By: James Pitt  Jan. 28, 2019
Dr. Christopher J. Evanich is a top-ranked orthopedic surgeon who practices at the Orthopedic Institute of Wisconsin. James Pitt interviewed Dr. Evanich about his practice, his method of patient education, what's good and bad in EHRs, and how his time as an engineer helped him in medicine. This interview has been edited for length and clarity.
What makes patients choose you and your team?
Being in practice now for over 20 years, a majority of my new patients come to me by “word of mouth” - recommendations from family, friends, colleagues, neighbors, et cetera whom I have treated. I believe these patients truly appreciate the care, compassion, expertise and respect my team and I provide. We exhaust all conservative treatment options before recommending any surgical interventions; and post operatively, we address their concerns, worries and expectations. It seems then that we really gain the patient's trust throughout the entire treatment process.
You're highly praised as a clinical instructor. Do you see educating physicians and educating patients as the same skill?
One has to possess a considerable amount of energy and enthusiasm in educating both the resident physician as well as the patient; however, the goals are slightly different. In resident education, I work to train the physician to wholeheartedly be an advocate for the patient: put the patient first; outline options that are best for the patient. In educating the patient, I try to explain their musculoskeletal condition in terminology they can understand, then present the treatment options and allow them to choose the path of treatment they believe is best suited for themselves.
What should residents learn?
LISTEN, listen, listen to your patients and always do a thorough problem-focused musculoskeletal exam. You will then make an accurate diagnosis over 75% of the time with these two things alone! Use lab work, radiographic studies and other tests to confirm your diagnosis, not search for one. What the patient tells you about their symptoms is so valuable in your quest to truly help solve the patient's problem.
I have spent time overseas in Kenya, Nicaragua, Honduras and other countries participating in medical and surgical mission trips where we did not have access to technologies such as labs, X-rays, and MRI scanners but still provided exceptional care and outcomes by just relying on the patient's history and physical exam.
[Dr. Evanich's 2018 mission to Honduras was covered in the Journal-Sentinel: Patient's humble gift moves Milwaukee orthopedic surgeon to tears]
Finally, I make sure the residents are aware that their concept of success as a physician/ surgeon only holds true if the patient deems your treatment a success! In other words, if the patient isn't happy with the outcome, then you should not consider it a successful case and work to remedy the situation if possible.
What's your approach to patient education?
After I spend time with the patient and formulate an accurate diagnosis, I try to explain their ailment in terminology they can understand so they can select the best treatment from the options I present to them. If they can't understand the problem, they certainly can't make an informed decision. I love asking my patients their occupations as this can help me present their musculoskeletal problems in a way they may understand. If I have a carpenter with a varus or bowed knee, I can explain to him or her that the surgical opening-wedge osteotomy to correct the deformity is similar to inserting a shim to level a newly installed window. Another example is telling a mechanic that I can't use cartilage plugs or stem cells on his severely arthritic knee but rather would need to replace it; analogous to what he or she would tell a customer about not plugging a nail hole in a tire with over 80,000 miles of wear and with no treads. Instead a tire replacement would probably be recommended.
And then finally, expectations are really important. We talk about treatment options and what you can expect out of each option. If I have a 60-year-old male who used to run marathons, and he's so arthritic that I have to do a total knee replacement, I need to tell him you're not going to run a marathon anymore; you probably need to get involved in other aerobic activities like, biking, swimming or elliptical exercises.
Before you were a surgeon, you were an engineer. How has engineering helped you in medicine?
My first job was as an engineer with GE Medical Systems, and we were working on the design of MRI scanners prior to its release to the public.
The musculoskeletal system is the ultimate engineering model. It incorporates everything from biomedical engineering to mechanical and electrical engineering as well as biomaterials.
The learning styles for the study of engineering and medicine are completely different; however, both very important, especially in the field of orthopedic surgery. In medical school, students are bombarded with an enormous wealth of information which has to be memorized, understood and regurgitated on exams and used in clinicals. It has to be “eternally memorized” — never to be forgotten! In engineering school, one has to know and thoroughly understand principles, then use the vast array of principles to solve complex problems either actual or theoretical — usually drawing from principles across many engineering disciplines: mechanical, electrical, biomedical. So my engineering background provided me with excellent problem solving skills which are used so often in my orthopedic career combining these skills with my medical knowledge — awesome combination!
What advice would you give providers who serve a large patient volume?
The answer to that is to assemble the best team you can with all team members having the same one goal in mind: provide exceptional patient care throughout the entire process! With the volume of patients, volume of surgeries we do, there's no way I could do all this by myself. I have nurse practitioners, physician assistants, schedulers, and medical assistants.
In the operating room, we've selected surgical techs, surgical assistants, the recovery room nurses, who are all people who really love their jobs and love to be there. It really shows when you're talking to people.
How are you going to treat your family, how are you going to treat your friends? That's how you should treat your patients. The Golden Rule really applies in the field of medicine.
And I think patients really appreciate that when they come in, we don't jump right to surgery. We don't just say "oh, you have a very arthritic knee" - which indeed they may have. We don't just say "here's what needs to be done." You really want to educate them on: here's the problem, here's some options. Some of these might not work very well, but if you want to go that route, okay.
Laying out the options rather than “Here's what I think is best”?
You explain all the options, let them think about what they want to do. Let them ask questions - you can address each of those one on one. And more times than not, they will say "Well doctor, what would you recommend?" And that's where you can interject, "Here's what I think will work." Here's a surgery, it will take this much of your time, you will miss work, invest six to eight weeks into your recovery for your total knee. And then they'll know if it's the right time or not!
Is there anything else you'd like to cover?
In any kind of business, if you love your work, if you enjoy going to work, it becomes obvious to everyone the joy and excitement that shines forth. Everyone you work with as well as your patients begin to have a more positive attitude. They find something to be happy about. They enjoy being around our staff. So I think if you love it and show that, you'll be busy, you'll be successful.
With all these changes in medicine, there are a lot of physicians who might be second-guessing "Did I make the right decision? Did I go into the right field?" Prospective students who are interested in medicine should talk to someone, shadow someone, get some exposure ahead of time.
So, the complaints about EHRs —
They're terrible in that it severely takes away from the patient-physician relationship. Studies show that over 70% of the time during a patient's clinic is consumed by entering data into the computer rather than the patient and physician actually talking to each other or performing an exam. Fortunately, I have been successful at preserving face to face interaction with the patient. That's where my PAs and NPs [physician assistants and nurse practitioners] have saved my life. When I see patients in the clinic, it's extremely rare that I have to write something down in EHR.
When I'm seeing a patient, I have ample time to talk to them, perform a problem focused exam and then discuss the diagnosis and treatment plan; all the while my PA or NP in the room is entering the data in the computer and printing whatever that given patient may need such as prescriptions, physical therapy forms, work excuses, et cetera.
I've heard a lot of optimism about voice recognition for transcribing notes.
We have that voice recognition, and it is really nice. The earlier versions were tough, but nowadays we use Epic, and I can dictate my surgical report. It's shocking how close it gets to exactly what I say. Even terms that I would not expect to be in its corpus.
You've found the human touch still crucial?
Oh, very much so. Now more than ever!