Category Archives: SLAC

Change Agents: Knowledge Prosititution*

Prostitution (prŏstĭ-tūshən) n.
  1. The act or practice of engaging in questionable work for hire.
  2. The act or an instance of offering or devoting one’s talent to an unworthy use or cause.

I couldn’t help the title – with all the Paris Hilton stuff in the news – you just have to wonder what people will really do for a buck. Therefore, it is with some surprise that I continue to learn about the questionable underbelly enabled by the Health 2.0 movement. Having already profiled Practice Fusion’s business model (and the subsequent industry satire)I can’t help but wonder about what Sermo is doing.

First off, I want to congratulate Daniel Palestrant, MD for bailing out of his surgical residency to pursue the dream of aggregating physician conversation. I like what Sermo is trying to do: challenge or corroborate each others opinions, accelerating the emergence of trends and new insights on medications, devices and treatments“. By enabling real-time conversations irrespective of geography and time constraints, Sermo functions as a powerful “collective physician intelligence”. Indeed, the “physician lounge” conversations have often been the best, most sanguine teaching moments of my career. Not only do you learn the scuttlebutt, but over time you can pick up the trends that give you an overall vibe for healthcare delivery at the hospital. I believe there is a very large and important role for a physician community like Sermo to play.

Obviously the Vulture Capitalist think so too. Now flush with more than $12M dollars, what is Sermo going to DO to go from an interesting sidelight to an ongoing business concern? Just as with other community aggregations sites (MySpace, Facebook, and YouTube), it probably doesn’t have to do much. Mere aggregation is seen as such a value add that people are literally willing to pay billions for it. The fact that Sermo has been successful aggregating nearly 15,000 physicians is enough to make most medical-industrial complex marketing and advertising schlicksters drool.

But I challenge the direction that Sermo is going. Reading further, “On Sermo, there is no cost to physicians to participate. In fact, Sermo also enables physicians to be financially rewarded for their astute observations and clinical insights. The source of the rewards is financial institutions who access a stream of fresh and actionable information on emerging trends and market-changing events in healthcare. A cash reserve is set-aside to compensate physicians for observations that are deemed highly relevant and valuable.”

I am uncomfortable paying physicians for their opinions in this way. A paid opinion is always an asterisk or a disclaimer. Or more perversely, this is knowledge prostitution. Put a quarter in (or give them an ipod) and watch what the doctor says. It just seems so distasteful. Is there any value in these paid opinions? To me, knowing that these physicians are paid is just another filter that I must put up when and if I read their stuff. Knowing now that the AMA and certainly others to follow are going to be trying to lurk in on my posts is even more unsettling.

But hey, maybe my conspiracy theory gene was just being translated. I love the free market, capitalism, and the roiling darwinism of innovation. So with that in mind, I wanted to try out the service for myself. I signed up last year out of curiosity and have only returned occasionally. As part of my evaluation of Health 2.0 companies, I have been posing a therapy question related to an elective procedure that I need to have done. I posed the question to my physician brethren (and sisters!) and was amazed with the response time:

First 3 responses received in 8 minutes.

Thirteen responses received within two hours


I had to wait two weeks before finally seeing the results: Fourty-three respondents. That is kind cool (my orthopedic question probably was probably a little esoteric for most physicians) but the quality of the responses was a little disappointing. I was hopeful to engage someone on some pedantic discussions regarding Four-Corner procedure, versus proximal row carpectomy versus various fusion alternatives, and instead I got this:

Final Sermo results from my SLAC Therapy question


So while these physicians took the time to answer, the quality of the information was not useful to me. Would my results have been better as part of some paid campaign? Furthermore, while my example was just a random question thrown out there, I remain distinctly uncomfortable with the concept of my knowledge, my experience, and my profession being for sale in this manner. I find the corrollaries with the oldest profession in the world to be a cautionary warning against the “Physician for Hire” mentality:

Prostitutes are often victimized by the person for whom they work, and by their customers. Other health issues related to prostitution are early pregnancy for juveniles, rape, tuberculosis, post-traumatic stress disorder, assault, and other acts of violence—including murder. There are also negative consequences besides those related to health issues. In places where it is common, prostitution lowers the value of property. It also degrades the status of women. Published research studies concerning prostitution as a public health issue in urban communities have come primarily from developing countries.

So, Sermo, I will give you the benefit of the doubt and wait a little longer for the market and your physician users to pass judgment. I love the collective intelligence, I love the aggregation, and I love the fact that you have been so successful in introducing core elements of the Web 2.0Architecture of Participation” to health care. However, I just throw up the cautionary comparison for pause.

As for this SLACer, I should just consider paying someone for their opinion.

* The ideas and concepts in this blog are not paid for by anyone (much to my wife’s chagrin)

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Filed under Change Agents, Health 2.0, SLAC

Tales of a SLACer

Scapholunate Advanced Collapse (SLAC)


1.
Refers to a specific pattern of osteoarthritis and subluxation which results from untreated chronic scapholunate dissociation or from chronic scaphoid non-union;
2. Degenerative changes occur most often in areas of abnormal loading; typically involves the radial-scaphoid joint initially, followed by degeneration in the unstable lunatocapitate joint, as capitate subluxates dorsally on lunate.


OK, I admit it, I am a SLACer.

After a 20 year career of serious hoops and football at the collegiate level, I was diagnosed with SLAC on my right wrist in November 2001. I had just finished competing in my first mini-triathlon and had noticed some increasing pain in my right wrist during training. I had noticed this pain on and off for several years, particularly after extended periods of intense weight training and occasionally after basketball. Usually, with a little time off I was able to return to my normal activity pain free. After the triathlon, the pain persisted despite rest and limited activity.

So one night, while working a shift the Northwest Medical Center Emergency Department in Tucson, I dropped by the radiology department to get a film of my wrist. I reviewed the image myself and did not see any obvious fracture or abnormal positioning of the bones. Later that night, I had to get an orthopedic consult for a fractured hip in an elderly patient and I curbsided the surgeon to look at the film. He casually glanced at it and said, “Dude, I feel sorry for this guy“. That wasn’t what I was hoping to hear from my physician colleague. Turns out he saw the subtle, but clearly present, dreaded widening at the scapho-lunate junction that is sin quo non for SLAC (the “Terry Thomas” sign).


Taken from Dr. K Orthopedic Case Study site.


In my case, it was most likely microtrauma of the scapho-lunate ligament over many years of competitive athletics. It was a slowly progressive condition, wherein the ligament ultimately gave way thereby creating an unstable joint. This instability, combined with ongoing high levels of activity, created a degenerative situation and the painful subluxation.
The problem with SLAC, and the reason for orthopedic surgeons comment, is there really are no good treatment options for this chronic condition. It can become particularly devastating to people who depend on the mobility in their wrist to perform their work (including intubating patients in the ED).

So, as an otherwise very healthy 31 year old physician, I was left with the decision about how to manage a potentially “career-ending injury”. I felt clueless about how to proceed, particularly given the ramifications, and so I did as nearly 20 million Americans last year by turning to the internet for health information. As a physician, I had access to additional resources, including primary clinical studies, orthopedic textbooks, and other advanced information sources to learn about SLAC and compare treatment options. After becoming familiar with the condition, I was able to back channel with my orthopedic surgeon friends to discuss treatment options. Even with all this inside information, I chose my physician solely on a personal recommendation without any clarity about outcomes, pricing, quality, or any other measurable indicator of rational healthcare decision making.

Fortunately, I chose a good friend and colleague to perform a four corner salvage procedure. While the surgical result was as expected (in terms of recovery, range of motion, and return of function) from a surgeon with an excellent reputation, the nature of the underlying condition has left me in chronic pain with intermittent paresthesias (fortunately I can still throw a near perfect 40 yard spiral and have been able to adjust my once deadly jumpshot to be respectable).

Fast forwarding six years, I knew I was in trouble when the familiar chronic discomfort began in my left wrist. Even without the X-ray (wherein I correctly diagnosed myself this time), I knew exactly what the problem was. So herein lies the SLACer tale that I will be spinning in this thread of blogs . . . what should I do?

How should I make a rational health care decision about how to manage this specific decision? What healthcare providers in my area are specialists in the treatment of SLAC? What are their outcomes in terms of recovery, range of motion, return of function, patient satisfaction, and overall outcome? What is the price of treatment over the full cycle of care? What hospital in my area, region, or nationally has the best orthopedic outcomes for this procedure? How much will the surgery cost? How much will the post surgery therapy cost? What will be my personal cost in downtime, wearing a cast, missing work to go to physical therapy, and dealing with the issues associated with recovery? Who will walk me through this process in order to help me make a rational healthcare choice?

This, my Health 2.0 doubters, is where I will show you the value of the new paradigm. I am going to use this blog, as a public educational forum, to show how the new school healthcare consumers can leverage the enabling technology of Web 2.0 coupled with the transparency catalyst of the current healthcare reform movement to redefine healthcare. Buzzword compliance aside, I want to test my theory that these new companies with their new technologies can help a new type of consumer maximize healthcare value (outcome/price).

I believe the Health 2.0 companies I have previously highlighted (Vimo, MedBillManager, Sermo, Subimo, Organized Wisdom, HealthGrades, HealthEquity, and even Blue Cross of CA) will rally to showcase their wares by helping me make a rational healthcare choice. I will be contacting the CEO’s or evangelists of each of these organizations to discuss this opportunity to demonstrate real value, and look forward to periodically reporting back on my progress. I have created a label called “SLAC” to allow you to track my condition and decision making over time. I am expecting that these companies will help me become an empowered consumer in principle, in practice, and in the practical – all right out here in the open on this blog. I hope you find this experience useful, and convincing, regarding the inevitability of Health 2.0.

No slackers in this showcase!

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Filed under Change Agents, Health 2.0, SLAC, Transparency, Value