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Complexity and Simplification

Biology, as it unravels itself, demonstrates complexity of apparently infinite dimension. This is far beyond the understanding of the individual human and perhaps beyond the collective understanding of humankind.

When biology is compounded with the abnormalities of biology, as in medicine, the challenge is, for all practical purposes, insurmountable. Combined with this is the complicating phenomenon of “distribution curves” where the biological bulk must be distinguished from the “outliers”.

Therefore, in teaching medicine it is necessary to no longer isolated facts, but to teach the concept of infinite “complexity”. This is the challenge that faces the medical academic in the present century. It is no longer sufficient to attempt to install a plethora of “facts”. Indeed the teaching needs be directed away from the concept of satisfied with unitary “facts” as being sufficient.

The great danger of allowing contentment with “facts” is that medical management can easily become a “tick box” or “cookbook” realm, lacking in the perspectives of the full dimensions of the challenge.

But another, perhaps greater, problem lies with those who do not have a medical training. That is the public perception of healthcare by the layman. There is the (natural) tendency for the lay to reduce the complexities of healthcare to the binary and ultra-simplistic. The self confidence and self-assurance of the public has increased (via multiple modalities). Likewise the power, leverage and “muscle” of the lay public have increased so much as to superimpose itself upon the complexities of healthcare.

Individuals have now reached a position where they often believe that they “know best”. Of course, the healthcare professionals themselves have limitations, and there are times when they fall short of full understanding or composite knowledge. The limitations and errors of healthcare professionals are often inappropriately extracted from context, and then disproportionately amplified in the press, or in the law courts. But that does not mean that medical professional training is invalid – far from it – it remains the best available.

The popular opinion can be so powerful that it impose and distorts the practice of medicine and, frequently, usurps sound medical advice and valid modes of management.

One appellate court judge told me that she did not need to need any special expertise in making a judgement of healthcare matters, because she could “read all she needed to know in the newspapers”.

Another example of destructiveness has been the lay perception of the role of medications, including antibiotics. The latter have been widely seen as “necessary” in a “knee-jerk” reaction to almost all forms of illness. The biological result of this abuse and these misconceptions about antibiotic usefulness has caused many such medications to become uselessly impotent and ineffectual.

Another realm which has been questioned is the costs of healthcare. Whilst one does not contestant that all human activities can be abused in competitive extraction, nonetheless, the technology and research advances in medicine become progressively more expensive, and need to be factored into the economics of health care. Where technical advances continue and investment and maintained, the cost of healthcare must increase beyond inflationary devaluation of capital. And yet this does not seem to be generally recognised, however obvious it might be to the healthcare worker.

A further perversion is the provision of “national healthcare” whereby the greater population believes that it is “due” healthcare and demands attention and a determined extraction from the healthcare budget without regard for or understanding that most illness, for most people, self cure by one of the most wondrous of biological capacities.

It can be predicted that healthcare, as it is currently practised and made available, will shortly become self immolating.

Humans therefore need forceful instruction as to how they should behave in relation to the science of healthcare and to protect its availability.

Emphasis must be given to the pernicious dangers of the politicisation of healthcare, solely for the benefit of political ascendancy.

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What is Orthopaedic Surgery?

This frequent question embodies other implicit questions. Those who ask this question might be asking “what services can an orthopaedic surgeon offer to my benefit?’ or “what are the qualifications of an orthopaedic surgeon and how is an orthopaedic surgeon constrained to practice within his capacities?”. There is yet another, more oblique, question which is “what can an orthopaedic surgeon find out about me which I may not be aware of?”

 

In attempting a definition the dynamic nature of professional healthcare and orthopaedic surgery needs emphasis.

 

Originally orthopaedic surgeons had little training, and their skills were evolved empirically. The “fathers” of modern orthopaedic surgery were intellectually impoverished by today’s standards. However, orthopaedic surgery evolved, along with other healthcare specialities, to become highly scientific, and well regulated both by the orthopaedic community and by statutory legislation.

 

Currently, in developed urban areas, the science of orthopaedic surgery had diverged into numerous sub-specialities and in there is now no such thing as an “orthopaedic surgeon”. Instead there are at least 12 sub-specialities which include spinal surgery, surgery of the hand, the management of peripheral trauma, paediatric orthopaedic surgery, microsurgery and re-implantation surgery, geriatric orthopaedic surgery and more. Naturally, the more distant the orthopaedic surgeon is from urban centres, so the more generalized he would be expected to be and such “general orthopaedic surgeons” can be exceedingly capable and diverse in their skills.

 

Many of the specialities mentioned can overlap with the fields which have other designations. For example many plastic surgeons are involved in surgery of the hand and neurosurgeons will overlap with orthopaedic surgeons in the management of vertebral pathology. Microsurgery has evolved from a large number of different specialities. The name given to the type of surgeon is probably irrelevant provided that in their ascendency into a super-speciality that individual is appropriately trained. It might matter little whether the individuals with a backgrounds in orthopaedic surgery or neurosurgery, manage vertebral pathology, given that proviso.

 

The foundation treatment of orthopaedic surgeons is one of the general physician. Orthopaedic surgeons are, first and foremost, “doctors”. Thereafter they would train (ideally) as surgeons in the broad sense with capacities in general surgery and other realms such as plastic surgery or neurosurgery. Only after that would the orthopaedic surgeon begin “post-graduate” training in a super speciality, such as those listed. The period of training a super specialist orthopaedic surgeon may well be 15 or more years.

 

Therefore the entrance gate to orthopaedic surgery is selection into a medical school. Because the profession has prestige and expectations of high income, competition to enter a medical school has been exceedingly high. One can therefore expect that these individuals are pre-selected for superior capabilities.

 

Since the attractions of entering healthcare are great, it is to be expected that there would be many “Johnny-come-lately” aspirants. Some of these have not succeeded in gaining admission to formal medical schools or might choose an easier (and cheaper) route. After (sometimes fierce) jostling, these “alternative” practitioners have often succeeded in becoming recognised as “legitimate” health carers. One example is chiropractic and the reader is recommended to explore the origin and evolution of this field.

 

Another parallel with orthopaedic surgery is the overlap between the super speciality of orthopaedic foot and ankle surgery with podiatry.

 

The advantage that the orthopaedic surgeon has over other competitors for healthcare is the training as a general physician. The reason why this is a benefit to the patient is to counter the superficial belief that the treatment of a particular region of the body can be done in isolation of the patient as a whole.

That is wrong. Body-wide illnesses can percolate into every system of the body and a sound knowledge of broad-based general medicine is, many would say, imperative. For example pain in the foot might originate from a brain tumour, an autoimmune disease, a cyst in the spinal cord, a parasitic infection and much more.

 

There are also some curiosities. One might wonder why there has been no attempt by the “parallel” specialities to undertake surgery of the hand. This has happened in surgery of the foot (with the evolution of the podiatrist). Why not the hand?   One reason might be the misconception that the intricacy and the delicacy of the hand are such that it could not be entrusted to anyone other than a fully medically trained super specialist, whereas the foot would be considered a relatively simple arena. This is also fallacious since the complexities and importance of the feet probably exceed that of the hand (or so say those who are trained as super specialists in both hand surgery and foot surgery).

Ageing and orthopaedics

 

 

Excess mass. Many of the degenerative changes of ageing are associated with excess body mass. It is a common perception that as one ages body-mass should increase. At times I am told by my affronted patients “I have always weighed this much, since I was a youth. How can you expect me to weigh less now?”

 

Get older, thinner. The reality is that an “ideal” body weight, which is probably acquired at the end of growth should, with ageing, decreased progressively. The reasons are that there is a loss of both the weight of bone and the mass of muscle. Therefore if the bodyweight remains the same it must be because there is more fat.

 

The lungs and stomach. The vertebral column shortens was ageing, and therefore the volumes in both the abdomen and thorax decrease . If the same amount of fat (or progressively more fat) is compressed into the abdomen then the diaphragm will be lifted and the space in the thorax compressed. This may be one of the reasons why reflux oesophagitis increases with ageing, as does the hiatus hernia. Add to that decreases in respiratory capacity, often in lungs which are functioning sub-optimally, and one has extremely good reasons for reducing mass. Oesophageal reflux can cause further deterioration in the lungs, coughing at night and so the cycle continues.

 

Weaker body more load. Therefore we have the unsatisfactory situation with weaker muscles and more frail bones being expected to carry a far larger body-mass, comprising a primarily of fat.

 

Metabolic effects. Excessive fat is not innocuous, as it has a huge influence on the hormonal balance of the individual, including the factors that go to create a diabetes, and creating excess female hormone.

 

Weaker structural tissues. Structural tissues, such as ligaments and tendons  lose their mechanical strength with ageing. This is partly because the blood supply to those structures diminishes and partly because the reparative processes following minor injury are slower.

 

Exercise plays many roles in musculoskeletal health (as it does in the health of the entire biology).

 

Hormonal benefits of exercise. There are general effects of exercise, which stimulate the production of natural anti-inflammatory medication substances, natural antidepressants and natural analgesics. For those with aches and pains, as well as the sense of depression that inevitably accompanies the degenerative processes of ageing, these are exceedingly important.

 

Strengthening benefits of exercise. In more specific terms exercise will retain, or perhaps increase muscular bulk and strength, which is so vital in protecting the joints. The calorie burn will be the most effective way of reversing the ratio of fat to muscle.There is nothing better than low impact exercise (such as cycling and swimming) to stave off arthritic degeneration in the knee

Osteoporosis. Exercise is the most specific counter to osteoporosis.

 

What type of exercise? In the ageing body by far the most effective form of exercise is swimming. However, if an exercise program is to succeed, and for that matter if any exercise patterns are to succeed, it must be firmly scheduled, so that the exercise is consistent. Three times a week is probably ideal, with a necessary day of “recuperation” between each session.

 

Particular care with swimming. Those who have problems with the joints, particularly with the vertebral column, but also the large joints of the body, need to exercise particular care in swimming. A painful back or a dowager’s hump, and many forms of scoliosis can make it exceedingly hazardous to enter the water unassisted. It is recommended that swimmers with these problems should always be accompanied whilst in the water, at least in the beginning.

 

Swimming and Gym coaching. It is also recommended that a swimming coach be employed initially. Many elderly people will regard this advice with scorn, saying “that is for children and toddlers. I know how to swim”.
However this is not an appropriate answer. Anyone who wants to brush up their foreign language or musical instrument playing needs help as an adult. Perhaps even more important is the fine tuning of swimming skills, which will allow the swimmer a more effortless period of exercise, and  consequently a longer period of exercise. Ideally the aim is to churn through the water without significant tension or stress for forty or more minutes during the session.

 

Cycling is a realistic form of exercise, with great benefits, particularly, to the knee. This is because it develops the quadriceps and other muscles which control (and so protect) the knee joint. The loads on the lower limb during cycling are less than walking and running, whilst the range of movement is often more than walking. If there are disabilities in the knees which prevent adequate movement then the use of shorter pedals shanks can overcome the problem. Ideally, adjustable shanks could be used and as the range of movement in the knee increases, so the length of the shank can be increased.

 

Cycling has the advantage that one can listen to music, dialogue or watch television. Reading a book is not realistic because of the jolting and sweating.

 

Making exercise fun. This is an important aspect of exercise as a therapy. Exercise must be attractive, appealing and fun. If exercise is a drudge then enthusiasm will be lost rapidly and ultimately the endeavour will fail, leaving only a large burden of guilt.

It is therefore suggested that careful attention be given to the “fun” aspects of exercise. The iPod has created a new dimension of music and literary content, and it might be that the iPod should be bought before the exercise bicycle.

Real cycling is an option which can give much additional interest to exercise, as well as a social and even the travel aspects. Many people combine an exercise bicycle with the “real” bicycle, and so are able to enjoy summer but continue to exercise during winter.

 

The importance of the logbook. Another ploy which is useful in maintaining stimulus and interest is to keep a detailed exercise logbook. This logbook should include details of the period of the exercise, and if it’s possible to measure  (as  is possible on many types of exercise bicycles) the total calorie burn. The logbook should also include a daily resting pulse (before getting out of bed) and the pulse rates before and after exercise as well as weight daily.
There is a tendency to forget how one improves was exercise and therefore the recording of this will not only stimulate the aim to keep improving, but demonstrate the efficacy of past exercise.

 

What can you expect if you  lose weight by reducing calories?

 

A number of chronic illnesses can be reversed, sometimes completely, simply by calorie reduced loss of weight. These include:

Diabetes of maturity

High blood pressure

Gout

Lower limb arthritis

Reflux oesophagitis

Respiratory incapacity and breathlessness

Prevention of hernias, or recurrence of hernias

 

Possible improvements include:

 A longer life. People (and animals) live longer on restricted calorie diets.

Reduced sleep disturbance from oesophagitis, reflux pharyngitis or apnoea

Urinary incontinence

Cardiac failure

Chronic bronchitis

Chronic sinusitis

Shoulder pain (when this is caused by lifting the body weight out of chairs).

Low back pain and sciatica.

Painful feet

 

All these illnesses are frequently treated by long-term medication. It seems so simple to be able to effect an improvement with less or no medication, at less cost, more energy, and a better quality of life by weight loss and exercise. Surely you owe it to yourself to try?