Regina Herzlinger: Innovating in Health Care

Innovating in Health Care
Regina Herzlinger, DBA
Harvard Business School
Boston, MA.

Grand Rounds presented on January 15th, 2015 at the O’Keefe Auditorium, Massachusetts General Hospital, Boston, MA.

Trauma Care in the Himalayas

David Lhowe, MD is an Orthopedic Trauma and Hip & Knee Replacement surgeon in the Department of Orthopaedic Surgery, Massachusetts General Hospital, and Assistant Clinical Professor of Orthopedic Surgery at Harvard Medical School.

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Sandwiched between its gigantic neighbors, China and India, the tiny nation of Bhutan is making a rapid transition from an isolated kingdom to a modern Asian democracy. Its 600,000 residents are almost exclusively Buddhist, and are dispersed over a landscape that remains largely forested with relatively little arable terrain. The population clusters in valleys, separated by Himalayan mountain barriers which have only recently become connected by two-lane roads. Through most of its history the country has been isolated from even its closest neighbors, and has only opened to Western tourists in the last 20 years. While visiting Bhutan from the United States is now possible it doesn’t come cheaply. The Bhutanese government charges US citizens a substantial daily tax for the duration of their visits.

Good As New: Guide to Total Hip Replacements

Here at Mass General, we are creating these patient guides for many of our top surgical procedures and services. This particular guide for a total hip replacement summarizes the entire joint replacement process at Massachusetts General Hospital. Includes: introduction to our care team, an explanation of treatment options, surgical preparation information, expectations after surgery and recovery at home. These Patient Guides also provide valuable information for patients’ family members.

Download PDF here:

Hands-Only CPR: No Training Necessary

How To:

1. Call 911
2. Push hard and fast in the center of the chest, without interrupting
3. Push deeply, about 100 times per minute. That’s faster than three times every two seconds
4. Do NOT be afraid, your actions can only help
5. Look around and invite your friends or other onlookers to help
6. Continue until trained Emergency Personnel arrive

The Plank: Strengthening the Core

The core is commonly thought of as only your abs, but consists of multiple muscle groups in your abdomen, back and pelvis. Core muscles are engaged during all activities requiring a coordinated movement of the upper and lower body. They generate the force and power required for many activities, while simultaneously playing a foundational role in stabilizing the torso.

Our modern sedentary lifestyle does nothing to working these important core muscles and over time result in their weakening, and the consequent injuries from seemingly simple tasks.

There are various ways to strengthen these core muscles. The PLANK, for instance, is easy to perform, effective and appropriate for any age and fitness level. With no special equipment, the plank can be performed on a carpeted floor or mat in your living room, in the gym between sets of other exercises, or at the end of a workout. Also, the plank literally only takes a minute!

In performing the plank, you hold a steady position by isometrically contracting the deep stabilizing abdominal muscles (transverse abdominus), while keeping the lower back (erector spinae and multifidi) stable, fighting fatigue and simultaneously building endurance. This exercise is not appropriate if you have any shoulder weakness or injury.

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Step by Step: How to perform and hold the Plank

• Have a wrist watch or clock nearby to track time
• Place forearms on floor, shoulder distance apart (see above) and elbows directly below the shoulders as demonstrated below
• Extend legs back, one at a time, straightening the knees and balancing on your toes
• Keep your body straight as a plank (see below)
• Relax your neck and look down at the floor
• As you fatigue, there will be a tendency for your hips to sag. Squeeze your deep abdominal muscles and glutes, and hold your hips in line with the rest of the body
• For starters, hold the position for 30 seconds and work up to 60 seconds or longer
• Rest on your knees; when ready, repeat plank for two additional sets

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For a more challenging workout: In the plank position, alternately lift and move each leg outwards (see demonstration below)

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The Plank was demonstrated by Julie Schlenkerman, certified personal trainer at the Clubs at Charles River Park, Boston, MA. Julie is an avid runner and ran the 2009 Boston Marathon in 3:16:14!

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From our Archives: Simple exercises & Related articles

• Scapular Exercises for Stronger Shoulders
• Heel & Achilles Tendon Stretch
• Stretching Calf Muscles – A Heel Drop
• Foot & Toe Extension
• Heel-Leg Stretch for Plantar Fasciitis
• Yoga for Arthritis
• Precautions to take before starting new exercises

Scapular Exercises for Stronger Shoulders

Exercises for Strong and Healthy Shoulders
Shoulders permit our arms to move in a wide arc and perform elaborate activities. This mobility is due to superb coordination of muscles and soft tissues around the shoulder and shoulder blades (scapula, SKA-pew-la), and is essential for performing activities in a pain- and injury-free manner. See related article on Rotator Cuff complications impairing shoulder movement.

Conventional shoulder exercises strengthen the larger muscles but tend to overlook the mid-back muscles that stabilize the scapulas. This can often result in muscle imbalance and consequently, bad posture. Even non-shoulder exercises like running on a treadmill with shoulders slouched can lead to stiffness and pain. These conditions increase injury potential and thus the need for corrective exercises.

Michael Bento, personal trainer at the Clubs at Charles River Park, Boston, demonstrates simple exercises you can do at home to develop shoulder strength and protect them from injury. As a bonus, these exercises also help tone the all important core muscles.

These exercises can be performed on a stability ball as shown, or on a work bench. Dumbbells or additional weights are not required. And as I surprisingly found out last week, you can do these scapular exercises while standing and starting with the arms in front! Yaay!

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Common Starting Position for Shoulder-Scapula Exercises

• Anchor heels to a wall, toes on the floor and slowly roll out on a stability ball.
• Rest upper abdomen on the ball and straighten body forming a line from ears to ankles.
• Pull your shoulder blades down, tuck your chin and look at the floor.
• Start with arms straight, hands in front of the ball (or bench), fingers lightly curled, palms facing each other and thumbs pointing forward.
• In this position, your core muscles including abdominal and gluteus muscles are engaged in stabilizing your body.
• For a challenging core-muscle workout, move your heels away from the wall as demonstrated above and use as starting position.

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Yoga for Arthritis

This piece accompanies the article Men are from Mars and Women get Arthritis.

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Yoga can provide immense physical benefits for women with arthritis.

For arthritis patients, aerobic exercises, muscle conditioning and increased physical activity can keep you strong and agile, improve heart fitness and reduce your weight. Yoga provides an effective alternative to the traditional strengthening and aerobic exercises, and offers other benefits as well.

While yoga may bring visions of complex body contortions, most yoga classes provide simple, gentle movements that gradually build muscular strength, promote balance and improve flexibility. Its meditative nature soothes and relaxes the mind, and is associated with increased mental alertness and enthusiasm. Scientific studies have shown that practicing yoga is a safe and effective way to increase physical activity, which is strongly recommended for arthritis patients. Yoga does not increase pain or worsen arthritis.

Lumps & Bumps

Lumps & Bumps: Things to consider when you notice a lump on your body
Download the PDF (220 KB), as it appears in the print edition.

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Over the course of a day, we all poke, rub, and scratch. Usually it’s an itch or a sore. Occasionally we notice a lump! What should we do? Rightly, some of us will worry about it and cannot rest until we find out what the lump is. Others will completely ignore it.

Fortunately, the vast majority of lumps and bumps are benign (see box at end) and do not threaten our lives. But some can be dangerous and require immediate medical attention. So which lumps should we worry about? Which lumps and bumps require a doctor’s care, and which ones can be ignored?

We usually discover lumps and bumps about our hands and feet earlier than if they were in our thighs or buttocks, for example. Our hands and feet don’t have as much soft tissue around them, making it easier to notice even small lumps. Our buttocks, thighs and even the upper arms can hide quite a large mass before we notice.

Magnetic Resonance Image (MRI) of a thigh, identifying a lipoma – a benign fat tumor, adjacent to the thigh bone.

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Feel the size of the lump carefully. Small tumors less than 2 cms are more likely to be benign. Is the lump painful? Benign soft tissue tumors tend to be painless. Does the lump move about as you press on it? A tumor that is not fixed in one place is not growing into adjacent bone or organs. Such mobile tumors are less likely to be dangerous. An important characteristic of a tumor is whether or not it is growing. Measure the size of the mass with a measuring tape and record its size.

A 2 cm lump would be considered a small tumor. However, if the tumor expanded from 1 cm to 2 cms in 2 weeks, then the tumor is growing relatively quickly and should not be ignored.

Patients should contact their primary care physician regarding any newly discovered lumps. In the meantime, perform a thorough self-exam of the rest of your body (including the hands and feet). Look for other lumps or bumps, or areas of skin pigmentation that are new. Make sure to look at the soles of your feet and the palms of your hands.

The doctor may order an MRI (magnetic resonance imaging) exam, possibly with the use of a contrast agent. A surgeon can use the MRI information to decide whether the tumor can simply be removed, or if it requires additional tests.

If the lump is greater than 5 cms, painful, or is growing, the doctor may recommend a biopsy. During a biopsy, a small portion of the lump is removed with a needle and analyzed by an experienced pathologist to determine if the lump is benign or malignant. Malignant lumps can be life threatening (see box) and often require sophisticated care and complex surgical excisions.

“It’s never a waste of a doctor’s time to have a lump or bump evaluated,” states Dr Kevin Raskin, Assistant Professor at Harvard Medical School and Tumor Surgeon at the Massachusetts General Hospital, Boston, MA. A physician should evaluate new lumps and bumps, those that have changed over time, or are causing symptoms. “The over-arching theme is ‘don’t be shy.’ Bring up even the smallest worry with your doctor. An ounce of prevention is worth a pound of cure, and peace of mind is priceless,” advises Dr Raskin.

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Benign: (beh-NINE); mild, gentle and non-threatening;
Tumors that generally do not threaten the life of the patient. They very rarely spread to other areas of the body, and often do not need to be treated unless they are bothersome to the patient.

Malignant: (muh-LIG-nunt); tending to spread and infiltrate;
Tumors that may threaten a patient’s life. They often spread to distant organs including lymph nodes and lungs. These need to be treated by experienced physicians.

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Men are from Mars and Women get Arthritis

Biochemistry, Anatomy and Lifestyle Explain Why more Women Suffer from Arthritis.

Titles in bookstores remind us that women think, behave and feel differently than men. Even in health, diseases in women manifest and progress uniquely, and the effectiveness of medications varies. Scientific research informs us that women are also more vulnerable to arthritis. Such differences may be due to hormonal, genetic, biomechanical, and lifestyle differences between genders, contributing to disparities in men and women’s treatments. Understanding these gender-specific differences will help us treat women’s arthritis more effectively.

Cartilage is the tough, slippery tissue covering the ends of long bones. As we move our bodies and go about daily activities, healthy cartilage permits bones to smoothly and painlessly glide over each other.

In patients with arthritis, particularly osteoarthritis (AH-stee-oh-ar-THREYE-tis), the cartilage is worn away, causing the underlying bones to grind against each other, driving the pain.

Sprains and Strains

Sprains and strains are a result of minor trauma to muscles, ligaments, and/or tendons. These are recognized by pain, immediate swelling in the area, and may be accompanied by discoloration of the site.

Difference between Sprains and Strains
A sprain is a stretching or tearing injury to one or more ligaments. The severity depends upon the extent of injury or tear in the ligament. Is it partially or completely torn? How many ligaments are involved? Are other soft tissues around the site injured? The most frequently sprained ligaments are in the ankles, knees and wrists.

A strain is an injury to either a muscle or a tendon caused by overuse, force, or stretching. Depending on the severity of the injury, a strain may be a simple over-stretch of the muscle or tendon, or it can result in a partial or complete tear.

Two common sites for strains are the back and the hamstring (muscle located in the back of the thigh). Contact sports such as soccer, football, hockey, boxing, and wrestling, put people at a higher risk for strains. Long distance runners experience strains in multiple muscles in their legs. Tennis, rowing, golf, and other sports that require extensive gripping can increase the risk of hand and forearm strains. Elbow strains can occur in people who participate in racquet sports, throwing, and contact sports.