Do I Need a Shoulder Specialist?

I'm Dr. Patrick Denard. I'm a shoulder specialist and orthopedic surgeon at the Oregon Shoulder Institute. I've been in practice for over 10 years and do 100% shoulder in my practice. So I thought it'd be interesting to talk about some of the, uh, choices that people have when they have a shoulder problem and if they need to see a shoulder specialist. And it's interesting when people go to see a, um, physician, whether it be a primary care physician or an orthopedic surgeon in general, they often don't really think about how specialized do they need that person to be. And what's interesting about this is that people often choose appointments based on first availability or even proximity to them. And I think this is quite interesting because when you look at other parallels, for instance, if we look at athletes, uh, it's very, very uncommon to see high-performing athletes be in multiple sports. There's some exceptions, the Bo Jacksons, the Deion Sanders, but by and large it is somebody doing one sport, and what else they're doing, one position, meaning that is what they practice to do, and that's how they excel at a very high level. But somehow we often think, well, they're a physician or they're a doctor, and that is just— that, that is just okay. And I would tell you, I don't think it's quite the same. So Let's talk about training. So in order to become an orthopedic surgeon, you have to complete 4 years of medical school and then 5 years of orthopedic residency. At that point in time, you can go into practice and then you can do multiple different operations. You can operate all across the body, in fact, as long as you have privileges at a given facility. And most facilities give you those privileges to do such, other than some rare exceptions like tumor or, oncology, they will give you a very broad basis for being able to have privileges to do different procedures. In fact, even as a shoulder specialist at my hospital, it says I can do foot and ankle procedures, hip procedures, et cetera. Now, when somebody decides they want to become a shoulder specialist, what they can do is there's one of two pathways, generally speaking. Probably the best or most thorough pathway is to do a shoulder fellowship. That's typically administered through the American Shoulder and Elbow Society of surgeons who have a fellowship program. That's an additional year of training where somebody goes and they are gonna just specialize in the shoulder and some elbow as well. The other pathway is to do this through sports medicine. So somebody will do orthopedics and then they will do a sports medicine program. In the sports medicine fellowship, they're gonna get a mix of shoulder, hip, knee, maybe even some ankle. But sometimes you'll see people go out and specialize in shoulder afterwards. That is, they'll gradually concentrate their practice. So the difference is, first off, in the training, you get an additional year of training with people that are very, very high level, and that is all they do. And then afterwards, somebody who is a shoulder specialist chooses to focus just on the shoulder. So for me, when I did my training, is I did orthopedic residency after medical school. I spent a year in Texas with a shoulder surgeon doing 100% shoulder, and then I went and got an additional 3 months of training in France uh, with an individual who's well known in shoulder replacement. And then when I started my practice, I concentrated just on the shoulder. I spent 6 months doing some elbow, and then after that it was just shoulder, shoulder, shoulder. So what does that mean? Okay. Does it really matter in the end? And I think it actually matters quite a lot. What does the data say? Well, there are multiple studies across multiple specialties in medicine which show that if individuals or surgeons do one procedure or one specialty area more, they are more likely to have better outcomes and a lower risk of complications. And this relates to both facility, so higher volume facilities typically have a lower complication rate, and the surgeon, higher volume surgeons, those who subspecialize, and typically because they subspecialize, they do more of just those procedures, are going to be able to have lower complications. So within shoulder, that has been actually shown, been shown as well. And so for my practice, I do about 750 surgeries per year. I would guess that about 725 of those are shoulder procedures because I do a couple of surgeries on call, but by and large, 99% of it is shoulder and all my elective practice is shoulder. So By doing that, I'm doing the, seeing the same thing multiple times, okay? Over and over and over. And that goes along with those outcomes. So with outcomes, you typically see a lower length of stay in a facility, lower, um, if it's a hospital, you typically also see lower rate of complications. One of the things that comes up is infection because one of the biggest things with infection, uh, is simply operative time. So if you look at operative time and your risk of infection, as the operative time goes up, your risk of infection dramatically increases. And after 2 hours, it dramatically increases. It in fact goes up higher, or the, the slope rises even more substantially. So most commonly, that is typically, not in all cases, but typically if you're with a surgeon who just does that specialty area, they're gonna have a shorter operative time. So for instance, I know some people take 2 or 3 hours to do a shoulder replacement. For me and my practice, it's 45 minutes on average, sometimes an hour or an hour and 15 minutes if it's a revision surgery. And that's not because we're moving really rapidly and all over the place. It just means we have a simplified approach, okay? Because efficiency in the operating room is about eliminating wasted movement. So you reduce the waste and you just focus on what needs to be done. That leads to a shorter surgical time and a lower risk of infection. Now, it's not as well proven, but my belief is that it also affects pain because the longer you have a wound open, the more time inflammation can go up. Inflammation leads to increased pain. Okay, so if you have a shorter operative time, you're likely going to have less pain after an operation, therefore less need for narcotics, etc. Now, in addition to this, there are some subtleties that I think are not as easy to prove, or there's some nuances that really go into this. So if you have somebody who's just a shoulder specialist, rather than having to read and follow a lot of different information, they're going to focus on just shoulder information. So for me, my practice I read 4 journals a month. One of those is an exclusively shoulder journal, and then a couple other of those are primarily sports-based, but I only read the shoulder articles within those journals. And then there's a more general one where I pull important shoulder articles, but that's all I'm focusing on. So rather than having to know a little about a lot, I know a lot about a little, which is the shoulder. Okay, so people who specialize in shoulder are also going to go to conferences more in that area. And dive into the little details. And the details are what separate the, uh, really good from the average. It's the analogy that has been popularized as the 10,000-hour rule that Malcolm Gladwell popularized, uh, in his book Outliers. And I think the same applies here. The more time you spend on something, the better you're going to be on it in general, all things being equal. Along with that, I think there's this underlying phenomenon that occurs in surgery that, that people don't talk about, where by, with volume, you are essentially accumulating information that's going into the database of your brain. And one of the things I've noticed with surgery is that as you go along, you start to notice details that you aren't even consciously aware of and modify as you go along. Because you develop a greater sense for things and how things can go wrong, and you prevent those things from happening. Okay, so there's this feedback. It's almost like an AI, and that's what AI is all about, is having a lot of volume of information come in and put output. But that's what happened to a surgeon with experience. You accumulate knowledge and then you start using it in ways that you aren't even consciously aware of to make things more efficient or better for the patient, and particularly prevent something from going wrong. Okay, so oftentimes I say that surgery is about eliminating wasted movement in terms of efficiency, but in some ways it's about preventing complications, right? Because a lot of things can happen in surgery and you're trying to weave through like Frogger and go across and reduce the risk of getting hit by something and having a bad outcome for the patient. So that probably leads to a lower reoperation rate as well. Other things that happen when somebody just specializes is they typically can pick up the subtleties. So when everything goes well, that is great. And most of the time that is what happens. But when things are not going well, there's both a need for recognition of when something just is not right. And that gets back to this data input, meaning having a lot of information of volume to be able to— is this normal? Is this not normal? Do I need to modify my rehab? How can I change here? Do I just need to wait more time or do something differently? And if you specialize and you see a lot of patients in this area, you can pick up these subtleties to help guide patients better. And these are things that can help prevent a bad outcome, but also can maybe even mean days of you getting back your function because you're able to make a modification sooner. Now, along with this, typically somebody who's a specialist is gonna have more of a detailed program. So for me, I give my patients a 20-page packet that outlines everything that has to do with the shoulder recovery, the preparation, recovery afterwards. So patients are very well prepared. And that goes along with having to answer these questions over years and knowing what to expect, what questions my patients ask. So there is no way I could do that for every ankle operation, every knee operation, every hip operation, every spine operation. But because I specialize, I'm able to concentrate and give somebody detailed information on exactly what to expect. So there's less surprises for the patient. So I think that program is very beneficial. So in summary, the training to become a shoulder specialist is more stringent, or it's longer, than just being a general orthopedic surgeon. The outcomes show that the outcomes are better when somebody is specialized, and that relates to specialization and volume. Interestingly enough, most surgeries, especially in shoulder and orthopedics, are still done by people who do many different ones and do a lower volume. So for instance, shoulder replacement, most shoulder replacements are done by somebody who does 10 to 20 a year, whereas somebody like me as a shoulder specialist, I do about 300 shoulder replacements a year and another 300 rotator cuff repairs a year. Um, if you look at the subtleties as well, I think this is about picking up the nuances or, uh, subtle kind of differences in an outcome that a specialist can help guide you through. And that's about having data input. That they are able to see and recognize differences that applies afterwards and also within the operating room. So as you can tell, I very strongly think that if somebody has a shoulder problem, they should really look for a shoulder specialist because I think that puts them in the best position to do long, uh, have a good long-term outcome. And that's really what it's all about because you're investing in your health and you're trying to ensure the best possibility that you get back to sleeping well and get back to your daily life. Thank you.