TRAVEL

COULD BE WORSE IN CLEVELAND

Frédéric Jacquot MD
Hôpital Raymond Poincaré, Garches, France

“Is this your first trip to the States?”
“As a matter of fact, yes.”
“You have a treat in store - you’ll see so much, so many new things. You’ll discover a new country, a new culture, because, as you know, everything is quite different over there. By the way - where exactly are you going?”
“To Ohio - to Cleveland.”
“Poor you!”
“What do mean, poor me?”
“But there is absolutely nothing to see out there - that’s what I mean.”

This conversation took place on a trans-Atlantic flight. The chap sitting next to me knew what he was talking about: He taught French in Virginia, and was an ardent francophile. He drew me a very sombre thumbnail sketch of what was in store for me over the next few months.

“Oh yes, if you are keen on that sort of thing - they have just set up a Rock and Roll museum over there. But I don’t know if it’s worth seeing.”

They say that if a bad thing happens, it could be worse in Cleveland. People had started warning me long before I left, and I was sure that I would be staying in the darkest and direst depths of industrial America.

And so, one May evening back in 1966, I arrived in that notorious city of Cleveland. A huge and filthy yellow cab took me along the freeway. On the horizon, I could see four or five real skyscrapers looming against a leaden sky. It all looked eerie and Gothic, darkly menacing like Batman’s Gotham City. Everything seemed somehow dingy and worn out. We went across bridges and over spaghetti junction flyovers, passing big American cars half-eaten by rust, jolting over the potholes in the road surface. It was cold. There was some bland rock music on the radio. We then left the freeway at a tree-lined interchange, and reached the university campus. I was surprised to see an odd assortment of buildings scattered throughout a vast park. The architecture on campus is monumental and OTT: a neocolonial building, a Victorian villa, a mock castle complete with gargoyles, a baby pink and blue glass tower, several pretty houses, a mock-Gothic cathedral, half a dozen museums - Welcome to Case Western Reserve University!

On a fine day, it’s Superman’s Metropolis.

My first night was spent in a large hotel on campus. Next morning, I was ready to meet Victor Goldberg MD, who was allowing me to spend a few months with him, as a Fellow in Research, at Lakewood Hospital, Case Western Reserve University, Cleveland, Ohio. As an orthopedic surgeon, I was most interested in basic research, joint replacement and spine surgery . Victor is the most senior orthopod at “Case.” His specialty is “Total Joint.” (They don’t bother with details, in the States!) He works with two other surgeons, his main associates; plus one fellow and two residents. He gave me a choice of what I was going to do on campus, by suggesting that I could get some lab training, doing basic research, and that I could also come to the OR and to his clinic. He also suggested that I could do clinical research in his Department. Faced with this multiplicity of options, I decided - to do the lot, and to work hard at all these activities.

In order to live and work in the States, one must have a Social Security number. Anybody would think that this has something to do with social security. It hasn’t: it is a personal identification number that plays a hugely important role in the lives of the natives and of (temporary) immigrants like myself. Without a Social Security number, one cannot open a bank account, pay one’s bills, be paid, sign an employment contract, register a vehicle, get a telephone line, obtain various passes. (The idea of a National Data Protection Commission like the one we have got in France seems to be quite alien here.) So, first of all, I had to go and get my SSN, as well as several identity badges with a magnetic stripe that would allow me to move freely around this universe. I was quite stupidly proud of my laminated hospital badge, which proclaimed that I was indeed “Frederic P Jacquot MD, Orthopaedics,” and which opened all the doors to me - real ones as well as figurative ones. Everybody working in the hospital environment has the same kind of magnetic photo badge indicating their function - from “MD” to “Floor Sweeper.” I also had a magnetic card stating that I was a “special foreign visitor.” That badge would unlock the doors of the animal house and of the University facilities. I got myself a driver’s license - also laminated and sporting my photo. And, finally, I got my Social Security card, issued by the government. This is the typical little card that gets dog-eared and gets lost, but it is a very, very important document. Getting all these bits of paper together took some time, and I had to fill in reams of paper. Having got everything together, though, I was ready to throw myself into my life in the United States.

The University Hospitals of Cleveland are the main teaching hospital of the Case Western Reserve University School of Medicine. It occupies a large part of the campus. It is a mixture of all sorts of buildings linked together by halls and criss-crossing covered walkways. Every building bears the name of the donor with whose money or on whose initiative it was built. The walls in the halls are covered in commemorative plaques. The whole thing has an air of luxury about it; everything is beautifully kept up; it’s like entering a three-star hotel. People passing in and out are checked by security staff (“May I help you, sir?”); at night, there are video cameras and electronic locks to protect the buildings.

University Hospital is a health care provider in a fiercely competitive market; the hospital is even developing its own insurance system, to stave off the HMOs. These health maintenance organizations provide health insurance for employees (through their employer), slashing the rates they pay to the providers.

UHC’s biggest rival is the Cleveland Clinic Foundation, two miles to the west. Like UHC, the Cleveland Clinic started out as a privately endowed charitable organization. The Clinic is huge. The Department of Cardiac Surgery enjoys a very high reputation. When I was there, there were some long faces at the Case, because the Cleveland Clinic had just snatched a major deal from under the Case administration’s nose, buying up a smaller hospital complex. When one arrives at Cleveland via the freeway, one is struck by the billboards extolling the respective advantages of the two arch-rivals. On the local radio station, commercials for CCF alternate with those for UHC: An old lady delightedly recounts that she has joined the new University Hospital of Cleveland health scheme, with which she is very happy. “And I didn’t even have to change doctors, because my doctor has already got a contract with the University Hospital of Cleveland. University Hospital of Cleveland, Top Quality Health Care.”

Apart from these two main competitors, there is a host of hospitals in Cleveland, who either operate independently or work with the one or other of the big centres, under contracts with a variety of insurance companies and HMOs.

The most famous Department of Orthopaedic Surgery is the one at Case. There are the “joints surgeons,” and several other orthopedic subspecialties, each with one or two surgeons and their retinue: there is Spine Surgery, and Pediatrics, Hand, and Sports Medicine. They each have their own carefully demarcated field of activity. The Department of Sports Medicine deals mainly with knees that do not require joint replacement (i.e. ligament problems and early stages of OA) and with shoulders (for shoulders, I think they even do implants ). The Department of Trauma is in another hospital that is associated with Case. Victor Goldberg is the Chairman, in overall charge of orthopaedics; however, he confines himself strictly to his subspecialty. The patients move on from one department to the next: I imagine knees start out in Sports Medicine, and finish up in Total Joint. Each chapter has its own wards, and its own organization, with Departmental meetings, operating sessions, etc. The residents get trained in General Orthopaedics, by moving from one sector to the other, at two-monthly intervals. There is little contact among the different teams. This extreme subspecialization can have bizarre consequences: A dear old lady was referred by her physician for hip replacement; she had pain, but her hip X-rays were virtually normal. However, higher up she had one heck of a spondylolisthesis. She was first sent for MRI of the hip, to make quite sure that there was nothing wrong with that joint; and only after that was she referred to the spine surgeon, who would then look at her spine.

Welcome to Case Western Reserve University	“Case” Medical School - The Clock Tower

My first week was spent, not just at the hospital, but in the hospital: I had complete faith in what I had been told over the telephone when I was still in Paris (“We’ll sort everything out when you are here.”), and promptly found myself housed in a room with bars on the windows. It took some time to find accommodation in a hall of residence, which reminded me vividly of my undergraduate days!

I soon found out that, in the States, life is impossible without a car. The distances are enormous, and nothing is designed for pedestrians: There is no corner grocery store. One goes to a near-by movie house, which is ten miles away. I soon managed to find an ancient Audi. It was like driving a battle tank, but everybody thought it was quite a normal-size vehicle - “just a regular car.” It was the butt of incessant jokes. I had got myself what they call a “lemon,” a car that is always breaking down, which one would rather see someone else drive. There are masses of lemons in the States. Car quality is not great, and proper maintenance is rare. Sometimes the vehicle catches fire on the road, and the Fire Department arrive and sort things out. “Don’t buy American,” I was told, “buy Japanese.”

The housing market in Cleveland proved less accommodating to the passing stranger than expected. Eventually, I was shown a third-floor “room” of truly American dimensions: three attic rooms, 75 square metres, all mod cons. I moved in p.d.q. Everybody in the lab helped me find some furniture that was not too rickety; and before long I was installed in near-luxury. My landlords soon became good friends. One was a medical student, and very proud of having started medical school. His brother was a resident doing General Surgery at Case. The house itself was just behind the hospital, on the fringe of “Little Italy,” one of more European-looking quarters of this sprawling metropolis, with little restaurants where Clevelanders go in the evenings. I was lucky enough to be able to walk to work. Going in in the mornings, I would meet nurses arriving in full OR gear - wearing blue scrubs and caps - which everybody seemed to think was completely normal.

Initially, the language was a bit of a problem - not so much in one-on-one conversation, but talking to several people at a time. I then thought that one can conduct an entire conversation without really saying anything at all. All one needs to do is throw in plenty of phrases like” you know,” “I mean,” “basically, I mean,” “come on, you guys,” etc. Grammar was not a major hurdle, since everybody would use English as they saw fit, mauling the old language of Shakespeare like terrible. Later on, I was told why I had had problems early on: “You already spoke English when you came here. So nobody tried to help you, because everybody thought you understood everything.” Of course, few people over there speak a foreign language, and the very thought that somebody might not understand an everyday conversation conducted in American English may be totally strange to them. Being able to speak French is an unimaginable luxury. In a country where everybody cultivates his own accent, my accent went down well.

I thought I was the only Frenchman lost in Cleveland, until I met some fellow countrymen - some scientists, who had no intention of staying in Ohio longer than absolutely necessary. It wasn’t that they disliked the place as such. What got them was the climate, which would tax the patience of a saint. (“There are four seasons in Cleveland: ‘early winter,’ ‘winter,’ ‘late winter,’ and ‘prepare for winter.’”) Also, this is thought to be Middle America at its most conservative.

Clevelands history is that of a huge industrial centre. One only needs to go to the museum and see the photographs and examples of “industrial neorealist” paintings to see quite how much it has been shaped by industry. Since its industrial heyday, the city has changed a lot. It is now a mosaic made up of smart residential quarters, where the same style of neat little house is endlessly repeated; and working-class areas, built on the same pattern. There are white areas, and black areas, and places where one doesn’t go after 6 p.m. for fear of having one’s car swiped. Overall, I think Greater Cleveland covers an area of about 150 square kilometres. The original town - what is now Downtown Cleveland - is virtually uninhabited, but remains an important and very busy commercial centre on the shores of Lake Eerie. The industrial zones have been converted into leisure areas: In the evenings, people go out on the Flats, the old port, to dine, dance, and enjoy a spot of “low life.” It’s not at all the cultural desert I had been told it was: The Cleveland Philharmonic Orchestra is one of the United States’ premier orchestras (Pierre Boulez was their conductor for several years). The university is among the best endowed in the States; it has several museums on the campus, with some superb exhibits: two of Rodin’s Thinkers are at Cleveland; Lucy, the missing link discovered by Johanson, is in the Museum of Natural History; and there is a fine collection of early 20th-century French paintings. Above all, I got the feeling that I was deep in the American heartland, close to the American subconscious that is never talked about - and which reminded me a bit of the attitudes and mind-sets of my native Lorraine! It was in Cleveland that Rockefeller built his first oil refinery and founded the Standard Oil Company (for the Rockefeller Center, though, he chose New York). Henry Ford’s first factory outside Detroit was sited in Cleveland. The radio says a Cleveland disk jockey invented the word ‘Rock’n’Roll, back in the 50s. Paul Newman was born in Cleveland, as was Superman, who was created by two local cartoonists. Tracy Chapman also comes from here, but went to university in Virginia, I think. In fact, staying in Ohio felt like being at the back of a huge store called ‘America’, whose shop window on the East Coast is New York.

I was introduced to the cell biology laboratory headed by Arnold Kaplan. He gave me my first lecture on the “mesenchymal stem cell,” which has been his subject of research for a number of years. I learned the essential features of the behaviour of the totipotent cell, which gives rise to all the cells of the mesenchymal tissue, including osteoblasts and chondrocytes. The number of these cells decreases with advancing age. “And when you don’t have any more mesenchymal stem cells, you die,” said Kaplan, staring at me. So - like most of the people working in the lab - I was to remove the bone marrow and culture these famous cells. I was introduced to the researchers: some Americans, some Japanese, one Brit, one Spaniard; PhDs, doctors, vets, even a dentist, attuned to the whims of those blessed cells, and who would advise the budding biologist.

Victor Goldberg had also asked his fellow to take me under his wings. So, equipped with the indispensable laminated badge, I went off to Surgery. Wowee! This brand-new shared facility has 22 operating rooms. All sorts of operations are performed there, from ophthalmology to orthopaedics, plastic surgery, urology, etc. The joint surgeons have two ORs of their own, but if they are not operating, other procedures may be put in there (regardless of whether they are clean following our standards, or not), without anybody finding this at all odd. The whole outfit is managed from a large glass-fronted office, a sort of control tower, where people sit at computers and produce the operating lists for the day.

Work in the OR starts at around 8:30 a.m. That’s when the first patient is put to sleep and positioned on the table. The surgical team aim to start before 9 a.m. The patients are never admitted the night before - that would be considered quite wrong, a waste of time and money. They arrive from home, having had nothing to eat or drink, and having taken a shower as instructed by the nurse; they are positioned and put on a drip in the induction room. (Small is not a word in the American vocabulary, so the induction room is the size of the departure hall at a railroad station.) Then the resident comes in to check the patients, and to get their consent - and their signatures! - before the anaesthesia is performed. The joint replacement patients are positioned by the fellow, who helps the resident. Then, Victor comes down to the OR. Victor is a dynamic person, so putting in a prosthesis is fairly swift. Inserting the implant is a very collective process, the whole team seems involved poking around at the same time. (Enough to surprise even me, who, goodness knows, tends to put his hands everywhere as my french professors often say). The french - style “No touch” doesn’t mean very much in the American OR. The scrub nurses like working with Victor, because he does not dawdle. As he himself says, he never shouts in the OR - he just speaks loudly, as he calls it. The residents say he speaks loudly quite a lot. What one needs to bear in mind, though, is that, for a joint replacement, the whole team disguise themselves as astronauts, wearing space suits, boots, and ventilated helmets; and the laminar flow clean-air system makes a fair amount of noise.. The number of sheets used in a joint replacement operation is about twice that normally used in France, because everything is done twice or three times over for security reasons. Once the implant is in, and the op is finished, Victor leaves the team and goes out, in his scrubs, to tell the patient’s family, who are outside in a special waiting room equipped with coke and coffee machines. Victor does two days a week, and does three knees on each of these days, or four if it’s bilateral replacement. The organization is somewhat cumbersome, which means that there is about three quarters of an hour to an hour between patients, as in some big french university hospitals. As a fellow told me, it’s the fault of the anaesthesiologists: For years, too many anaesthesiologists were being trained; they earn less than the surgeons, and are not motivated to go faster. An operating day can be long. At the end of the day, one goes to the wards, to see the patients operated on earlier in the day. The mean in-patient stay of a knee-replacement patient is four days only; hip replacements go home even earlier, if possible! The patients are discharged to a rehab centre, where they stay for only two weeks on average, before going home again. This is a problem as far as the hospital is concerned: Some of the rehab centres do not send the patients back for check-ups, and not all of the patients operated on at the hospital can be easilly followed up by the hospital. I did not scrub in to assist Victor, he seemed a bit worry at having a foreigner wanting to assist, but I could see the main surgeries, almost exclusively primary knees, with little revision surgery.

It was the joint surgeons who first took me to the OR; however, I soon became somewhat unfaithful to prostheses surgery, and would go off to the other ORs, to see what was happening there. On my first day in Surgery, one the most senior spine surgeons in the north of the United States, as far as I can tell, was on the table: He was being operated on by one of his collaborators. I was to meet him properly three weeks later, when he was working again. I went to his OR, and told him that I was a temporary French visitor. He then looked at me and said:“Oh, you are French. Raymond ( Roy-Camille) was a very good friend ...” Thereafter, I felt allowed to be present whenever he was operating.

I often went to see the spine surgeons at work. Everything was different from the joint replacement arena: No space suits, but headlights and surgical loupes. The spine surgeons would come in in the morning with their little collections of CDs. (There are CD players and hi-fi systems in every OR.) Henry Bohlman, the senior spine surgeon, would arrive with his little case, 50 CDs at least, and a large camera. The music would be Chopin or Mozart, and everyone would work away calmly. (Other spine surgeons seemed to favour Rock’n’Roll.) Henry always has a story to tell while scrubbing in; he recounts the history of the patient, with lots of graphic details. He lets the resident and the fellow do the initial bits; often, he stands in the background and lets the juniors muddle on and tinker with the instruments until they have completed the incision. Then he comes in, and takes the instruments only if things start getting difficult. If things are going all right, there will be a short break during which the assistants are allowed, turn and turn about, to look, while having everything explained to them. Everybody is allowed his or her turn - the visitor from France, the resident, the third assistant from Japan, the forth assistant from any country, they all dance around the surgical field. When everybody has had a peep, the instruments are returned to the fellow, and the operation continues. As a result, procedures may take time, but nobody seems to be in a hurry.

I was advised to scrub in to assist, “otherwise, you won’t see anything in this patient.” So, no problem there - the spine surgeons are used to having visitors from other countries around, some of them with a rather poor command of English. I would, therefore, scrub in for spine surgery, except for “ordinary” cervical spine procedures, because the way the patient is positioned - in Gardner-Well’s tong traction, with the anaesthesiologists at the head and the drape at the hair-line - one can see better from the anaesthesiologist’s end than by standing at the surgeon’s elbow. I became friendly with the anaesthesiologists, and they would keep a space for me.

Evoked potentials are recorded routinely, in all procedures. Henry does 50% C-spine, 20% T-spine, and 30% L-spine. The other surgeons do 30% C-spine, which is quite a lot; they find this quite normal. The Department does a lot of degenerative spines and multiple cervical disk hernias, including soft and hard disks. The basic procedure is an anterior corpectomy, done with a burr over 3 or 4 levels, followed by reconstruction with a fibular graft, without internal fixation.

I am impressed by the way they do degenerative cervical spines in that Department. I am a bit less enthusiastic about the way the - rarer - cases of trauma are treated “American style.” Cervical spine fixation as we french usually do from a posterior approach is unusual and considered venturesome.

I used to sit in on Victor’s clinics, in two different hospitals. Everything looked sumptuous; everybody was meticulously well-dressed; every detail was carefully recorded.

At a clinic, one sees twenty or so patients, old ones and new ones. Most of them are very youthful senior citizens, the typically American kind wearing Bermuda shorts and golf or baseball caps, and chewing gum, as we can encounter them on vacation Place de l'Opera in Paris. They come because “my knee hurts, and my doctor says I should see you to get a new one.” It’s not always as simple as that, and Victor does some infiltrations. Before coming for joint replacement, many patients will have had arthroscopy by a sports surgeon - in the States, everybody does or used to do sports, even at 60, - “but it didn’t help much,” and the cartilage was found to be damaged. So, it’s time for a joint replacement, and the patient is told about the advantages and disadvantages, the risks and benefits of, and the alternatives to, the procedure. The informed consent is carefully completed and forms a vital part of the patient’s file. The surgeon adds, “I have explained to John (or George, or Trevor) the risks etc., and he seems to understand.” At this point in the ritual, the patient searches his pockets, and comes up with a list of questions which, as he says a bit sheepishly, was given to him by his daughter (or his mum, or his wife). He then reels off all the questions concerning his hospital stay, but also questions about the metals used in the implant, and the friction behaviour of the polyethylene. The final question usually is, “Since the arthroscopy has shown that the cartilage in my knee is gone, and they are now doing cartilage grafts, shouldn’t I wait until that technique has taken off, and then come for grafting?” Victor then explains that, of course, the technique is not fully developed yet, but he is very hopeful that it will come off, but that it will take another ten years or so, maybe even 15 years - well, ten, anyway. Whereas with prostheses, surgeons have many years of experience, and in ten years’ time, further improvements will certainly have been made. That is reassuring for the patient, who is worried that he will be given an implant that will be obsolete in six months’ time, like a desk-top computer. Talking of cartilage grafts reminds me of the Thursday morning research meetings, where we discuss how we could get to making those f... cells stick in the knees of those f... rabbits, with a huge effort on everybody’s part.

Patients who have been operated on in the past need reassurance and sometimes are welcomed by “How you doin’? You look great!!” - and this “Grrreat” always reminded me of the Kellogg’s tiger in the TV commercials (!)

In the States, a surgeon will give his patient his personal telephone number, and allow himself to be contacted any time, even at weekends ! Victor is very busy as a surgeon, and has many other activities (research, travel abroad); he therefore employs a nurse to help full-time with his patient relations. The nurse takes calls on her mobile phone both before and after surgery. If Mr. X complains about pain in his implanted knee, she prescribes a more potent analgesic, and even calls the local pharmacy to have it delivered to the patient’s home address. Every day, she goes through the list of calls with her boss, and tells the patients - “I’ve seen the Doctor, and he says that there is no need to worry about the pain, just go on as we said, good-bye Mr. X, and give our regards to your lovely wife.”.

The threat of litigation is very much in the surgeon’s mind during these clinic sessions, and seems to shape a fair part of the surgeon-patient relationship. The patients ask lots of questions, they draw their knowledge and high level of anxiety from the newspapers and the television; but, equally, they have a great deal of trust in their surgeon. If a patient feels that this trust has been abused or that he has been let down, he can get nasty. The specialty with the highest litigation rate is orthopaedics, mainly because patients are unhappy with the functional outcome. Anaesthesiologists are much less at risk, because they have collectively, over the past 15 years, developed a minimal risk policy, with very precise guidelines. “You don’t know what people here are like,” said a surgeon. “They’ll sue you for anything.” So, I was allowed to ask any questions I liked, but not within earshot of the patients.

In the Yellow Pages, the biggest section is that of lawyers - 15 colour pages, real tear-jerkers: There is a photo of a wheelchair-bound manual worker (still in his overalls), surrounded by his distraught wife and his miserable-looking children. And there they are again, in the lawyer’s office, wearing their Sunday best, and all smiles again. It’s all along the lines of “Victim of medical malpractice? Call us toll-free. We will visit you at home or in the hospital. Call us from hospital. Our law firm has attorneys with medical training - we specialize in medical and surgical malpractice cases. No fee unless benefits are obtained. Fifteen years’ experience means rapid settlements and fair compensation.”

Henry Bohlman is the most relaxed of all the surgeons in clinic. His patients are younger, and come to him from all over the States with their very complex problems. He likes to astonish them by introducing his multinational team who are sitting in: “This is Dr. Nakamishi from Tokyo, and that is Dr. Frederic, from Paris, and Dr. X, from Seoul, etc.” He enjoys that sort of thing immensely. One tends to see a vast range of spinal disorders, mainly degenerative C-spines, and every kind of low back pain in the book.

Henry is one of those who feel very strongly that smoking is a major cause of spinal fusion failure. When he meets a patient, he can instantly detect the smell of tobacco, which he abhors. “You are a non-smoker,” he will say, “I won’t put screws into you.” The feeling at the hospital is that smokers be managed with pedicle screws, while non-smokers will need no screws. “In the latest paper by Sandy Emery [his closest collaborator], we were able to show that smoking is a major risk factor for the failure of lumbar spine fusion. At the cervical level, we haven’t yet got the evidence, but we are on a good way to get it,” he told me.

There are many Departmental meetings. The joint surgeons’ meeting is held every morning, in a small room off the ward. The resident presents the cases of those who have recently undergone, or will shortly be undergoing, surgery. The operations are compared and discussed in a very postgraduate manner, not at all unlike the way we would discuss our cases here in Paris. One day, somebody showed a hip replacement from another institution, which I thought was just perfect: the cup was nicely lodged under the roof and with respect to the teardrop; the stem filled the canal very well and was well seated on the cortex. One of the surgeons used the opportunity to explain to the residents that that was a good example “of how not to do it.” “The cement mantle is quite inadequate - it will fracture and allow the stem to migrate. This stem will need revising in two years at most, and while we are at it, we’ll have to revise the cup for the same reasons. With this sort of technic, there’s is high loosening rate in the literature.” I had just finished my thesis, and was reasonably au fait with the literature; so (much against my usual habits) I spoke up and said that, in Europe, according to our habits, that pattern was considered just about ideal, and that there was nothing in the literature that would condemn it. The audience obviously felt somewhat ill at ease; there was some cursory discussion, and the conclusion was that patients in Europe were different. Thereupon, everybody changed the subject. It is true that none of the cases shown involved highly severe OA. Whenever there was a severe case, they would turn to me and say, “This is a difficult case - the kind of OA that you operate on in Europe.” That’s not quite true, of course; but I sensed a certain respect and, perhaps, a touch of envy in those words.

A UHC ambulance - American size and style, like the ones on ER. These things make an infernal noise.

The preferred technique is cement less implantation. The argument about cemented vs. cement less goes on forever. The residents - and the patients - are taught that Without Cement is Good; and With Cement is Bad. However, cement is a necessary evil, because it allows the surgeon to do joint replacement in poor bone stock or when things are getting impossible otherwise. “How did it go this morning?” “Badly, I had to use cement.”

Privately, the arguments in favour of cement less implant fixation are less strong. Surgeons tend to talk their way out of the argument by stating that the long-term behaviour is not well known, and that “cement less” is easier and more reproducible. That is true: Great efforts are made in the OR to fit the cement less implant into the femoral shaft. However, that is nothing compared with the implantation of a cemented prosthesis: The shaft gets flushed and brushed at great length; the cement is mixed in a vacuum, using a special tool; it is then centrifuged by the scrub technologist, in an appropriate device; then handed, with due precautions, to the scrub nurse in the sterile enclosure. It is injected under pressure into the shaft, using a cement gun. The implant is inserted into a thick cement mantle, care being taken to avoid touching the cortices. The implant is then held by hand while the cement is hardening. For cemented fixation, the current practice is to use four lots (!) for the stem, and two for the cup - cement is put everywhere, and the excess has to be carefully looked for and removed. “Third generation” cementing has made cemented arthroplasty very complex indeed.

Saturday mornings are the time for the only meeting that brings the entire Orthopaedics Department together. This is (somewhat grandiloquently) called a Grand Round. It’s a bit of a do - all the orthopods are supposed to be present. Every effort is made to present subjects of general interest: The Spine fraternity may yawn discreetly when someone asks a question about hips; the Total Joint contingent will have forty winks while idiopathic scoliosis is on. Everyone, however, will wake up to listen to (and to josh) a resident they all know. These meetings are held to ensure that the hospital’s residency program is at a proper graduate level. Sometimes, a guest speaker comes in, from Chicago or from Philadelphia; sometimes, they lay on a lawyer or a financier. These lectures have the biggest and the keenest audiences: The future of the health care system, and the financial implications of any changes being made, are discussed in detail. Everybody is concerned about how things are going to go.

Medical school in the States takes four years. Those who want to study medicine leave high school at 17. They then spend four years at college. Those who have the necessary grades may then apply to a medical school. The age at entry to a medical school is about 22 years; the students’ basic science background varies, their knowledge of anatomy is largely “there is a femur, there is a tibia.” "Case" is a famous medical school. Fees are high: more than $30,000 per year, $150,000 for four years. The national average is $20,000 - 25,000 a year. A lot of cramming is required in order to learn all about Medicine in four years, starting from scratch. The students at Case are hard-working and highly motivated young people: When questioned during their first year, 80% of them (including the women!) want to go in for orthopaedic surgery - it’s the discipline that allows loans to be repaid fastest. Hands-on clinical experience is limited. From time to time, students (readily identifiable by their short white coats) get taken through a hospital ward, but hardly see a real patient. I would describe French style medical training to them - the system where you start medical school at age 18, and are involved with the actual treatment of patients by the time you are 22. This left them somewhat bemused. “And medical school is free of charge, then?” Of course, I did not tell them about how impoverished our universities are.

University Hospitals of Cleveland - Main entrance

During the second year, students sit the exams of their own medical school as well as Step 1 of the United States Medical Licensing Examination (USMLE); Step 2 comes in the fourth year. Those who have passed these exams may then apply for a place on a residency program. The whole business is very complicated: Applicants will travel all over the States, references and grades in hand, to attend several interviews with the hospitals of their choice. The applicants will then produce a rank order list of the programs “tested”; while the organizers of the programs will rank each candidate in order of preference; all this data is fed into a large computer, and out comes a list of residents for each program and each specialty. This exercise is known as the Match. Orthopaedic surgery is the specialty where selection is the most stringent.

The residency lasts five years. During the first year (known as the internship), the young specialists-to-be are knocked into shape: They have to do all the unpopular jobs, and in doing so acquire the clinical experience they never got as students. After one year, the intern becomes a proper resident. Clinics held by the resident are free of charge (imagine having that in France!), as is their work in the emergency room. The social and ethnic mix of the patients seen there, and the disorders encountered, tend to be very different from what one meets with in the surgeon’s clinic. “You come across incredible things in this country, Frédéric. The condition of the people is unbelievably awful; you would think you were in a Third World country,” I was told by one of the residents, who was somewhat older than the others. He was from an african country, and had trained in Europe. The other residents could not see anything unusual. All, even the least motivated ones, know that they are there to learn their craft. People are kind to them, they rarely get their heads chewed off during staff meetings. In the OR, they ask questions - intelligent ones, or dumb ones - and everybody answers them, politely and unwearyingly. At Case, they do not seem to have our French philosophy that learning is a painful process and if it doesn’t hurt it won’t stick. Otherwise, American residents live like their French counterparts: They are often on call, and extremely busy while they are on; however, that is not considered a reason for them not being fresh and bright and properly dressed next morning. “There comes a time,” as one of them put it, “when what you want most is somewhere to lie down and get some sleep.”

The residents in Orthopaedics are impressively self-assured: Nothing appears to be too difficult for them; all problems can be solved; and there is no room for doubt. Even the younger ones among them have all the self-assurance that we see in North American participants in medical conferences. Their bookish knowledge is vast (worries about the board exams are a powerful spur, and there are well-attended revision sessions for the benefit of the residents). They are taught the Truth (with a very capital T). However, I sometimes got the feeling that they had limits in clinical training.

The real problems start during the residency period: That is when the cost of medical education starts having to be repaid. A resident earns $1,800 a month, which includes his time on call.

On completion of the residency period, a surgeon may go into General Orthopaedics, or opt for further specialization through a fellowship. The subspecialties offered are Hand, Spine, Trauma, Sports Medicine, Pediatrics, and Joint Surgery.

I was amazed at the degree of hyperspecialization at Case, and asked the fellows, who told me that with the recent relative overproduction of orthopods in the States, there was little prospect of newcomers being able to find enough patients within their subspecialty. So, unlike their elders, they would need to practise General Orthopaedics as well. They do not seem to be too unhappy with this prospect. Many residents have no wish to spend an additional year in a fellowship; some vacancies are not filled. With the emergence of the HMOs, I was told, there would soon be only a limited, if any, market for the hyperspecialists; whereas there would be a keen demand for orthopaedic surgeons who could cover the whole range, or several subspecialties, of orthopaedic surgery.

CWRU - The laboratory

Theoretically, the fellow is the equivalent of our Chef de clinique. However, there are major practical differences between the grades in the two countries: Whereas the French chef de clinique enjoys a certain amount of autonomy in the OR, in the clinic, and stays for two to four years, the fellow remains tied to the surgeon of his or her choice, almost in their everyday lives ! Surgery will be performed under the control of the master, who may be a brillant teacher. After one year, the fellow is rated to have acquired all the knowledge and skills that it takes. Nobody would dream of carrying on for a longer period of time.

The attending is the full-fledged surgeon, he seems to act completely on his own responsibility and shares in the on-call duties. The first years in this post are spent paying back the loans taken out in previous years.

Being there as a foreign visitor puts one in a special position. I allowed myself to look and listen, but to give my own opinion as little as possible: My job over there was not to tell them how things are done in Europe, but to see how they do things in the States. I had noticed a similar attitude in foreign doctors training in France, and subconsciously adopted it when I was in Cleveland. I could go to the OR of my choice; stand where I could get the best view; scrub in and stand at the surgeon’s elbow, or else peep discreetly over his shoulder. I could ask any questions, even if what I was asking might sound odd because of the culture gap between our two countries. Not scrubbing in allowed one to just look, and to save time by skipping the incision and suturing stages of the operation. Overall, the most interesting procedures were the ones where things did not go as planned, or even went disastrously badly! Where the result was excellent, I was pleased to have come from so far away to learn about orthopaedic surgery. When the result was less than optimal (often because of a certain inflexibility preventing surgeons from trying a different tack in mid-procedure), I would say to myself that they would do things better - or worse - in France.

The residents would say a few nice words, but were basically pretty indifferent. They were always very busy (how - as a matter of interest - do we treat our foreign visitors in France?), and when they did notice my presence, tended to regard me as some sort of savage: “Do you have good hospitals in France?”; “Do you do internal fixation?” they would ask me in all good faith. The fellows were a bit wary. (“Who is this foreigner asking all those weird questions?”) The attendings were much more amenable: They like to explain what they do, and are interested in how things would be done abroad. They see France as a country that has contributed exciting innovations in surgery, and as a slightly mysterious country at the same time. As one of the surgeons said to me, with a sincere interest, “You French have interesting ideas, but why don’t you publish them?” (Meaning, of course, in English...) “I’d like to go and see what you are doing in France,” said one surgeon, “But is it true that nobody in your country speaks any English.” So, to the Americans, we are a very small country where they do interesting but slightly odd things, which are published in a language that only insiders can understand. After all, the United States is not like any other country in the world: It is The World. Not surprising, then, that they think they have to reinvent everything.

I shuttled backwards and forwards between the hospital and the lab, where I kept a log on my rats and my dear little cells. Having compiled the references on the mesenchymal stem cell, and been taught the laboratory methods, I started my routine of producing dozens of little Petri dishes full of marvellous cell preparations, which would fill half of a large incubator and which I would go and inspect daily. Initially, I had thought that the chief problem would be doing surgery on the rats using a consistent technique. The real limitation, however, proved to be the cell cultures: There was a huge scatter, which nobody around could account for. The work was financed by a grant from the National Institutes of Health, and the money had been given for a very specific purpose. My cultures varied so much that I heaved a lot of them, thinking that they had been infected. (Eventually, I heard that the whole lab was affected at this time, because there was something wrong with the calf serum medium.) I learned by the by that a resident had done very similar work in the lab the year before, which had been hushed up because the results scattered so badly. Also, the results of my bone marrow implantation were less than convincing. I started reviewing the methodology from scratch. Going through it step by step, I eventually managed to obtain proper implantation in my 90 rat femurs.

Following Victor Goldberg’s suggestion I also did some “clinical research.” For this, I reviewed the charts of patients who had undergone cement less knee replacement in the Department (in all, a little over one hundred cases). In fact, that was my raison d’être in Cleveland: thanks to Victor, I was paid out of the Orthopaedic Department’s research funds. What does an American orthopod do if he wants to perform a clinical trial? He may have the funds to pay someone to review the charts, not like us who have to do it by ourselves or motivate a resident to work for free. Often, this someone will be a student on vacation (I was to meet several, who were working on similar projects). A secretary went round to the administration and the archives, to collect the charts and the X-rays. The task was complex. In order to save money, the hospital administration had recently decided to destroy all X-ray films older than five years! the recent radiographs were therefore being scanned and stored post-haste by two “information technologists.” In all, I had a huge pile of charts made up of administrative documents - receipted invoices, and disclaimers signed by the patient to document that he or she will not hold the hospital or the surgeon responsible. I was wondering how, under these difficult circumstances, do one of those elegant studies published in the JBJS, even when ample funding is available. In the end, I managed to get quite a detailed picture of how things worked and how knee implants were done at Case; and I finished up with a reasonably complete list, including a Knee Society rating of the implanted knees. A nurse was detailed to call the patients and ask them to come back to the center.

When I first came to Cleveland, I had wanted to go and see Arthur D. Steffee, who is probably the American spine surgeon that is best known in Europe. I therefore contacted Acromed. Unfortunately, Steffee had ceased his clinical activities in early ‘96, to concentrate on his work as director and PR man of his company. I was introduced to the Spine and Arthritis Center, in a medium-sized hospital west of Cleveland, where I met Robert Biscup, his main collaborator. We made a number of appointments, because he was very busy seeing several foreign surgeons. He kept me informed about scheduled procedures. I therefore went to his hospital, scrubbed in, and assisted at surgery; and he explained to me the rationale of Steffee’s implants. Disk prostheses were no longer being used at the time: The first generation devices had consisted of a vulcanized rubber nucleus between two metal end-plates. They were still giving good service, I was told. However, a rat study had shown the rubber to be carcinogenic, and no more of these devices were being implanted. Subsequently, silicone had been used for the nucleus, but the results proved not satisfactory. So this avenue had not been explored any further, and work was in progress on a new implant. “You know,” said Biscup, “having the FDA to contend with makes it very difficult to develop something new. In France, you haven’t got these problems.” However, he had heard that the European Community was going to adopt a system patterned on the FDA. “Have fun,” he said with a laugh.

The atmosphere at the Spine and Arthritis Center is quite different from that in Bohlman’s Department, which is considered to be on the conservative side. Here, even higher-grade spondylolistheses are reduced; spinal canals brought back to their physiological width; herniated disks are destroyed by laser under a microscope (with a noise that reminds me of the bombing of Baghdad on the 8 o’clock TV news); and carbon cages are used plus-plus, even in the C-spine. I was able to see the reduction of a Grade II spondylolisthesis using the latest equipment: at L5 and S1, the pedicle screws are linked with a transverse bar, which is then used to obtain a purchase for the reduction by means of a tool that looks like a crowbar or a jemmy. The reduction manoeuvre made me shudder slightly; when asked, “Bob” Biscup replied (briefly and to the point) that there had never been any nerve root complications.

Again, the end of the procedure, Bob goes off to tell the patient’s family in a special waiting room.

At last, I was able to meet the grand old man himself: Somebody made an appointment for me to see A.D. Steffee. He welcomed his French visitor very kindly, in his office at the Acromed headquarters. He said he was depressed: It had become very difficult to develop new ideas, because of the FDA, but above all because of the risk of litigation. A major law firm had brought a class action against all manufacturers of pedicle screws, all surgeons who had inserted such screws, the American Association of Orthopaedic Surgeons, the North American Spine Society, etc., in favour of all patients who had been managed with this hardware, whether or not there had been complications. His name was top of the list of those being sued. Under US law, such actions can be brought on the initiative of lawyers who do not actually represent any of the patients. After this case, Arthur Steffee had given up his clinical activities, and begun to work exclusively for Acromed. (Incidentally, theclaims were dismissed by the judge, in early ‘97.) “Doctor Steffee” took me along to his packaging plant, and showed me a whole range of implants, cages of all shapes and sizes, including prototypes and customized implants. He collected several carbon cages, because - busy as ever - he was off to California next day, to assist a surgeon who was going to put in the cages. That’s how he saw his work - travelling up country and down with his implants. We then talked about his designs, the history of the carbon cage, and future prospects. He was thinking of filling the cervical spine cages with a mass prepared from bone marrow cells or stem cells - a very in subject, which brought me back to my own cell cultures and my implants in rats.

At the time of my stay, there was a whole raft of spine surgeons in and around Ohio. Apart from H.H. Bohlman and Arthur D. Steffee, both with large teams of surgeons, there was a team in Akron (the other major industrial city, compared with which Cleveland is Brainsville, OH). Herkowitz was 200 miles away, in Michigan; John Kostuik used to be next door, in Toronto, Ontario, but had since moved to Baltimore, MD. McAfee was also in Baltimore, but he is one of Bohlman’s oldest collaborators. Also, there was Michael T. Modic (the one who does MR imaging of the disk), a radiologist at the Cleveland Clinic Foundation, 2 miles to the west. Edward H. Simmons (not the “Cage Simmons”, but “Keystone Simmons”, who does interbody fusion in the cervical spine) was 100 miles away, in Buffalo, NY. He came over frequently, and I was able to listen to a lecture he gave at the Cleveland Clinic.

Henry Bohlman is not only a renowned and respected surgeon, but also a great connoisseur of wine and, hence, I guess, a lover of all things French. Some years ago, together with some North American surgeons, he founded the Wine and Spine club. He says it was meant as a bit of a joke, to allow surgeons to get together over some good bottles, to talk shop. Since then, he says, the club has become an important forum of spine surgery, with two meetings a year and an agenda that features, turn and turn about, lectures on surgery and lectures on wine, both at a high level.

Henry Bohlman had seen me in the OR, and eventually invited me to a party he was giving for his colleagues, at his house. I was told that it would be an interesting evening, with good food, and - as everybody said - “there’s going to be some good wine.” Henry lives on Cleveland Heights, in an affluent, tree-studded part of town, where some of the houses are more like stately homes. All the spine surgeons and the fellows were there, with their wives. The evening started with a guided tour of the house, from the cellar to the attic. The house is huge, and Henry is justly proud of his demesne. The two features Henry is particularly proud of are the attic and the cellar. The attic has been comfortably furnished, and houses all the charts and all the radiographs of all his patients since he was a fellow! Everything is properly filed, with slides, an X-ray viewing box, and enough supplies to keep one alive for several weeks. This means that a member of his staff can retire to the attic to review a series of cases, with impressively long clinical and radiologic follow-up of somewhere around 25 years. In a corner, an original article has been left “lying around” - the first hip implant, developed by Dr. Bohlman Sr., back in 1937 - “long before Robert Judet,” as Henry pointed out with a wink. I was told the story of Arnold Bohlman, who joined up at the age of 20, flew fighter sorties over France and Belgium in 1917, and, on his return home, decided to study medicine. He went on to become a famous orthopaedic surgeon. Henry is also very proud of his wine cellar, which is hidden in the basement like a treasure. The huge cellar is famous far and wide. It contains some 10,000 bottles, all arranged on shelves, and kept at the right temperature by means of an air conditioning system. There are many grands crus from France. We had a little photo session in front of the jeroboams: Henry said he had always wanted to photograph a real Frenchman in his cellar, but had not managed to get hold of one before (unfortunately, I know quite few about the great knowledge of wine!). For the aperitif, we went to the poolside, and the first bottle was opened. Thereafter, we went through a range of wines from France, from Italy, and from California. To my surprise, the food served with these superb wines was buffet style: We went to the kitchen to fill our plates, and then sat awkwardly in the easy chairs in the living room, terrified that we might spill our precious drinks. Henry would move among us, treating us to new bottles and more oenological commentary. Towards the end, we were all pretty mellow, telling jokes and anecdotes in an atmosphere of well-oiled bliss.

Our genial host had decided that we should have a pictorial record of that evening. The photos caught up with us a few days later, when Henry handed them out with a huge grin and a wicked wink.

The summer months just flew by. It gets very hot in Cleveland - not a dry heat, but sultry and humid. Everywhere is air-conditioned, with temperatures ranging from arctic in the hospital to temperate/subtropical in the lab. Weekends offer an opportunity for going out in groups: There is a beautiful beach 30 miles away, on the shores of Lake Eerie. The lake itself is a fresh-water sea that extends as far as the eye can see. Going to the beach is not, however, the done thing. Young men are suspected to go there ogle the girls - and in the America of the 90s, that is not a PC way to spend one’s leisure time.

As a Frenchman, I was expected to fit into a certain pattern: Not only was I expected to have certain culinary preferences (an O.K. thing), it was also thought that I would be whimsical and indolent. The young people over there were eager to talk to me; for many of them, I was “their” first Frenchman. However, Ohio is not used to a lot of foreigners passing through, and people from abroad are viewed with slight suspicion. I found that I was mainly associating with other foreigners, from Europe or from the Far East; there was little contact with the natives. We discovered American culture as a group, and would compare life in Paris with life in Tokyo - I learned almost as much about Japan as I did about the US of A.

After a sweltering summer, it was suddenly fall: what could almost be described as the “rainy season.” However, the rain did bring out the colours. At this time of year, the deciduous woods of the northern States turn flaming yellow and red. I spent a little time vacationing in Quebec (what bliss to hear French again!), and then winter set in. And with it came the time to return to Paris. I had to relinquish my work at the lab and my trappings of the foreign visitor. It had been an unforgettable experience - I felt that I had lived an incredible adventure in my everyday life. For a few months, I had been an American; and I had met some fascinating people. In addition to biology training and knee and spine surgery tips, I had also gained a much better understanding of things that I had previously only known from hearsay: the way our American friends live; the way they think; and what American orthopods do or are thought to do.

I had to leave a few more of my rats to be studied, hoping that I would be kept informed of the further progress of the research work. I also left behind my friends, some of whom would shortly be returning to their countries, at the other end of the world. We promised each other that we would stay in touch via e-mail, to tell each other how things were going in Cleveland, in Paris, and in Tokyo. “Keep in touch,” were the final words.

Paris, December 1997. My thanks are due to Prof. Laurent Sedel, without whose help and support I would never have gone to Cleveland.

Frederic Jacquot