Key thoughts on outpatient orthopedics from Dr. Shariff Bishai

Shariff K. Bishai, DO, is an orthopedic surgeon with Associated Orthopedists of Detroit. Dr. Bishai is a fellow of the American Osteopathic Academy of Orthopedics, and regularly performs outpatient orthopedic procedures.

Here, Dr. Bishai discusses decreasing opioid utilization in orthopedic surgery, innovations on the horizon and more.

Note: Responses have been lightly edited for style and clarity.

Question: How can surgeons reduce opioid use among patients undergoing outpatient surgery?

Dr. Shariff Bishai: I think it's a loaded question, because it's not as simple as just decreasing opioids. I think it's a conversation worth having with the patient. In medicine, and especially the surgical medicine that we have today, there's an unrealistic expectation that it should not hurt after surgery. It's going to hurt. We're violating the body to do what we need to do to fix something, so there's definitely going to be some pain just by definition. Our goal is to manage expectations in the clinic, and then at the time of surgery.

I think a multimodal technique of taking care of pain is helpful. It could be as simple as starting with an anti-inflammatory, and if that fails, then you go to the narcotic. We need to get away from starting with the narcotic, treating it as the final need for pain relief, not the first need for pain relief. We're doing that at our ASC. We're using a long acting bupivacaine block with ofirmev, which is Tylenol.

It's important to discuss opioids with the patient, and help them understand what they need to know about the procedure, and build from there so that the narcotic is the last ditch effort to help with pain, not the first.

Q: What advancements do you expect to see in orthopedic surgery in the coming years, and how do they relate to reducing opioid use?

SB: History is the best way to look at the future. I'm a shoulder surgeon primarily, and previously we did rotator cuff or looking at instability surgeries open. It's not to say you can't do them open now, but as we started to enter into arthroscopic and minimally invasive procedures to fix those injuries, we realized that opioid consumption was reduced because there's something that has to be said of making small holes into the joint versus opening the skin, moving muscles, tendons and ligaments around. As we advance toward doing things more arthroscopic or minimally invasive or with robotics in the future, I think that will help in decreasing the need for opiates.

Q: With the many orthopedic and spine procedures moving to the outpatient setting, what cases do you expect to be performing in the ASC?

SB: We're doing total hips, total knees and one level spines out of our ASC. Again, the biggest thing is we have an unhealthy population, so if we can find the right patient who is healthy and is able to have a simpler, pretty straightforward joint replacement or even spine surgery or shoulder replacement, those do well.

The problem is when you have unhealthy patients that have comorbid states that prevent them from coming to the center because of a medical problem; those are the ones that I think still need to be treated in the hospital setting. Even in the clinic, we're talking more about smoking cessation, we're talking about obesity and making sure that we're communicating with the primary care physicians. As we get a healthier population, I think more will be driven to the ASC to do what are now routine procedures just as joint replacement and spine surgery.

Q: How can surgeons prepare to take more cases outpatient?

SB: Well, I think it's about realizing that you still have to have a plan in place. When you look at a joint surgeon, those patients postoperatively need anticoagulation and they need to start their therapies. You need that team approach of planning out the procedure. You need to put everything in place for those patients so that they're getting the outcomes we were seeing with a hospital-based surgery, but on an outpatient basis.

Once you set that up, then you're ready to go. You can't just start doing outpatient procedures and expect the same outcomes. You have to put your team together.

Q: Do you have any tips or best practices you've used to take cases outpatient?

SB: When you're talking about joint replacement, if the patient is going to spend a week or so at home before starting formal therapy, you need to set up a home physical therapy. You need to work with some sort of a physical therapy company to have your protocols, to put those in position. You have to be in contact with the primary care physician to know what's the appropriate treatment for anticoagulation for that patient. You need to have communication with the patient themselves. Let them know that you have an open door policy for them should they need you in the perioperative and postoperative period so that they're not just going right to the emergency rooms or right to urgent cares. That, again, means building your team to delete who patients should contact. Is it your physician assistant, is it your nurse practitioners, is it your office or is it your partners?

Once these protocols are all positioned, then your best practice comes from utilizing that team and knowing that patient has outlets for when and if they need them. If everything goes great, fantastic, but if there's a little hiccup here or there, patients know what the next step is. In many of those cases, like for my total shoulders that are outpatient, I have a packet that I give the patients. They know exactly who to call, depending on which hour of the day it is. Therefore, they never feel like they're on an island. They always have an opportunity to be addressed in a very fast fashion.

Q: What trends are you seeing now in outpatient orthopedic surgery?

SB: Well, I think we've talked about joint replacement. I think that's becoming more and more of an outpatient procedure. I know when I talk to certain colleagues of mine, rotator cuff repairs are still one-night stays in some hospitals. I've been in practice 12 years now, and I can count on one hand the number of patients that have spent the night. Again, it's an expectation.

I think the trends are going to outpatient procedures being performed across the board as long as the patient is healthy.

Q: Any final thoughts?

SB: I'm starting to get to the point where I'm a middle-aged surgeon. I'm not new anymore, and I'm not old yet, but I'm somewhere in the middle. Graduating fellows and residents from our programs that I work with are seeing a different medicine than what I was trained with. I'm seeing a different medicine that my predecessors were trained with. Surgeons need to evolve with the times, otherwise you're just going to be left behind, unfortunately.

For younger physicians, it's important that they understand this and evolve. Older physicians, as they're heading towards retirement, understand that there's going to be patients that want to do it their way. Somewhere in the middle is where everyone has to meet so that everyone's getting something out of this experience. The physician is giving the patient the best medicine that they can offer, and the patient's getting the best medicine they could receive. When everybody has those expectations going in, they can be achieved postoperatively.

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