This next weekend we’re teaching an orthopedic stem cell training for physicians course in Colorado through the Interventional Orthopedics Foundation (IOF). Maybe because of this, the past few weeks I’ve noticed the different levels of expertise at which orthopedic stem cells are delivered. The problem is that while this impacts the quality of the treatment patients receive, most of what I notice is invisible to patients.
The problem stems from what we doctors call “see one, do one, teach one.” This idea is that doctors are more used to watching someone do a procedure once or twice and then trying that procedure in one of their patients. They’re also used to claiming expertise enough to teach a procedure long before they actually have any real expertise. This then erodes the quality of medical treatment and education, as we have non-expert physicians performing treatment and teaching procedures. In the stem cell world this idea is rampant. I’ve seen physicians claim expertise in stem cells and offer up their teaching services literally days after taking a weekend course!
Add “see one, do one, teach one” to our world of fast-paced, no-time-with-the-patient medicine, and quality tanks. This is why the IOF has developed a structured learning and testing methodology to improve the quality of orthopedic stem cell training for physicians.
This week I had a few experiences that explain the concept that the patient doesn’t really know if he or she is getting a low level of orthopedic stem cell care or a high level. Let me explain.
This week a spine surgeon wanted to take a course that the Interventional Orthopedics Foundation is giving in late July. Since the topic is how to inject stem cells into a disc, the prerequisite is that the doctor knows how to guide needles most of the way. In this case that means that he or she has performed many epidural injections through the foramen (the place where the spinal nerve exits, or transforaminal). The students for the course were to submit images proving they had done this before. However, we couldn’t get any images from this spine surgeon. So I called him and learned that while he had never done this procedure before, he felt that since he was a spine surgeon, we would just let that fly. I made sure that he understood that learning how to accurately place needles under guidance is a separate medical specialty and without that training I couldn’t accept him in this course.
The point brought up by this spine surgeon is the same for many orthopedic surgeons—they are used to “see one, do one, teach one.” They have never before been trained in how to perform image-guided injections. This is also more than just a lack of experience as the types of treatments that image-guided injections of platelets and stem cells allow dramatically rewrites the book in how you approach the patient. So learning the new techniques is only half the battle; the other half is giving up on the many traditional surgeries that the techniques replace. In addition, it’s also learning how to examine the patient in new ways. For example, in an orthopedic surgeon’s mind, the exam for a knee ACL is to decide if it’s lax or torn enough to require a surgical reconstruction. However, once you have the ability to tighten a loose ligament through precise injection, your exam also has to include loose ligaments. This would seem like a simple thing, but until retrained, it flies over the heads of most surgeons.
A second story will also illustrate. A patient called this week after having been treated with “stem cells” at another clinic. We were surprised to learn that all the patient received was a simple injection of fat inside the joint. Given that based on what we know, since there are no viable stem cells in a simple fat-graft injection, the patient didn’t actually receive a stem cell injection. In addition, none of her issues outside the joint were addressed, which is common. All the doctor knew how to do was a very simple injection inside the joint. All the patient knew was that she didn’t improve—that is, she had no idea that she never really got a stem cell injection and that the doctor delivering it performed the procedure at the lowest possible level of sophistication (injecting simply inside the joint versus precisely into the many structures that were a problem). The same thing happened in a conversation I had this week with a colleague about a stem cell clinic. This group had a plastic surgeon injecting knees blind and has now upgraded to getting novice physicians trained to perform injections. The good news is that the clinic realizes that charging top dollar for blind injections isn’t a good idea. The bad news is that rather than steeply discounting the care of the first 20 or so patients for their doctors now fresh off a weekend “how to inject” course rather than a program which provides adequate stem cell training for physicians, they are continuing to charge top dollar and hope the patients won’t notice.
The upshot? There’s a broad spectrum to the quality of care out there in orthopedic stem cells. The IOF has begun to educate all qualified physicians in a level-1, level-2, and level-3 structure so that more physicians know how to precisely place stem cells in many different areas of each joint. However, in the meantime, given the scarcity of adequate stem cell training for physicians available, there are many physicians operating at a very low sophistication level, and it’s very hard for patients to tell the difference. Hence, as IOF ramps up its course work, we hope that patients will have a gold standard to compare doctors. Is your doctor IOF trained, or did he or she learn in the traditional “see one, do one, teach one” fashion? I know what type of doctor I would want injecting my knee, hips, back, or shoulders!
About the Author
Christopher J. Centeno, M.D. is an international expert and specialist in regenerative medicine and the clinical use of mesenchymal stem cells in orthopedics. He is board certified in physical medicine as well as rehabilitation and in pain management through The American Board of Physical Medicine and Rehabilitation.…