Can Residents Flourish? Managing Common Foot and Ankle Conditions

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By Sohaib

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week’s topics include methods of suicide, managing common foot and ankle conditions, daily toothbrushing and pneumonia, and flourishing among medical residents.

Program notes:

0:32 Can medical residents flourish?

1:32 What are factors associated with it

2:32 Characteristics that are ‘individual’

3:32 Feel as a calling

4:00 Method specific suicide mortality

5:00 Lifespan typically 7 years shorter

6:00 Getting rid of firearms won’t solve

7:00 Brushing teeth and pneumonia

8:00 Also secondary outcomes

9:00 Patients feel better

9:15 Management of foot and ankle conditions

10:00 Manifest as burning pain in ball of foot

11:01 Platelet rich plasma

12:01 Off the shelf orthotics

12:53 End


Elizabeth: How has suicide changed in the 21st century?

Rick: Can doctors flourish?

Elizabeth: How are common foot and ankle conditions treated best?

Rick: And daily toothbrushing to prevent pneumonia.

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: And I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, how about if we start first with Annals of Internal Medicine? This really interesting thought of, “Gosh, can residents actually flourish as they are doing their training?”

Rick: We commonly talk about things like happiness or life satisfaction or burnout. Those are individual characteristics. What we really want to know is, can internal medicine residents flourish? That’s kind of a more holistic concept of wellbeing and it integrates a number of the other things that I mentioned, but also psychological, social, and physical aspects of wellbeing.

There are ways to measure this. There are surveys that you can take, one called the Flourish Index and one called the Secure Flourish Index, and they were developed to measure 5 domains: happiness and life satisfaction, physical and mental health, meaning and purpose, character and virtue, and close social relationships.

They administered these surveys to 14 residency programs in Connecticut, Illinois, and Pennsylvania in 2021 to determine whether residents could flourish and what were the factors or variables associated with that. They surveyed 277 residents; nearly half of them were interns. That’s the first year; that’s most stressful. About half were women.

Overall, when they compared the mean scores of the residents to those of the general population, they were a little bit lower. But they were able to associate flourishing with several characteristics, some of them individual characteristics and some things that the program actually had control over. There was a positive correlation of flourishing with quality of life, work/life balance, resilience, doing medicine as a calling, and intrinsic religiosity. Conversely, there was a negative correlation with emotional exhaustion and depersonalization. [Schools] can foster flourishing through advocacy curriculum, through stress reduction, and through celebration of workforce diversity. But the short message is residents can indeed flourish.

Elizabeth: Have to don my chaplain hat here for a moment and say that I believe that even those characteristics you’ve identified as individual — for example, either religiosity or spirituality — I think that even naming those and enabling those to be a part of the environment is also supportive of their existence and calls them out in a way that’s very powerful.

Rick: I think you’ve summarized it very well. I mean, these are individual characteristics. But when there is high-quality leadership that cares for residents’ wellbeing and supports them and the camaraderie, and allows for these positive correlations to flourish, it allows the residents to flourish as well.

Elizabeth: I think this is something we all need to pay attention to, because given the rate of healthcare professionals walking out of the profession, even after substantial investments — both personally and monetarily — to get to the places where they are, none of us can afford that.

Rick: Elizabeth, there are a lot of pressures: keeping up with medicine, caring for patients, COVID-19, regulatory issues, all of these things. When people feel it’s a calling and they want to take care of individual patients to make them better to increase their wellbeing, all of these tangential things sometimes interfere with it and increase physician burnout. You summarized it well. Not only physicians, but healthcare providers in general are leaving the workforce at very high rates.

Elizabeth: Remaining in Annals of Internal Medicine then, a rather sobering report on method-specific suicide mortality in the United States in the 21st century. This study purports to assess temporal trends and patterns in method-specific suicide by sex and race. They use nationally representative U.S. data from 1999 to 2020. This is against the background of the fact that although global suicide mortality rates decreased by almost a third between 1990 and 2016, suicide mortality in the United States has been increasing rapidly.

We’ve discussed this phenomenon before. There are some groups in whom it’s really noteworthy how much it’s been increasing. This study estimated age-standardized suicide mortality rates per 100,000 persons among men and women by method and race using 5-year age- and sex-specific population in 2000 as the standard. They showed that the increase in suicide mortality rates has occurred across all groups. It is especially pronounced between white and American Indian or Alaskan Native peoples. Those folks in particular have a life span that’s typically 7 years shorter than that of the white population in the United States. They found that among American Indian and Alaskan Native people, this number increased from 19.6 to 26.5 per 100,000. That’s a 35% increase — that was among the men — and then among the women, they experienced a 65% relative increase.

Firearms is the most common method of suicide among men; hanging also increasing rapidly among both men and women. We have also seen substantial increases in rates of hanging in white women. Trying to understand exactly why and how these things are taking place is important for trying to develop specific interventions.

Rick: I found this alarming that, as you mentioned, worldwide suicide rates are going down, but in the U.S. suicide mortality has actually gone up. These particular groups have gone up 35% to 65% over the last decade or so.

Firearms remains a major cause of suicide, but what this story tells us is getting rid of firearms isn’t going to solve the issue because the rate of hanging as a method of suicides increased dramatically, and there is no way to control that. I appreciate the fact that you said we need to identify the issues, whether that’s economic, social inequality, remoteness, racism. But whatever the cause is, unless we address the underlying cause, we’re never going to address this issue properly.

Elizabeth: The authors also cite, of course, rapidly changing economic factors, cultural background, and the potential for social media as a means of suicide contagion, which is a phenomenon that’s been identified before.

Rick: They call these cluster suicides. A single suicide leads to, basically, a cluster of suicides in the same people group. As you mentioned, social media can be a way that actually fosters that. On the one hand, very sobering. On the other hand, this is a call to action as far as I’m concerned.

Elizabeth: I agree. Let’s turn from here to JAMA Internal Medicine, a look at, gosh, brushing your teeth every day — it’s got a bunch of powerful positive impacts.

Rick: Well, I mentioned pneumonia. We’re going to talk specifically about hospital-acquired pneumonia. That’s classified into two different categories. One is for people that are on the ventilator and get hospital-associated pneumonia, and those that aren’t on the ventilator, but still acquire it in the hospital.

It is a significant problem because both lead to poor outcomes. Both of those conditions are thought to be due to aspiration of the flora that we have in our mouth — the oral microbiome — because it contains over 700 species of bacteria, fungi, viruses, and protozoa.

There has been a link between the oral microbiome, oral health, dental plaques, periodontal disease, and the development of pneumonia. Now, in the past they used chlorhexidine, an antiseptic, to put in the mouth, and that seemed to decrease the pneumonia. But on the flip side, it increased mortality, so that’s gone by the wayside.

What these investigators did is they sought to determine whether daily toothbrushing was associated with lower rates of both hospital-associated pneumonia, but also secondary outcomes like mortality, how long the person was in the hospital or the ICU, or how long were they on mechanical ventilation, and antibiotic use.

There were 15 different studies that met their criteria, almost 3,000 patients in these studies. What they found out is that the individuals randomized to toothbrushing, it lowered the risk of hospital-acquired pneumonia by 33%, primarily driven, by the way, by the effect on ventilator-associated pneumonia. Toothbrushing was also associated with a lower mortality in the ICU, a shorter time to get the person off the ventilator.

This is toothbrushing 2 to 4 times per day. By the way, if you do it 2 times per day, there is no more advantage to doing 3 to 4 times a day. But this is incredibly simple. It doesn’t really have any bad side effects, it’s inexpensive, and to decrease the hospital-acquired pneumonia rate by 33% — that’s pretty remarkable.

Elizabeth: I think this truly is a remarkable study, not to mention the fact that I suspect patients probably feel better when their teeth have been brushed.

Rick: Yep, this meta-analysis shows that routine toothbrushing is really an essential component of standard care, especially in individuals that are on a ventilator.

Elizabeth: Okay. Finally, let’s turn to JAMA and this is a review. It’s looking at something I don’t think we’ve ever talked about in all the podcasting that we’ve done: foot and ankle conditions. Can you recall anything we’ve ever talked about with those?

Rick: First time. We’ve been doing this for almost 20 years, Elizabeth. I’m kind of surprised this is the first time we’re reporting on this.

Elizabeth: I’m really surprised by it, too, which is one reason why I chose this, even though it’s a review paper. This, of course, took a look at all the literature that’s out there and it looked at three specific foot and ankle conditions — Morton neuroma, plantar fasciitis, and Achilles tendinopathy — very common, associated with pain and disability. Also, most of them happily can respond to non-operative treatment.

The first one, Morton neuroma, otherwise known as interdigital neuroma thickening and fibrosis; we manifest that as a burning pain in the ball of the foot and numbness or burning pain that can go to the affected toes. Looking at the literature, they find that the first-line, non-operative therapy consists of reducing activities that caused this pain, orthotics, and interdigital corticosteroid injections. They note, however, that about a third of the patients may not respond to these conservative treatments.

Plantar fasciitis — I have had it myself. I bet you have too. It accounts for more than 1 million patient visits per year in the United States and typically presents with plantar heel pain. Here is the really bad news that I didn’t realize, and I blessedly cannot complain that I still have it, 15 years after diagnosis almost 44% of patients continue to have pain.

What do you do about that? Well, you stretch your plantar fascia and you use foot orthotics. You can also use extracorporeal shockwave therapy, corticosteroid injection, and they also cite platelet-rich plasma injection, which unfortunately we’ve panned in other places, so I’m a little bit not persuaded by that.

Finally, they take a look at midpoint Achilles tendinopathy, so in the middle of the Achilles tendon versus more distally or proximally. In this case, this non-operative treatment involves eccentric strengthening exercises and also the potential for extracorporeal shockwave therapy.

I think the good news about all of these things is that there are things to try that aren’t necessarily going straight to having an operation. The other thing that they note in here that I was glad to see was that they did not recommend expensive, custom orthotics for the most part.

Rick: First of all, these are the most common foot ailments. Number two, as you mentioned, the vast majority are treated with non-surgical methods. That’s incredibly important. You mentioned orthotics and it’s not that orthotics aren’t particularly useful, but general orthotics that you buy off of the shelf were just as effective as those individualized for the particular patient. They are less expensive, they are easier to obtain, and the off-the-shelf orthotics are just as useful.

You mentioned extracorporeal shockwave therapy. It’s particularly helpful in plantar fasciitis. In a trial in which it was compared to placebo, those that had the shockwave therapy had less pain at 6-month follow-up. For those individuals that have any one of these conditions, a long trial of conservative therapy that’s non-surgical therapy appears to be beneficial in most patients.

Elizabeth: This is excellent news. On that note, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.

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