We thank all of this month’s #JHSJC discussion participants! We talked about two articles from Volume 46, Issue 2 of The Journal of Hand Surgery and addressed a number of critical topics: The Association Between Electrodiagnostic Severity and Treatment Recommendations for Carpal Tunnel Syndrome and Relevance of Diagnosed Depression and Antidepressants to PROMIS Depression Scores Among Hand Surgical Patients.
Feel free to continue the conversation below in the comments! And please check out previous #JHSJC transcripts (please scroll to the bottom of the page).
Brent Graham @BgTalkinman:
Welcome to the February session! Let’s start with the study on #EDS and #treatment in #CTS https://www.jhandsurg.org/article/S0363-5023(20)30536-0/fulltext #jhsjc
Here is a link to my interview with @ErikaDSears: https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/February_2021.mp3 #jhsjc
Dr. Ray Raven @RayRavenMD to @BgTalkinman:
Welcome! #JHSJC
Warren @whammert:
Interesting study, but I found the results confusing. For me, surgery is recommended for severe CTS #jhsjc
Brent Graham @BgTalkinman:
The main point of this study was that #EDS findings didn’t seem to align with Rx for #CTS #jhsjc
Warren @whammert to @BgTalkinman:
I found this surprising. Different than what I think my practice is #jhsjc
Brent Graham @BgTalkinman to @whammert:
Exactly! Why was that only done in 53% of cases considered “severe” by #EDS criterias? #jhsjc
Dr. Ray Raven @RayRavenMD to @BgTalkinman:
you mean that electrodiagnostic testing #EDT #EDSmay may not be of any value in the management of #CTS? #jhsjc
David Ring @DrDavidRing:
I was also confused. Hand surgeons don’t use EDx to diagnose idiopathic median neuropathy at the carpal tunnel (IMNCT). #JHSJC
Brent Graham @BgTalkinman:
This was a single center study. Do people think the findings generalizable? #jhsjc
David Ring @DrDavidRing:
Hand surgeons use EDx to cover their butts because people can be unhappy after surgery and we want some documentation. What is the setting where half the tests are mild or normal. Seems like over use of EDx #JHSJC
Brent Graham @BgTalkinman to @DrDavidRing:
I don’t – no surprise there — but evidently the test are ordered. The failure seems to be the link to Rx #jhsjc
Dr. Ray Raven @RayRavenMD to @DrDavidRing:
this hand surgeon hasn’t ordered #EDT #EDS for more than 3 years for routine #CTS #JHSJC
Warren @whammert to @RayRavenMD and @BgTalkinman:
More that I was surprised it didn’t change tx. For severe, more than 50% of my patient have sx #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
To me that is the point of the study and why it’s important. It points out that #EDS and Rx are not clearly linked. #jhsjc
Warren @whammert:
Paper was not about who needs edx as that is a different debate. But should results change treatment recommendations #jhsjc
David Ring @DrDavidRing:
Mild or moderate–that’s a choice. So the only interesting finding is that only half of severe were offered surgery. Tell me more. #JHSJC
Warren @whammert to @DrDavidRing:
exactly! #jhsjc
Brent Graham @BgTalkinman:
Study after study seems to show the absence of this link. Why are the tests being done? #jhsjc
Brent Graham @BgTalkinman to @whammert:
The proportion who underwent surgery and the time until surgery was done seemed to reflect the #EDS severity #jhsjc
Warren @whammert to @BgTalkinman:
Still different question – if you didn’t order, but someone else did, should they be used for tx recommendations? #jhsjc
Dr. Ray Raven @RayRavenMD to @BgTalkinman:
Low value services are one of the worst characteristics of US health care. #jhsjc
Erika Sears @ErikaDSears to @DrDavidRing:
that was the interesting thing for me and what I want to understand…did they intend to never act? if so why order EDS? #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
The study doesn’t address the question of why they didn’t have sx and there could be many reasons #jhsjc
Dr. Ray Raven @RayRavenMD to @whammert and @BgTalkinman:
good question. I mention it in my note but don’t use it to make decisions in most cases #jhsjc
Brent Graham @BgTalkinman:
The senior author is here: @ErikaDSears!! Ask her your questions! #jhsjc
Dr. Ray Raven @RayRavenMD to @ErikaDSears:
Thanks for joining! #jhsjc
Brent Graham @BgTalkinman to @whammert and @ErikaDSears:
Who ordered the test? I don’t remember. Was that known? #jhsjc
Warren @whammert to @BgTalkinman and @ErikaDSears:
So why do you think the severe did not have surgery almost half of the time Erika #jhsjc
My take was not all were ordered by surgeons #jhsjc
Erika Sears @ErikaDSears to @whammert:
It wasn’t known who ordered the tests. A challenge to really understand b/c sometimes pcps order b/c someone else requires it #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
co-morbidity, inconvenience, maybe even insurance issues, time from work. All could be factors #jhsjc
Brent Graham @BgTalkinman to @ErikaDSears:
Has that not been shown in your earlier work? #jhsjc
I think the study is here: https://www.jhandsurg.org/article/S0363-5023(19)31393-0/fulltext
Erika Sears @ErikaDSears to @whammert:
I think some tests are ordered for confirmation but pt may not want surgery or referring thinks too severe for improvement #jhsjc
Warren @whammert to @ErikaDSears:
It can almost always get worse. One of the few things we treat where I strongly encourage patient to consider #jhsjc
Brent Graham @BgTalkinman to @whammert and @ErikaDSears:
This paper suggests that it may be a way to expedite access to the surgeon: https://www.jhandsurg.org/article/S0363-5023(19)31393-0/fulltext #jhsjc
Peter DeNoble, MD, FAAOS @peterdenoblemd:
Would be a nice follow-up to this data set, and compare hand surgeons vs primary care docs vs neurologists. #JHSJC
Brent Graham @BgTalkinman to @peterdenoblemd:
Agreed! The motivations likely vary-access to a surgeon seems to be one in the earlier paper by @ErikaDSears #jhsjc
For some neurologists and physiatrists, sadly, there are obvious conflicts of interest and ingrained beliefs #jhsjc
Surgeons also have their ingrained beliefs! #jhsjc
Dr. Ray Raven @RayRavenMD to @peterdenoblemd:
thanks for joining, Pete! #jhsjc
Brent Graham @BgTalkinman to @BgTalkinman:
What about the seemingly random use of non-op Rx – that didn’t seem correlated to #EDS severity? #jhsjc
Erika Sears @ErikaDSears:
I’d love to understand decision-making in patients with severe CTS for future study #jhsjc
I do see seemingly random use of splints (prior to referral) or injections without consideration of severity (motivation for study) #jhsjc
Brent Graham @BgTalkinman:
The inevitable question: What is the role of insurer policy here? #jhsjc
Warren @whammert to @BgTalkinman:
Required in NY for WC only #jhsjc
Brent Graham @BgTalkinman to @whammert:
Do private insurers allow #CTR without #EDS “confirmation”? #jhsjc
Warren @whammert to @BgTalkinman:
Yes – only required by WC in NY #jhsjc
Erika Sears @ErikaDSears:
even though i don’t require EDS, so few come without it b/c many require it. they can’t keep track who wants what. #jhsjc
Brent Graham @BgTalkinman to @ErikaDSears:
That probably varies by region. #jhsjc
Brent Graham @BgTalkinman:
One justification for #EDS always seems to be insurer demands. Is that really true in 2021? #jhsjc
Warren @whammert:
#CTS6 #jhsjc
Brent Graham @BgTalkinman to @whammert:
That was the motivation for the #CTS-6: model what experts do so PCPs + others can use the same approach as a hand surgeon #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
It’s a legal/policy issue state-by-state in the US #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
It always baffles me bc insurers would probably benefit from fewer #EDS. #jhsjc
Peter DeNoble, MD, FAAOS @peterdenoblemd:
EDS play almost no role in my practice for routine, straightforward CTS, but I’m in NJ so ??♂️ #JHSJC
Brent Graham @BgTalkinman to @peterdenoblemd:
My sense is that is a gradually evolving approach in many places but it remains regional. #jhsjc
Brent Graham @BgTalkinman:
Really stimulating discussion – lots of great insights! Let’s move onto the other study, #depression among hand clinic patients. #jhsjc
A cross-sectional study in a single center. Is there any reason to suspect the results are not generalizable? #jhsjc
https://www.jhandsurg.org/article/S0363-5023(20)30610-9/fulltext
Warren @whammert to @BgTalkinman:
I think we would see similar results in large multi enter study #jhsjc
Brent Graham @BgTalkinman to @whammert:
I agree — I think it is very likely that the results are generalizable. #jhsjc
Brent Graham @BgTalkinman:
Hand may surgeons recognize that #depression exists in their patient populations but don’t see that as something in their scope #jhsjc
Assuming that these findings are real – untreated, undertreated depression is prevalent -what should be the role of hand surgeons? #jhsjc
Warren @whammert to @BgTalkinman:
Missed opportunity to help. But not easy and takes a lot of time, which many surgeons don’t invest #jhsjc
David Ring @DrDavidRing to @whammert and @BgTalkinman:
Ryan is reproducing prior findings. We are often in the best position to diagnose mental health opportunities #jhsjc
Brent Graham @BgTalkinman to @whammert:
The feasibility question is paramount. We aren’t very good at referring for things we know about like osteoporosis #jhsjc
David Ring @DrDavidRing:
The illness journey doesn’t start with symptoms. Symptoms are often accommodated. Illness starts when symptoms become a concern. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing and @whammert:
I agree – although quantifying the problem is important. What is a practical strategy? #jhsjc
David Ring @DrDavidRing:
It’s important to identify the misconception, loss of hope, worry, and stress that are at the heart of those concerns. #jhsjc
Daniel A. London, MD MS @LondonDA to @BgTalkinman:
Connecting patients to resources. Psychologists and cognitive behavioral therapy may be a solution. #JHSJC
Brent Graham @BgTalkinman to @LondonDA:
If 30% of patients are affected, should those professionals be in the hand clinic? #jhsjc
Daniel A. London, MD MS @LondonDA to @BgTalkinman:
Maybe not in the clinic, but definitely part of the treatment team no different than a CHT. There are app-based opportunities for CBT, too, which could also be an option. #JHSJC
Warren @whammert to @BgTalkinman:
This is here we need better health care systems. Often a silo and can’t get help so eventually stop trying #jhsjc
David Ring @DrDavidRing to @BgTalkinman and @whammert:
Symptom intensity greater than expected. Incapability more than expected. #jhsjc
David Ring @DrDavidRing:
Think mental and social health. Get to know the person with the symptoms. Their hopes. Their fears. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
At a more basic level for hand surgeons-we see that depression is prevalent but we’re busy. What should we do? #jhsjc
David Ring @DrDavidRing:
Look for the verbal (excruciating, unbearable, high tolerance…) and non-verbal signs. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Of course, I don’t disagree but it’s not practical no matter how humane it would be. What is a feasible approach? #jhsjc
I also agree that being humane is critical but it’s not enough. That’s the challenge I see. #jhsjc
Warren @whammert to @BgTalkinman and @DrDavidRing:
The best thing is often the most difficult – take more time #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
And when those are identified, then what? #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
Prioritize the relationship over the medicine. Diagnosis and treatment can wait. #jhsjc
Be honest and ethical. Open the conversation with their regular doctor and the people they trust. #jhsjc
Brent Graham @BgTalkinman to @whammert and @DrDavidRing:
Devil’s advocate warning!! Time is a premium for many reasons. The other pts need us too, so What is the way fwd? #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
Incrementalize care. You can give people more time over many days. No need to solve it all in one visit. #JHSJC
People might end up in a specialists office because non-specialists are confused. Don’t try to solve everything all at once #JHSJC
Incrementalize your care and build a relationship. Build trust. #JHSJC
Brent Graham @BgTalkinman to @DrDavidRing and @whammert:
It isn’t only a lack of compassion. Most surgeons are compassionate. #jhsjc
David Ring @DrDavidRing:
Surgeons are compassionate. No issue there #JHSJC The sacrifices we make to help people. Humility and curiosity are traits for us to expand.
Brent Graham @BgTalkinman to @DrDavidRing:
Should the hand surgeon be the one to solve it? Isn’t that the question this begs? #jhsjc
David Ring @DrDavidRing:
The hand surgeons may be the only clinician that can confidently say, “these symptoms are more than what we expect for the pathology.” We can be the first to accurately diagnose mental and social health opportunities. #JHSJC #StepUp
Brent Graham @BgTalkinman to @DrDavidRing:
I agree, but like our poor care of osteoporosis, we can’t rely on hand surgeons to take the time and do this in a way that actually does anything but the most basic preliminary recognition. Much more is required.
I couldn’t agree more but this is something that most surgeons are just not going to do. We need systems to help. #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
And we can work upstream to teach non-specialists and everyone that symptoms are partly due to pathophysiology and partly due to worries, despair, and stress. #JHSJC
Warren @whammert to @BgTalkinman and @DrDavidRing:
Yes – I think if here was an easy process to get patient help, it would be used. #jhsjc
Brent Graham @BgTalkinman:
What I’m getting at here is that there is a large problem and we have to advocate for practical effective solutions. What are those? #jhsjc
Warren @whammert to @BgTalkinman and @DrDavidRing:
but also need to not take advantage or use it as a dumping ground #jhsjc
David Ring @DrDavidRing to @BgTalkinman:
Surgeons can do something. They can recognize when the priority is not pathophysiology. #JHSJC And they can prioritize compassion and relationship. Please start tomorrow.
Brent Graham @BgTalkinman to @DrDavidRing:
It’s not going to be a frequent situation that we can take the required time for this many people. #jhsjc
Dr. Ray Raven @RayRavenMD to @DrDavidRing, @BgTalkinman, and @whammert:
there are people that would argue with you there. But not me. #jhsjc
Brent Graham @BgTalkinman to @DrDavidRing:
Agreed. This is an area where we can do the most good by advocating, not necessarily addressing these issues ourselves. #jhsjc
Brent Graham @BgTalkinman:
When poor results are linked to quality and then to reimbursement is that when this will be addressed? #jhsjc
Warren @whammert to @BgTalkinman:
Poor results is very broad. When you look at complications in large joint arthroplasty, it seems easier to change #jhsjc
Brent Graham @BgTalkinman to @whammert:
That may be true but this is what is coming. #jhsjc
Brent Graham @BgTalkinman:
This is such an important topic and I’m glad that we’ve discussed it tonight, exhausting though it is! Keep being good caregivers! #jhsjc
Dr. Ray Raven @RayRavenMD to @BgTalkinman:
I agree Brent. Thank you for spotlighting it in our online journal club #JHSJC
Brent Graham @BgTalkinman:
Thanks to everyone for their participation! We are back March 9, 9 pm EST #jhsjc
