Dr. Fetter explored the use of pain medication in orthopedic patients. She specifically examined the use of opioid medications in the treatment of pain for common orthopaedic fractures at two level I trauma centers (hospital 1 and hospital 2) in the same city. A second aim of her study was to determine the level of training and methods for opioid pain medication prescribing and administration by orthopaedic nurses and residents. The total dose of narcotics received in the postoperative setting was calculated and converted to equivalent morphine dose. Dose, gender, age, presence of a block and opioid-related over-sedation adverse events were analyzed. Orthopaedic nurses and residents were anonymously surveyed regarding their training and experience with the prescribing and administration of narcotic pain medications. She found that no difference between the two hospitals with respect to morphine dose per day for ankle or distal radius fractures. There was a significantly higher morphine dose for femoral shaft and tibial plateau fractures at Hospital 2 as compared to Hospital 1. Orthopaedic nurses were more likely to feel that they had received training at the hospital for pain management and were more likely to follow a protocol than orthopaedic residents. However, the nurses at Hospital 1 were more likely to receive on-the-job training for pain management than those at Hospital 2. Dr. Fetter concluded that there are differences in pain medication between the two offices. The difference in administration may be a result of differences in on-the-job training.

Dr. Janfaza discussed Dr. Fetter’s study and noted that above all, pain scale is multidimensional and not a simple number. He also noted the inherent problem of using a morphine-related conversion scale to rate pain. Finally, he raised the question of using a scale other than VAS to evaluate trauma patients similar to a CAGE screening questions. Dr. Weinstein noted the difference between “soft” and “hard” measures and agreed with Dr. Fetter’s assessment of the Dutch data as groundwork for pain management.

Dr. Boulton investigated the potential risk factors for the development of nonunion when locked plating is used in the fixation of distal femoral metaphyseal fractures. She used a case-control design of 68 distal femoral fractures treated at BIDMC over the past 5 years. A total of 14 (21%) went on to nonunion. Factors more prevalent in the nonunion group included open fractures, medial comminution, history of diabetes, and obesity. Her data also suggested that these factors have a cumulative effect. Patients with zero or one out of four of these characteristics went on to uneventful fracture healing 91 percent of the time. Whereas patients with two out of four characteristics had a 76% percent healing rate and those with either three or four out of four characteristics only healed their fractures 14 percent of the time. She concluded that the previously published incidence of nonunion in distal femoral fractures is likely under-reported given the growing popularity and increased use of this technique for a wide variety of injury and patient types. Obese diabetic patients and/or those with open or comminuted fractures are likely at an increased risk of failure. She added that such patients may benefit from supplementary agents such as bone stimulation and osteoconductive agents.

Dr. Vrahas discussed Dr. Boulton’s study on locked plates. He posed the question of whether or not obesity, diabetes, open fractures or medial cortex fractures were independent predictors of non-union. Dr. Weinstein also acknowledged the growing endemic of large obese trauma patients and if they are a unique subset of patients with specific risk of non-union.

Dr. Sethi examined the prevalence and costs of defensive medicine in Massachusetts using a survey of practitioners of 8 different specialties. Using multiple imputation analysis, 83% of respondents reported ordering imaging, laboratory tests, or specialist referrals defensively. More than half the sample (57%) reported they had been named in a malpractice suit, an average of 2.4 times. Twenty to thirty percent of all ordered tests were for defensive reasons, at a cost of $281 million/year. Lab tests were the least defensively ordered (21.2%) compared with CT scans, which were the most favored defensive modality (30.7%). Physicians who considered their malpractice premiums as very burdensome ordered 4-5% more x-rays, CT and MRI scans for defensive reasons as compared to other physicians. Those physicians who were most concerned about lawsuit concerns affecting their practice ordered 4-6% more CT and ultrasounds scans, and laboratory tests. Physicians who had a history of being sued for medical malpractice ordered 5% more MRIs compared with those who had never been named in a suit. The total estimated cost of defensive medicine is $281 million per annum. In conclusion, Dr. Sethi surmised that defensive medicine behavior is common and costly to taxpayers.

Dr. Chiodo congratulated Dr. Sethi for not only his thesis presentation, but on a landmark study appearing on the Globe, CNN and on the desk of President Obama. He stressed the importance of having hard data as the vehicle for change. Dr. Springfield raised the question of tort reform in today’s medical climate while Dr. Sethi stated the need for medicine to selfpolice in order to potentially do away with tort law. Dr. Weinstein raised the notion of matching law with a DRG to help tort reform.