Friday, July 31, 2015

Knowing the science, while practicing the art-of medicine

Using an example from osteoarthritis treatment, Dr. Hong explains the balance that all doctors strive to maintain.

Knowing the science, while practicing the art-of medicine


There is a saying taught in medical school to all medical students—usually around the second year—that a key part of becoming a good doctor is “knowing the science and practicing the art of medicine.”

I learned this particular mantra over 20 years ago and still find it very much relevant and applicable today as it was two decades ago (and likely will continue to be in the future). I was recently reminded of this important principle in medicine because of an issue that is a source of discussion (some say semi-controversy) among healthcare providers in sports medicine and musculoskeletal medicine—how to best manage knee osteoarthritis in an active person.

My intent in this blog is not to review the medical literature and cite medical studies supporting one treatment over another; rather, my intent is to highlight to readers of this sports medicine blog that while we know some things about the science of medicine, there is still much room for practicing the art of medicine.

An illustrative example, unrelated to sports medicine, is the treatment of an overactive thyroid condition called Graves’ disease. In medical school, we were taught that the correct ‘scientific’ treatment is to ablate the thyroid using radioactive iodine, thus ‘curing’ the patient but committing the patient to a lifetime of taking a thyroid medication to replace what was lost. Later, as a young doctor in training, I learned that the art of medicine—taking care of the actual patient in front of me—included considering another treatment for Graves’. A medication is given for a limited period of time to control the disease, and that after that time period the medication is stopped. Approximately 50 percent of patients will go into remission and will not need any further medication or treatment. In other words, the right answer from the medical textbook is not always the right answer for the real life patient.

The Arthritis Foundation estimates that 1 in 5 adult Americans have some form of arthritis or arthritis-related condition, and that in the next 10-15 years it will be 1 in 4. Osteoarthritis is far and away the most common type of the many subtypes of arthritis in the U.S., with rheumatoid being a distant second. Knee osteoarthritis can be a difficult challenge for a person of any age and activity level, limiting comfort and functionas well as causing symptoms such as intermittent swelling or instability.

In the past year, two respected medical professional organizations have published statements that have argued against the use of a widely used treatment for knee osteoarthritis, injecting hyaluronic acid into the affected joint (also known as viscosupplementation). The two groups felt that scientific evidence had not convincingly proved the efficacy of this treatment for knee osteoarthritis. Hyaluronic acid is one of the components of normal joint fluid, and the analogy used with patients is that the treatment is akin to injecting artificial joint fluid to lubricate the joint (and thus improve comfort and function).

Last month, a third respected medical professional organization, dedicated to research in arthritis, issued a statement that said that hyaluronic acid injections can be considered in knee osteoarthritis treatment—i.e. that the research does support some benefit even if the evidence does not meet the “beyond a reasonable doubt” level of proof (which to my knowledge is not routinely used in healthcare in any case).

Professionally, I feel that there is a role for viscosupplementation in some patients to help manage a condition for which there is no cure. Unfortunately, what may happen is that the first statement from the two professional groups could be used by insurance companies to justify not paying for this form of treatment (a treatment of injections can cost approximately $400-600). This is not, however, a blog about the rising cost of healthcare or the Affordable Care Act (for the record, I am in favor of all Americans having some form of health insurance).

I do agree that some medical studies have shown little to no benefit with the use of hyaluronic acid, while other studies have shown benefit to its use in helping patients with knee osteoarthritis improve their comfort and function. Until we have the cure for arthritis, or better treatment options, I would recommend keeping viscosupplementation in the toolkit for sports medicine providers and their patients. Know the science and practice the art of medicine. Now just don’t get me started on the use of glucosamine for knee arthritis.
Read more Sports Doc for Sports Medicine and Fitness.
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J. Ryan Bair, PT, DPT, SCS Founder and Owner of FLASH Sports Physical Therapy, Board Certified in Sports Physical Therapy
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Ellen Casey, MD Physician with Drexel University Sports Medicine
Desirea D. Caucci, PT, DPT, OCS Co-owner of Conshohocken Physical Therapy, Board Certified Orthopedic Clinical Specialist
Michael G. Ciccotti, M.D. Head Team Physician for Phillies & St. Joe's; Rothman Institute
Julie Coté, PT, MPT, OCS, COMT Magee Rehabilitation Hospital
Justin D'Ancona
Peter F. DeLuca, M.D. Head Team Physician for Eagles, Head Orthopedic Surgeon for Flyers; Rothman Institute
Joel H. Fish, Ph.D. Director of The Center For Sport Psychology; Sports Psychology Consultant for 76ers & Flyers
R. Robert Franks, D.O. Team Physician for USA Wrestling, Consultant for Phillies; Rothman Institute
Ashley B. Greenblatt, ACE-CPT Certified Personal Trainer, The Sporting Club at The Bellevue
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Julia Mayberry, M.D. Attending Hand & Upper Extremity Surgeon, Main Line Hand Surgery P.C.
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Thomas Trojian MD, CAQSM, FACSM Associate Chief of the Division of Sports Medicine at Drexel University
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