Knee and Hip Osteoarthritis (Smith, 8/5/2020)

I am always grateful to Sutter Medical Group's Dr. Briant Smith for his orthopedics teaching, and this week's Grand Rounds was no exception. Dr. Smith reviewed the basics of non-surgical evaluation, diagnosis and treatment of osteoarthritis of the hip and knee, definitely very common conditions seen in primary care! 

Here are Dr. Smith's tips:

Examination of the patient with knee pain 

• Gait: ask patient to walk across the room and back (look for flat feet, among other things)
• Alignment: look at legs standing (varus=bow-legged, valgus= knock-kneed)
• Range of motion: looking for difference in joint ROM compared to the OTHER knee
• Joint line tenderness
• Effusion?
• Check hips (seated internal rotation-- this is to be sure you are not missing a primary hip problem)

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Imaging for a patient with knee pain

• X-ray is the imaging modality of choice for osteoarthritis 
• For knees, always get standing AP views of BOTH knees, lateral view of BOTH knees
• For hips, always get images of BOTH hips
• Remember, sometimes the xray may be incongruent with the patient's symptoms (e.g. both hips look severe, but patient only has pain on one side)
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• If you look at the x-ray (ideally look at the image WITH the patient), you are looking to characterize mild-moderate arthritis (some joint space narrowing, small spurs) vs moderate-severe changes (bone on bone, bone sclerosis, sub-chondral cysts)

• Do NOT order an MRI before an xray because. . .guess what?
• If there is evidence of DJD on the xrays, you don't actually NEED an MRI! 
• You have made the diagnosis and can start the treatment.

What about arthritis and meniscus tears?

• All knees with arthritis have meniscus tears
• The pain is almost always due to the arthritis, and arthroscopy (meniscectomy) doesn't help, with very rare exception

Treatment of knee and hip arthritis

• Don't forget to explain the diagnosis: "you have arthritis in the right knee""
• Make the distinction between mild-moderate and mod-severe "You have severe arthritis in your right knee"
• Dr. Smith recommends this analogy: The protective coating on the ends of the bones has worn away, like the tread on a tire. You are now on the steel belt (mild-mod arthritis) or the rim (mod-severe arthritis)
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What can patients do?

• Relative rest/modified activity: many patients love to walk and run, but probably best to switch to swimming and/or stationary cycling (then they can keep up their aerobic exercise)
• OTC meds: NSAIDs (if not contraindicated, be sure to check labs, particularly for SCr), acetaminophen, glucosamine, fish oil, CBD. Avoid opiates.
• Physical therapy,  (it's good idea to do some PT before knee or hip replacement, but remember Medicare only covers 18 visits/year, don't use them all up if a patient is going to get surgery)
• Steroid injection: if the injection works and lasts a few months, okay to repeat (up to 4 times/year) for severe pain, but if only helps for a week, then probably not worth it
• hips done by radiology at the hospital 
• Not great evidence for hyaluronic acide injections (costs $500-1000, usually cash)
• Knee bracing not indicated, some patients feel more comfortable/supported in a neoprene knee sleeve. This isn't helpful but if it makes them feel better is fine

When is a patient ready for surgery ?

• When they are ready.
• When you might consider them ready?
• If they are having sleep issues due to pain
• If they have significantly modified their activity and are missing out on things they would normally enjoy because of their pain
• There is no lower or upper limit of age for hip or knee replacements. It's really the severity of the arthritis and their degree of illness/wellness.

Surgical Preoperative Optimization

• Anemia, goal Hb>12 reduces transfusion risk (perioperative transfusions actually increase the risk of infection and LOS)
• Smoking, goal quit at least 6 weeks before surgery, including ALL nicotine products (nicotine affects wound healing and infection risk)
• Diabetes, goal <7.5 (infection risk)
• Obesity, goal BMI <30, most surgeons won't operate if BMI>40
• Malnutrition (albumin >3,5)
• And more! 
• immune status, hypothyroid, low vitamin D, CV disease, ASA class, opiates, CKD, sleep apnea, psychiatric illness, social factors, deconditioning

Mental Health Disparities in Latinx (Flores, 7/29/2020)

A big thanks to CEDAWG and Dr. Yvette Flores, clinical psychologist and professor of Chicano/a studies at UC Davis, who gave a powerful and heartfelt Grand Rounds presentation this week on how to consider and approach the mental health of marginalized groups, particularly Latinx , in this time of COVID. Again, it is hard for me to give her words justice in summary, but the following is my attempt.

Dr. Flores started with "stating the obvious": 1) That racism, sexism, homophobia and other forms of discrimination affect the mental health of those who experience them, 2) That stress affects well-being and 3) That yes, in fact, we are all in this together.

If I don't wear a mask, I affect you.

If my grandchildren don't wear a mask, it affects me.
We are all a little anxious, depressed, and experiencing past traumas as we live this pandemic.

We all need to be in this together, including in mental health.

Dr. Flores spent some time reviewing the important effects of stress on mental health.

Social stress: stress is produced not only by personal events but also by the social conditions that surround us-- and for all our patients, their intersectional identities (gender, class, nativity, immigration status, length of residence in the US). 

Minority stress: high levels of stress faced by members of stigmatized minority groups (race, gender, sexuality, linguistic ability, physical/mental abilities), including:

• lacking proper social supports
• socioeconomic status (SES)
• interpersonal discrimination

Marginalized status affects physical and mental health.

Good stress vs. bad stress: a little stress has been found to improve performance, but a lot of stress can become problematic. In what ways is minority stress a risk factor? And how may minority stress also be a protective factor?

I love considering the possibility that the very minority stress our patients are experiencing may make them simultaneously vulnerable and resilient. 

What has COVID-19 Revealed?

1) Health disparities have been made more visible

2) Xenophobia and hate crimes against Asian Americans

3) Disregard for these disparities from politicians at the highest levels

4) People of color disproportionately work in front line jobs

5) Disproportionate unemployment rates for Latinx and African Americans

6) Ageism (are old people important enough?)

How can we translate scientific data in a way that people can understand?

How do we frame the message?

"There is no one to blame here, but we all have responsibility."

Role of Gender: For the working class, life and work are often synonymous. How does unemployment affect men? How does unemployment impact women who are single parents and have to work? People of  color will often go to work despite the risk because of their gender or cultural mandate that it is their obligation to provide. But this is also a class issue (always need to think intersectionally).

What are the protective factors in communities of color that might mitigate the crisis?

1. Resilience: Immigrants are tremendously resilient. It takes incredible courage to make the journey that many immigrants (particularly undocumented immigrants) make.
2. Stoicism:  coping, "it's alright, I am fine", challenging for healthcare professionals to care for someone who says they are fine (when they clearly aren't). Dr. Flores' rec: Bring in partner if there is one/
3. Religious faith: "Si Dios quiere" God willing. Can be frustrating because seems fatalistic but is also protective. How can we leverage this?
4. Networks of support:  Overcrowded and/or Multi-generational households, which make them more vulnerable are also the very support structures that allow people to survive. How do we mobilize the 
5. Positive ethnic, racial and gender identity: reaffirm their identification (whatever they may be). Call them what they want us to call them. 

Remember that mediational factors may ADD to minority stress

• Internalized racism
• Controlling images (often propagated in the media-- more serious and perverse than stereotypes), many are gender specific (angry black woman, loud Latino, Latino male as criminal or rapist). How does this affect internalized perception of people of color?  How are people in power speaking about these controlling images?
• We must uphold the identities of the people with whom we work: we need to counter these controlling images (mental health workers)

And finally, on coping: how to potentiate coping, so we can be better healthcare providers and caretakers. 

Dr. Flores called this digging into our ancestral well: we have all learned lessons from our family that can help us to serve our patients. In times of crises, we can draw from the stories/legacies that the elders and ancestors have shared with us (and with each of our patients), which can help transform our fears into opportunities

Where do you draw your strength to continue to care for your patients?

Self care is essential during COVID-19:

It is important for us to promote self-care and resilience as we do this work.

Gendered expectations (nurture ourselves in order to refill the well)

Remember to check out and disconnect in order to connect to ourselves 

Cultural traditions can offer balancing and healing: including prayers, smudging, meditation, mindfulness, exercise, baking, cooking

Health Equity (Muodeme, 7/23/2020)

Special thanks to Dr. Ada Muodeme for her thoughtful and thought-provoking Grand Rounds this week on Health Equity. 

A friend and healthcare provider asked me this week, "Why are you hosting  so many Grand Rounds on race, racism, equity, and inequity?" My response is the following: "We bring you these topics because we-- the Sonoma County medical community-- need formal education on these topics. We need race discussions in our academic centers, in our hospitals, in our clinics, in our classrooms, break rooms and beyond. Grand Rounds is a natural place to start these conversations."  

And I am so grateful to our brave residents for being the leaders of this education!

While social justice was definitely integrated into my own medical training, race and racism in medicine were definitely not a part of any training. I did not get taught about how race and racism are structurally a part of medicine. I was not trained on allyship, anti-racism or white privilege. These are topics most white people (myself included) need to hear, read about, grapple with, and consider both personally and professionally. While many of our current residents come to us now with formal training in race and medicine, their teachers have little to none. 

And so we do this work.

This is another GR presentation by a BIPOC better listened-to than summarized by a white gal like me, but here are a few key points:

• Dr. Muodeme reminded us that healthcare comprises only 10% of an individual's health and well-being-- the remaining 90% includes behaviors, environment, societal factors, etc. She grounded her talk in the historical perspective of the African American citizenship status and health experience from 1616 to 2020-- slavery, Jim Crow, and Civil Rights. 

• Dr. Muodeme also shared with us a definition of health equity: "The attainment of the highest level of health for all people". Health equity-- she continued-- requires valuing everyone equally, societal efforts to address avoidable inequities and injustices, and the elimination of health and healthcare disparities.

• But what I appreciated most about Dr. Muodeme's presentation was her focus on the concept of unconscious bias, and the process of self-reflection and self work we all need to do to help mitigate those biases. "I don't know a doctor who comes to work thinking I don't want to right by my patients today," she said. "I don't know a doctor who thinks I am going to treat my black patients differently". And yet, we know we do. The system does. And we do. 

And so, pay attention, watch your thoughts, all. And see you next week!

Allies and Accomplices: How Health Care Providers Can Cultivate Equity (Washington 7/15/2020)

Well, Dr. Sharon Washington did it again. And this time on Zoom (which is no easy task). She pushed us. And moved us. To think differently. To act. To do better. To question the insidiousness of race and racism embedded in our society and in medicine. To not be not racist, but rather to be ANTI-racist. She is such a tremendous speaker and incredible teacher, and we at the Santa Rosa Family Medicine Residency are so lucky to have had her with us this last year and a half. 

A summary cannot really do Dr. Washington's work and words justice. I highly recommend you watch the Grand Rounds if you did not attend live, but nevertheless, here are some highlights. . .

Racism is not merely one individual's negative thoughts about another person of a different race. Racism is more layered and complex. It includes:

• internalized: the devaluing of one's own identity and culture according to societal norms
• interpersonal: the way in which we perpetuate racism on an individual basis
• institutionalized: the way in which institutions perpetuate racism
• structural: system of public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways, to perpetuate racial group inequity

Dr. Washington highlighted the legacy of inequity for African Americans in the US dating back 401 years (see image)

Dr. Washington reminded us that:

• There is racial bias built into almost every aspect of healthcare.
• Significant health disparities exist for people of color in chronic disease (diabetes, cancer, heart and kidney disease), infant and maternal mortality, stroke, addiction and mental illness.
• People of color receive fewer/less breast cancer screenings, kidney transplants, vaccinations, eye exams cardiac care, cancer pain meds, revascularization procedures, and mental health treatment.

In order to not be part of the problem, health care providers have a responsibility to be ANTI-racist: the active process of identifying and eliminating racism by changing systems, organizational structures, policies and practices, and attitudes so that power is redistributed and shared equitably.