and Major Changes in the Field

Brock likes the immediate gratification he gets before and after surgery. He finds it awesome to see someone with a horrible arthritic joint do their surgery and they can already walk 500 feet the next day.

On the flip side, what he likes the least about joint replacement surgery is some of the situations where patients are in a bad way. Whether the patient has a chronic joint infection you can’t get rid of or when they’re coming to you. Or they may have the perfect x-ray and they tell you everything but no matter what you do. It’s just difficult to track some of the puzzles and figure out why are some of the patients are hurting and whether it’s legitimate or not can be a struggle.

As to the major changes coming in the field of joint replacement, Brock mentions two things – 3D printing and robotic surgery. They use 3D printing to print on the back of the implant’s actual bone that improves the quality of ingrowth. They also started designing custom implants that are shaped just like an individual patient’s shape instead of a one-size-or-shape-fits-all implant. On the other hand, robotic surgery is starting to push towards the front. You can get a scan of the patient’s affected joints and then plant a surgery ahead of time. Then get into surgery and take the knee or hip through a range of motion, stressing it and making adjustments to your plan before you make a single bone cut. A robotic arm attached to it will guide you and make sure you make the bone cuts exactly how you planned it before surgery. This makes sure everything is as precise as possible. This system is also used for total hips and partial knee replacement. Brock describes how it’s such an exciting technology.

Ultimately, if he had to do it all over again, Brock admits he asks this question all the time. There are days he would probably have done it again. And there are other days he did his best and the patient is not happy with their joint, and it’s a tough day. So you just have to take the good with the bad. Nonetheless, he would still have chosen joint replacement surgery.

[29:11] Final Words of Wisdom for Medical Students and Residents

Finally, he wishes to tell medical students who may be interested in joint replacement is to make sure you try everything. But if you really have your heart set on something early, try to get involved in that specialty whatever it is. Try to do as well as you can on Step 1 and just get involved in what you’re interested in because that’s going to help you always when you’re trying to get into residency.

As far as residents go, try to do well in all your rotations. Ask anybody for a letter and then try to figure out where you want to go and what type of fellowship you want to do. You may want to go to a fellowship where you watch another surgeon operate for a year or where you do all the operating for a year. Or something in between. See if there are any connections to those programs and start working on those connections.

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