Addressing biceps rupture, at what price?
I was glad to see you publish “When is a conservative approach best for proximal biceps tendon rupture?” (J Fam Pract. 2013;62:134-136), as it addressed an injury commonly seen in sports medicine practice, but one not often written about. However, I believe the approach the authors presented—which included both an MRI and specialty referral—is expensive and unnecessary.
Biceps tendon rupture is primarily a clinical diagnosis, and the findings are so classic that imaging is usually unnecessary. Adding a $750 MRI to the cost of treatment is wasteful, and not done by any of the orthopedists I work with. If imaging is "necessary" due to patient desire or diagnostic confusion (hard to imagine), an ultrasound has very high sensitivity and specificity.
Since the lesion is almost totally cosmetic, there is little reason to consider fixing it. The biceps is not really used in many sports activities, and strength is not impaired. In fact, John Elway, a prominent football player in the National Football League, played most of his games with this injury.
In 40 years of practice, I’ve seen about 15 patients with biceps tendon rupture. Only one opted for surgery, and that was because he wanted to look good at the gym. Usually, a careful discussion is adequate to manage this problem. Yet the authors noted that 2 orthopedic surgeons examined their patient. My concern is not about the accuracy of the data they presented, but about turning a $200 problem into a $1500 expenditure.
James Kennedy, MD
Winter Park, Colo
Drs. Sofya Pugach and Isaac Pugach respond:
We thank Dr. Kennedy for his letter. We’re glad our article prompted a discussion of different approaches to proximal biceps tendon rupture, including the conservative management (no MRI) he discusses as well as surgical repair. Treatment of this condition is still a subject of debate in the medical literature, and there is no one correct "recipe."
Sofya Pugach, MD, PhD, MPH
Isaac Z. Pugach, MD
Dallas, Tex
Saying No to EMRs
"End EMR tyranny!" (Editorial, J Fam Pract. 2013;62:173) reminded me of my own experience. As a solo practitioner, I began trying to implement my own EMR 13 years ago. I kept switching to bigger screens and newer computer system, but things just got worse.
Finally, I bought a top-rated pen-based tablet, but even then, voice and handwriting recognition didn’t work. I had to stay in the office until 9:30 pm just to type my notes. My children were asleep by the time I got home.
So I revolted. I went back to paper and pen and opted out of Medicare. Now I’m home at 5:30 every evening, seeing my children and enjoying my life—all because I got rid of this bureaucratic burden. I regret that I have only one practice to give to paper and pen!
Farid Taie, DO
Plano, Tex
… and saying Yes
For the past 2 years, our large multispecialty group has been in the throes of transitioning 250 doctors from the inadequate but familiar paper charts to the daunting EMR system.
I’ve been in practice for 36 years. Most of my colleagues are in my age group, and don’t take easily to change—or to computers. Three colleagues opted to retire rather than accommodate the changes, while others of us would never want to return to paper.
To be sure, it requires an investment of time to assimilate quick texts, problem lists, and myriad other details, but once that’s done, the EMR is a far superior system.
In a very few years, those of us who paved the way to EMRs will be retired, proud that we were the pioneers who brought about this important transition.
Cherry Brandstater, MD
Redlands, Calif