The New York Times - 30.07.2019

THE NEW YORK TIMES, TUESDAY, JULY 30, 2019 N D5

MY SON ERIK,then 23, was playing basket-
ball when an opponent stepped on his foot
and the anterior cruciate ligament in his
right knee ruptured with an audible pop.
This critically important ligament, best
known as the A.C.L., is a ropelike structure
that connects the femur (thigh bone) to the
tibia (shin bone), stabilizing the knee joint.
A torn A.C.L. is an all-too-common injury
that typically results in complex surgery
and prolonged rehabilitation. It can spell
the demise of a promising athletic career
and limit an amateur’s ability or willingness
to participate in sports like tennis, basket-
ball, soccer, football, skiing and gymnastics
that involve quick twists and turns or
pounding stress on the knee.
But Erik was lucky. His anterior cruciate
ligament tore about a quarter of the way
down the ligament, and the orthopedic sur-
geon he consulted immediately after the in-
jury was a maverick decades ahead of his
time. Ignoring longstanding professional
practice that still calls for removing and re-
constructing the torn ligament with a ten-
don from elsewhere in the leg, Erik’s sur-
geon simply stapled the longer piece of the
torn A.C.L. to his femur.
Twenty-seven years and countless hours
of tennis and basketball later, Erik’s re-
paired knee is still intact, stable and pain-
free. He recently learned that, despite con-
tinuing orthopedic orthodoxy that insists on
reconstruction, many others with a torn
A.C.L. — perhaps as many as 40 percent
with this injury — could benefit from a mod-
ern version of the simplified procedure and
more rapid recovery Erik experienced.
One of the pioneers in modernizing sim-
pler anterior cruciate ligament surgery is
Dr. Gregory S. DiFelice, who has done
A.C.L. repairs, instead of reconstructions,
on about 250 patients during the last decade
at the Hospital for Special Surgery in New
York. Dr. DiFelice maintains that repair
rather that reconstruction is especially
helpful for children 18 and younger who are
more likely than older patients to reinjure a
reconstructed A.C.L. Over all, he said in an
interview, the risk of reinjury with the re-
pair method has been no greater than that
following reconstruction.
Reconstruction involves removing the
torn ligament and replacing it with a graft

— a tendon surgically removed from the patient’s hamstring, quadriceps or kneecap, or sometimes taken from a cadaver — and attaching it with screws or buttons through tunnels drilled into the femur and tibia. As it heals, the grafted tendon develops scar tis- sue that results in a firm, reliable knee joint with an overall failure rate of about 5 or 10 percent. But Dr. DiFelice said that when the damaged A.C.L. is removed, the patient loses the nerve endings within it that send sig- nals to the brain about what the knee is doing. Also, range of motion may be compro- mised, and during the lengthy recovery that can take six to eight months or longer for the graft to be strong, thigh muscles atro- phy and must be rebuilt before the patient can safely return to demanding activity. Thus, Dr. DiFelice said he wants to en- courage other practitioners and their patients to pursue the lesser surgery and shorter rehab whenever circumstances permit, especially when the full length of the A.C.L. tears directly off the bone. How-

ever, he explained that even when the torn ligament is not quite long enough to reach the bone, he’s developed an augmentation procedure to add a small strut to make it reach. Using this method, he said, he now has to resort to the standard reconstruction surgery for less than a third of the patients he sees. There are at least two important caveats to this story: 1) Unlike the introduction of new pre- scription drugs, new surgical procedures are not subject to government approval and typically are not tested in controlled clinical trials, at least not until they have been used for years. So patients must rely on what surgeons tell them about the effectiveness of their procedures, supplemented perhaps by reports from patients. 2) Training and practice are required before a surgeon attempts what Dr. DiFelice does, and thus far there are not many al- ready adept at the technique. Changes in medical practice can sometimes proceed at a glacial pace, and it may be up to patients to

pressure doctors to depart from accepted procedures. Also, it may require pressure on medical insurers to cover the costs of a new operation. Another surgeon in the New York area now doing ligament repairs in lieu of reconstruction is Dr. Howard J. Luks, at West- chester Medical Center. He reports that the loss of nerve connections to the brain after A.C.L. reconstruction may explain why such knees sometimes feel unstable. However, Dr. Luks emphasized that “cur- rent repair techniques only allow us to con- sider tears which occur high in the A.C.L. near the femur insertion” and that “the tear cannot be too old. If the tear is old, then the ligament will degenerate, and it may not be able to be brought back to the part of the bone it needs to be repaired to.” Keep in mind, too, that there are risks as- sociated with any surgery, including infec- tion, stiffness, pain, blood clots and with the A.C.L., ligament failure. For children who are still growing, there is a risk of damaging growth plates during the surgery. Those with an anterior cruciate ligament injury should also know that surgery is not their only option. My brother, in his 50s when he tore his A.C.L. while skiing, opted not to have surgery. Instead he did exten- sive physical therapy, and by wearing a leg brace for added support, was able to ski and play tennis despite his damaged ligament. The American Academy of Orthopaedic Surgeons suggests that nonsurgical man- agement may be appropriate for those with partial tears and no symptoms of instabil- ity; those with complete tears without in- stability during low-demand sports who are willing to give up high-demand sports; people who do only light manual work or are sedentary; and children whose growth plates are still open. The academy says that a person’s activity level, not older age, should be a considered when deciding on surgery. “Active adult patients involved in sports or jobs that require pivoting, turning or hard-cutting as well as heavy manual work are encouraged to con- sider surgical treatment,” including older patients once excluded from surgical con- sideration, the academy wrote. Whether repair or reconstruction is done, postoperative physical therapy starting right after the operation is vital to a success- ful outcome. The academy cautions that patients should return to sports only after pain and swelling are gone and full range of motion, muscle strength, endurance and leg function are fully restored.

An Alternative to Replacing a Torn A.C.L.

Repairing the damaged

ligament can lead to a shorter

and more complete recovery.

GRACIA LAM

Changes in medical

practice proceed slowly,

and it may be up to

patients to pressure

doctors to pursue them.

PERSONAL HEALTH JANE E. BRODY

We l l

Dr. Michael Gabriel Galvez, a pediatric
hand surgeon who treats mostly low-in-
come patients at a hospital in California’s
Central Valley, jokes with families that he
went to “30th grade.”
But that did not come cheap. The debt he
has accrued from 18 years of higher educa-
tion and medical training, including Stan-
ford Medical School, fellowships and resi-
dency, is about $250,000. (And that does not
include credit card debt.)
Almost all of his student loan debt is
about to be wiped out over the next five
years through CalHealthCares, a new state
program intended to avert an impending
shortage of health care professionals, espe-
cially those willing to treat recipients of
Medi-Cal, the state’s version of Medicaid for
low-income people.
“We know it’s a big deal that college stu-
dents are taking out significant amounts of
money in loans,” Dr. Galvez, 36, said. “Even
for physicians, it’s a significant burden they
have to undertake.”
Across the country, the escalating costs of
medical school have driven young doctors
away from lower-paying specialties, such
as pediatrics and psychiatry, as well as jobs
in rural or less wealthy areas.
The lack of primary care physicians is
acute in California, which has a growing ag-
ing population and the country’s largest
Medicaid population — and one of the low-
est state reimbursement rates for doctors in
the country. California is projected to have a
shortfall of 4,700 primary care clinicians by
2025, according to a 2017 report by the Uni-
versity of California, San Francisco.
The new program aims to change that us-
ing revenue from Proposition 56, which im-
posed a tax on tobacco products, to help
physicians pay back their loans. It will dis-
burse a total of $340 million. To qualify, the
physicians, who receive up to $300,000 each
in debt relief, must agree to spend a third of
their time with Medi-Cal patients over the
next five years. As part of the first round of
funding, announced this month, 247 physi-
cians will receive $58.6 million and 40 den-
tists will receive $10.5 million in debt relief.
Nearly 1,300 providers applied for the
awards, according to the Department of
Health Care Services. The program’s ad-
ministrators said they assessed candidates
based on personal statements, work history
and specialization, among other factors.
Applications for the next round of awards
will be accepted in January.
Dr. Rishi Manchanda, who was part of a
commission that put forward a $3 billion, 10-
year plan to address the shortfall of doctors
in California, called the repayment program
“a big step in the right direction.” But more

needs to be done, he said, to bolster the pipeline of doctors practicing in the state. Among the commission’s recommenda- tions: increasing enrollment at medical schools in the state, raising reimbursement rates for doctors, giving nurse practitioners greater authority in the doctor’s office and a shift toward “value based” payment sys- tems, which reward providers based on per- formance. Some of those measures would require action from lawmakers, who must also face critics who have raised alarms about the cost of the Medi-Cal program, which ex- panded sharply under the Affordable Care Act. Today, over 13 million Californians — almost a third of the state — rely on it for their health care, including over half of all children, the commission’s report noted. The loan repayment plan is notable because it provides more generous funding to a larger number of doctors than similar programs, said Janet M. Coffman, a professor of health policy at the University of Califor- nia, San Francisco. The physicians will be required to regularly submit documenta- tion to prove they are meeting the program’s requirements. Dr. Galvez, who grew up in the Bay Area without health insurance, has relied on his parents to help support his wife and two children through surgical fellowships. “It’s been a constant struggle just to get by,” he said. We talked to other doctors about the impact of the debt repayment program.

Dr. Molly Dorfman, 39 Pediatric critical care specialist Total debt: $320,000 Dr. Dorfman, 39, said at one point she was paying $4,500 per month on a single loan, or 30 percent of her take-home pay. She cares for the most critically ill patients and directs their transport at Valley Children’s Hospital in Madera, the only free- standing pediatric hospital between Los Angeles and San Francisco that predomi- nantly treats Medi-Cal patients. Most loan forgiveness programs are geared toward primary care, she said, mak- ing it harder for sub-specialists like herself to find help. The grant has lifted “an emotional burden,” she said, adding, “I can focus on my patients.”

Dr. Camila Susana Cribb Fabersunne, 31 Pediatrician Total debt: $76,000

“I have always viewed medicine as my tool for social justice,” said Dr. Cribb Faber- sunne, who grew up in an impoverished farming community. “The forgiveness allows me to not have to weigh the impact between following my heart and life’s work and the impact on my family,” she said. Her husband, who will be a resident

trainee for the next four years, also plans to serve the Medicaid community, she said. The couple recently had their first child.

Dr. Jasmin Marie-Hatcher Brown, 30 Pediatrician Total debt: $256,556

For years the decisions Dr. Brown and her husband, a dentist, have made about where they live and what they buy have revolved around their student loans. The debt forgiveness is “something out of a dream,” she said. “Now we’re able to give back to charities,” she added, like the schol- arship foundation that supported her through college and medical school. This week, Dr. Brown began work at a pediatric outpatient clinic in Coachella.

Dr. Marc Anthony Bernardo, 33 Dentist Total debt: Over $500,000 Dr. Bernardo graduated from dental school in May. He is the son of two dentists and works three days a week at his family’s pri- vate practice in Southern California. He also does mobile dentistry with bedridden and special needs patients twice a week. He recently married a physician, who has lots of debt of her own. The couple had thought about moving out of state to some- where with a lower cost of living and higher reimbursement rates. But now, thanks to the debt forgiveness, they will be able to stay in California for the foreseeable future,

and to begin thinking about buying a home and starting a family. “I’m just beyond grateful,” he said.

Dr. David Benavidez, 40 Child and adolescent psychiatrist Total debt: $340,000

Dr. Benavidez, who grew up poor and moved constantly, wanted to work with marginalized communities because of his own experiences. But the economics were difficult to justify with loan payments due every month. After years of accruing debt as he put himself through college and medical school, he finally sat down this year to sort out his finances. At the time, he was working with low-income patients as part of a fellowship in Alabama. The exercise was dishearten- ing. “Burnout is very real,” he said. “And part of the issue is, you come to this crossroads where this idea of wanting to be helpful now butts up against being compensated appro- priately.” He stumbled across CalHealthCares on- line and applied. Without such a program, he said, he would not have considered going back to California, where he had moved at

He was put off by the high taxes and cost
of living.
He started work this month at a commu-
nity clinic connected to the University of
California, San Francisco.
“It is life-changing,” he said.

Physicians Gladly Strike a Deal With California

Doctors who agree to accept

Medicaid are provided with up

to $300,00 in debt relief.

Dr. Michael Gabriel Galvez, a surgeon, and Dr. Molly Dorfman, who works in pediatric critical care, will receive debt relief from California in exchange for serving Medi-Cal patients.

PETER DaSILVA FOR THE NEW YORK TIMES

The escalating costs of

medical school have

driven young doctors

away from lower-paying

specialties as well as jobs

in less wealthy areas.

By EMILY S. RUEB and KAREN ZRAICK