James Rubano, M.D.//Photo by Luigi Ciuffetelli
Over the past decade, advances in materials science have helped artificial joints last longer—up to 25 years compared with 10 or 15 years in the past.
In coming decades, stem cells just might revolutionize joint repair with injections that form new bone or cartilage.
But as for today, much of the focus on joint replacement is about reconsidering opioid pain relief, says orthopedic surgeon James Rubano, M.D. While the addiction epidemic is bringing attention to opioids, there are other reasons to consider different forms of pain relief in joint surgery.
Opioids have side effects, like nausea and sleepiness, that can make it difficult for patients to get up and moving after a joint replacement. Getting moving quickly is key to recovering from this surgery.
The ability to speed up recovery is one reason Rubano, like many joint replacement surgeons, is moving away from overnight stays in hospitals and toward surgical centers where patients go home within 24 hours of their operation.
“I’m hopeful that within the next 12 months, my patients with low risk and social support will become outpatient (occurring outside a hospital) surgeries,” he says. Like other surgeons at Delaware Orthopaedic Specialists, Rubano specializes in a small area; in his case, it’s knee and hip replacements.
No matter where joint replacement surgeries occur, obesity and an active but aging population will conspire to make them more and more common.
“People are exercising more, but at the end of the day, they do put wear and tear on their joints,” he says.
Obesity, especially, takes a toll.
“I see 40- and 50-year-olds with knees that look like they’re from an 80-year-old,” he says. And, starting at a body mass index of 35, extra weight adds risk to joint replacement surgery. Like many surgeons, Rubano asks patients with a BMI of 45 or higher to lose weight before surgery.
Many patients say they want to get a joint replacement to exercise and lose weight. However, for reasons not fully understood, most patients actually gain weight after having a joint replaced.
It’s a reminder, Rubano says, to get as much mileage out of your natural joints as possible.
Borislav Antonov, M.D.//Photo by Luigi Ciuffetelli
Decades ago, hospital patients could expect to look up and see their family doctor at their bedside. But, as the demands of family practice increased, the care a hospital delivered became more complex. So these hospital visits became impractical for busy family doctors.
In 2004, Borislav Antonov, M.D., MPH, joined a burgeoning medical specialty that aimed to resolve this contradiction and rewrite the playbook for hospital medicine. He became one of the new and aptly named hospitalists, who work exclusively in a hospital.
“I have witnessed the dramatic increases in the influence of hospitalist medicine,” says Antonov, who practices at Beebe Healthcare in Lewes. “When we started 15 years ago, many people were very skeptical about the profession of hospitalist physician, to the point where today we are an irreplaceable part of healthcare.”
As they care for patients admitted to a hospital for just about any reason, hospitalists treat a wide variety of conditions. In rural Sussex County, where the population over age 65 is nearly 50 percent higher than the state as a whole, common conditions include problems with breathing, heart disease and stroke.
Even if they rarely see family doctors in person, hospitalists like Antonov still work with their patients’ regular doctors.
“Very often, the first question we get is, ‘How can you involve my doctor in my care?’” he says.
And, because getting a regular doctor involved is key to preventing that patient from returning to the hospital, Antonov and his fellow hospitalists are increasingly concerned about what happens outside of the walls of hospitals like Beebe Medical Center.
Most people’s health, often described as 80 percent or higher, is determined by the course of their lives outside doctor’s offices.
In other words, even if a hospital perfectly manages patients, the ability to keep them from being readmitted—a key way in which hospitals are ranked for quality—depends on the ability to keep them healthy after discharge.
“We make sure they follow up with their primary doctor and specialists, that they have other healthcare arrangements and that they’re monitored to ensure they’re taking their medications,” Antonov says.
Enrica Arnaudo, M.D.//Photo by Luigi Ciuffetelli
When our muscles fail to contract or a nerve fails to deliver a message to them, Enrica Arnaudo, M.D., steps in to decode the hidden messages behind these mysteries.
“Every patient for me is a humbling experience,” says Arnaudo, an electrophysiologist who specializes in disorders of the nerves that deliver electrical impulses from our spine to our muscles. “Most often, they come with a problem that has not been diagnosed, and it is a privilege to be able to shed light on their symptoms.”
These symptoms include pain, numbness, tingling, muscle weakness and even problems with balance, as it can be hard to walk if you can’t feel the bottom of your feet.
As she’s trying to trace where a problem originates, Arnaudo often conducts a nerve conduction test to learn how well a nerve is transmitting electrical signals to muscles.
That test is often paired with the insertion of a hairpin needle to test the activity of a muscle. If it sounds like detective work, that’s because it is.
“Sometimes there are surprises and you follow where the test leads you,” she says.
Many of the cases she investigates are at first mistaken for brain problems. However, often when our limbs tingle or ache, it is not the nervous system’s command center at fault, but its messengers.
Disorders of the nerves outside the brain and spinal column are called “peripheral neuropathy,” and they affect about 10 percent of Americans over 40 at some time in life.
Arnaudo recently closed her practice and will focus more on advocacy for doctors and patients. As the American Medical Association’s delegate representing her subspecialty, Arnaudo has experience lobbying politicians in Dover and Washington.
More importantly from an advocate’s perspective, she has the experience of a doctor working in private practice with only her and a secretary to understand the ever-changing landscape.
The ultimate consequence of a heavy regulatory hand, she fears, will be the loss of the small, independent private practice.
“We should not lose the choice to access medical care close to home through a private physician,” Arnaudo says.
Kelly Eschbach, M.D//Photo by Luigi Ciuffetelli
The promise of robotics in the restoration of human ability is grand: where the body fails, a machine can step in.
A missing hand can be replaced with a prosthetic controlled by the brain. To go even further afield, an entire exoskeleton can wrap around a person and help them walk again.
“The biggest change on the horizon that’s the most exciting for us is the use of technology in rehabilitation medicine,” says Kelly Eschbach, M.D. The headline-grabbing work that’s happening in research labs shows a promising future, but even everyday technology is making a difference now.
“Voice recognition allows people to do tasks they otherwise couldn’t and perform tasks their own body can’t,” Eschbach says.
Even when technology can help, most rehabilitation today is still made by slow-and-steady improvement.
For all of her 23 years as a physiatrist—a doctor who helps people recover from illness, disability and injury to regain their abilities and quality of life— Eschbach has worked at the Center for Rehabilitation at Wilmington Hospital, a 30-bed unit that is something of a “hospital in a hospital.”
It is for patients who’ve recovered well enough to be discharged from a hospital but not well enough to go home. A patient with a hip fracture may stay as they learn how to walk again, or a stroke patient may try to overcome problems with balance, thinking and vision.
In the era of 15-minute doctor appointments and pressure to discharge patients from hospitals, Eschbach has a luxury afforded to few others: She can form weeks-long relationships with patients and families. The average length of stay at the center is about two weeks.
“That’s the fun part,” she says, “sending them home better than whence they came.”
Still, at a time when insurance companies paying for healthcare are trying to minimize expensive hospital stays, time is becoming less of a luxury.
“We have to make every day in the hospital count,” she says.
Kunal Agarwal, M.D., FAAFPâ€‹//Photo by Luigi Ciuffetelli
As a sleep medicine specialist in southern Delaware, Kunal Agarwal, M.D., sees how many of his patients suffer from undiagnosed sleep apnea. Their breathing stops and starts several times each night for 10 seconds at a time. This triggers a fight-or-flight response and strains the heart—all without even waking up.
Treating sleep apnea can lower the risk for a range of dangerous conditions, like high blood pressure and diabetes.
Controlling such long-term conditions is one of the main roles for a family medicine doctor like Agarwal, medical director of the Nanticoke Sleep Disorders Center.
“I prevent complications that send patients to the ER or to urgent care, saving them money and time,” he says.
As an expert in both family and sleep medicine, Agarwal realized treating patients’ sleep apnea on a larger scale would have a ripple effect on their lives. So he spoke to the leaders at Nanticoke Health Services, where he works in Seaford, about ways to test for sleep apnea at a larger scale than he could accomplish in his practice.
The health system agreed to give every patient in Nanticoke Memorial Hospital an eight-item questionnaire to determine if they might have sleep apnea. Warning signs include snoring loudly, being tired during the day or choking in your sleep.
“It’s all tied in together,” he says, “weight and sleep apnea, fatty liver, joint pain, heart issues.”
Just as sleep disorders can arise from a range of physical and mental causes, sleep medicine incorporates several specialties, including neurology, psychiatry and pulmonology, which involves the lungs and breathing. Agarwal approaches both sleep and family medicine with an eye toward how their interplay affects our health.
“In that sense, I’m better prepared,” he says.
Claire Coggins, M.D.â€‹//Photo by Luigi Ciuffetelli
Claire Coggins, M.D., is a doctor who spends much of her day looking at images of torn rotator cuffs, herniated discs and other musculoskeletal injuries. That she can view these images at home— enabling her livelihood as an independent contractor—is a testament to the revolutions in digital imaging.
But an even bigger change is on the horizon: The use of artificial intelligence to scan images for patterns that a person could miss.
“At first, radiologists started panicking about jobs being replaced,” Coggins says. “I see it as more of a tool that can help a radiologist. I don’t care how good you are, everyone misses something.”
In the field of radiology—the discipline of using X-rays, MRIs, ultrasound and other types of imaging technology to create pictures from inside the body— Coggins has specialized further, into images of joints, muscle and bones.
After working in academia and private practice, she went into business for herself in 2012. She spends two days a week working from home and three days in the office, taking images of joints after injecting a dye to make their soft tissues more visible.
Most of the time, patients whose images Coggins analyzes are driven into the doctor’s office by pain. Some were injured in an accident, others are athletes who want to get back in the game while still others can no longer cope with long-term pain.
“Some will tough it out and finally come and say, “I can’t sleep because my shoulder is hurting so bad,” she says. After years of looking at images of injuries, Coggins has become wary of exercise regimens that push people too hard, too fast.
“I don’t love high-intensity, repetitive exercise,” she says. “I think yoga is fantastic.”
In rare cases, while Coggins is looking for a bone or muscle problem, she’ll spot something worse, called an “incidental finding.”
“In at least one case it turned out to be cancer,” she says. “I consider that a huge part of my job, rather than just looking at all the ligaments and menisci, I’m looking at everything.”