Administrative And Educational Considerations In An Amputee Clinic
J. Leonard Goldner, M.D.
The maintenance of useful records of amputee patients who are seen in the Upper and Lower Extremity Amputation and Prosthetic Clinics presents a difficult problem which becomes more complicated as the years go by. Even the seemingly simple task of bringing a patient back to the clinic for a routine visit is not easy. Many patients must be given frequent reminders, assisted with their travel expenses, and made to realize that regular care of the prosthesis will prevent the development of stump complications and reduce the likelihood of major damage to the prosthesis.
Our clinic does not have funds available for a full-time secretary or for payment of a part- or full-time assistant who could be consistently and constantly responsible for our data. Even our follow-up appointment lists have to be compiled by members of the team at a cost of considerable time and effort. Those of you who are involved with this problem are aware of the great volume of correspondence that must go out in order to keep the patients returning at regular times for adequate follow-up. Obviously a card system which will be relatively simple to maintain and yet complete enough to record all the necessary data is required.
From time to time, various groups or individuals request statistics concerning certain aspects of prostheses, the number of individuals using a particular type of prosthesis, or isolated factors associated with etiology, training and function. The provision of this kind of information requires both accurate records and a means of extracting and reproducing segments of the data when needed.
We have IBM equipment for hospital records, but these do not carry amputee information in the desired detail. For example, if we wished to know how many patella tendon-bearing prostheses had been constructed during the past two years and to secure the names and addresses and other details of each of the patients fitted, we would have to request from the record library a list of all of the below-knee amputations coded during this period. These would then have to be sorted, the records culled, and eventually data would be gathered. If the appropriate material had not been recorded, the record would then be useless for this particular study. Problems of this type, as well as many others, were considered when we designed a filing system appropriate for our particular clinic. Others in the same situation might find it equally useful.
It is true that filing cards which may be kept in a small box and "thumbed through" quite rapidly are satisfactory for obtaining such information as name, address, date of last visit, and type of prosthesis. However, these cards are also filed numerically or alphabetically, and much sifting and straining is required before specific information concerning a particular group of facts relating to amputee patients can be located.
The first step in the organization of our card system took place in 1961 when I assigned an interested sophomore medical student, Charles Virgin, to a summer project in the orthopedic amputee and prosthetics service, under a grant from the Vocational Rehabilitation Administration. Mr. Virgin worked with me in organizing a set of cards that could be utilized to record details pertinent to amputee patients and their prostheses.
All of our record problems have not been resolved, but considerable progress has been made. At the present time we have all major identifying information, excluding details of congenital anomalies, recorded on cards for each of our patients. Progress notes are written on the backs of the cards after each clinic visit; the cards are marked by a member of the Orthopedic House Staff assigned to that clinic, and are punched at the same time the progress notes are written. Pertinent information from the prosthetic shop is added by the prosthetist. The cards are stored in an easily manipulated file which is on wheels.
Obviously, the ultimate success of this procedure will depend upon the enthusiasm of the personnel involved, and on constant review by the Clinic Directors. Otherwise, the system could very well fall by the wayside because of neglect and lack of interest, which frequently occurs with changes in personnel responsible for a particular project.
A sample of the cards we are utilizing appears with the article (Fig. 1 and Fig. 2 ). The basic elements of their application are self-evident. The appropriate data for a given patient is recorded and/or punched on each of the two cards comprising the set. In the case of patients with multiple amputations and prostheses, we attempt to compile all data on the same two cards. However, if it appears that this would lead to confusion, we add extra cards, as appropriate. The cards, of course, may be sorted on many bases - amputation type, prosthetic components and etiology - to mention a few.
The comments of readers of the Inter-Clinic Information Bulletin relative to the system will be appreciated. It would be very interesting and constructive, I believe, if in future issues of the Bulletin, other clinic chiefs would discuss how records are kept in their clinics. They could also reveal how follow-up visits are planned, how pertinent information is gathered, and the number of persons available for doing this. This would serve to make us aware of each other's problems, offer insight into administration and financing, and reveal how one group may solve a problem that appears insurmountable to another.
The educational aspect of the amputee and prosthetics program, both for the house and the senior staff, is another area of major concern. We make it a practice to send our senior staff, prosthetists, therapists and house staff to the conventional courses so that they will obtain a concentrated introduction or reinforcement of the general aspects of the subject as they are so well presented in the prosthetic schools. Continuation of this education in the form of reinforcement, repetition and presentation of new material is not only desirable but essential.
During the past year we established an inter-orthopedic amputee teaching program which offers many advantages, the greatest of which is the group conference through which information is disseminated to residents at all levels, starting early in their training and continuing through a three to four year period. This program exposes every man in training, on several occasions, to the principles involved in treating patients with amputations and prostheses, and allows them to discuss, question, and even disagree with the so-called accepted principles.
At some point during the total training period, each resident is assigned to an upper and a lower amputee clinic and is given specific responsibilities. In addition to the clinics conducted at Duke, two men rotate through the Amputee Clinics at the associated Durham Veterans Administration Hospital. One resident attends the bimonthly Regional Out-Patient Clinic sponsored by the Veterans Administration Regional Office in Winston-Salem, which is conducted by Dr. Frank W. Clippinger of our Orthopedic Staff. These experiences allow a rapid, practical association with the patient and his various medical and prosthetic problems.
In addition, each member of the House Staff is assigned to a specific phase of amputee and prosthetic education. Each doctor is responsible for five patient records which have been maintained for at least a year, so that the various complications will be evident. The physician is given several weeks to prepare a two-hour presentation covering a specific aspect of the clinical and prosthetic field, and is required to use the best illustrative material available including slides, motion pictures, patients currently under treatment, and material from the prosthetic shop.
Value of Program
This preparation places a responsibility on the doctor unequalled in other forms of teaching. He must demonstrate initiative and use ingenuity in order to retain the interest of his colleagues during the two-hour conference. Each doctor is thus exposed to at least one phase of the prosthetic problem in depth and is given a feeling of confidence he would not acquire in any other way. They become aware of terminology, prosthetic problems, the location of and the functions performed in the prosthetic faculty, and the elements of limb construction. They review the prosthetist's records, as well as those of the clinic, and familiarize themselves with etiology, pathogenesis, genetic associations, parental adjustment factors and the emotional problems of the juvenile and adult amputee.
They are also exposed to Welfare Department routines, Public Health service personnel, the mechanics of the Crippled Children's Division, the functions of Vocational Rehabilitation and the methods of applying to each for assistance in providing the best care for the amputee patient. The importance of follow-up care, early adjustment to the prosthesis, and the advantage of the McBee punch card, take on a new importance to the doctors. The value of gait training, the adjustable Leg, the use of a pre-fitting pylon and the value of using X-rays as a fitting aid, become something more than words on a printed page.
During the past year, all of us have learned a great deal through our participation in the program, and we are beginning our second year with renewed vigor and enthusiasm. It has been established that a busy amputee clinic, attended by a great many patients and the amputee clinic team, is a major advance in the care of the amputee. The regular educational conferences have allowed more time to recognize our shortcomings and to disseminate available information in a meaningful way. This type of conference and teaching program has enabled us to eliminate a great deal of the haphazard instruction received by the members of the House Staff during any given year. By the time a physician is assigned to one of the amputee clinics, he has an awareness of the amputee patient which was not available previously. After he has served for several months on one of the clinic assignments, he can be sent to one of the regional schools where the information he receives is of much greater value to him than if he used the school as his introduction to amputations and prostheses.
It is hoped that teaching of this type will spread information over a broad area, since each of these men, in daily association with his general surgical and medical colleagues, will feel more confident in offering instruction and advice relative to the amputee. It is hoped that stimulation of bright young minds will identify research problems that can be investigated with enthusiasm and resulting benefit to all involved.
J. Leonard Goldner is Chief, Amputee Clinics, Duke University Medical Center, Durham, North Carolina