Wednesday, August 9, 2017

Fundaments II: The Societal Importance of Healthcare


 
I hadn't even put my soapbox away from the other day and now I find another use for it.. It's too tempting to climb onto it and make one more pronouncement.

The most frequent question asked about Healthcare today (and by "Healthcare" I mean access to and insurance for) is whether it is a right or a privilege. Without staking out either side of the proverbial aisle or commenting (for now) on the means of providing healthcare, I will state that this debate misses another definition, probably the most important one. 

There is no question that Healthcare is a responsibility.

From a societal standpoint, it is not a matter of whether we can afford to pay for access to proper medical care, including both preventive and responsive treatment. It is whether we can afford not to.
 
Uninsured medical care is a huge burden on the financial well-being of this country. The mere fact that you don't have insurance does not protect you from medical calamities. Accidents and illness must be treated whether they can be paid for or not. Our society in its civilized state has quite rightly accepted this as fact. But even if you believe insurance is "fake money" the resources used to care for the sick and the injured are very real. Real instrumentation, real medicines, real space and real manpower are utilized. The money to pay comes out of taxes, charity funds and federal grants-in-aid. In other words everybody pays when patients are uninsured.

Beyond the financial issues though are the rather terrifying public health ones. There are few areas of the country where people can truly retire from the world. Some folks may have cabins in the woods or yurts in the dessert. But the vast majority of Americans, even in rural parts, live in defined municipalities. Most have some shared water source, shared public space (schools, church, stores) and some need to interact on a regular basis with other citizens.

Can you imagine a country where medical care is unavailable or ignored? A country where infectious disease is untreated despite continued social interaction? Where the contamination from illness is left uncleaned and unmanaged? You don't need to have too vivid an imagination to see the results. It has happened in this country. Google the Spanish Influenza of 1919 or the Polio Epidemics of the '30s and '40s. Imagine what SARS might have been or Ebola without proper healthcare and containment.

These are horror stories but not scare tactics, unless you are one of the growing number of young and healthy folks that is convinced that they will remain healthy and immune forever. Only if you can promise that you will never get meningitis or hepatitis, never fall and have a head injury, never be struck by a car or a falling object, then you need not buy into the societal protection that is insurance. But only in those remote shacks or distant huts can you assure that you will never burden a community with the detritus of your health issues. Even then, the mountain, forest and desert are interconnected ecosystems. They can be poisoned by death and disease as surely as a village, town or a city.

Not having insurance when you can is a personal choice but a uniquely selfish one. Not providing the means of access to healthcare to large portions of the population is a cruel and dangerous mistake.

Thursday, July 27, 2017

We Are All Charlie Gard


 
In medicine, less frequent than in politics or entertainment, there are cases which rage in the public imagination. Most often they are about end of life decisions, usually of a younger individual for whom the treatment options have run out and the decision to “pull the plug” is fought vehemently in the wards, the courts and the press.

It is rare, thank mercy, for such a case to involve a newborn. But the tragic situation that unfolds in London with Baby Charlie Gard is one of those rare and horrific occurrences. The child is dying, born with a syndrome that rapidly degrades DNA in the energy supplying portions of his cells. His family wished to pursue experimental therapy in the hopes of survival but the medical establishment and the courts would not allow them to do so.

It is easy to side with Charlie’s parents. I cannot imagine the horror that the young couple is living with, knowing that their little child is terminally ill without hope of rescue or cure.  Like everyone else, I pray for the miracle that will allow the small boy to survive while knowing that such a miracle does not exist.

But this is not a case where there are good guys and bad guys, despite how it is often portrayed in the inflammatory headlines of the press and social media. I wrote that it is easy to take the parent’s side, but that is tempered with the fact that the parent’s side is neither realistic nor necessarily kind. There is no cure for Charlie’s condition. Even if the therapy were to work the best hope would be stabilization. But no one, not even the expert in New York who offered treatment, can predict Charlie’s condition in the future or his prognosis. No one can estimate the cost and effort that will be required to keep him alive or what his quality of life might be. My heart cheers that his family has said they would do whatever it takes to keep him with them, but no one should have to face such an unimaginable and indefinite burden.

Nobody wants Charlie to die. There is a tendency for lay people to use terms like “The doctor gives him six weeks to live,” or “the doctor says he will never walk again,” as if the provider is condemning the patient to his doom. Perhaps doctors are at fault because we explain prognosis in such a detached manner that it is easy for us to seem remote or callous. But doctors don’t choose the outcome. We merely predict and facilitate. No one, beyond the family itself of course, would be happier if Charlie were to survive and thrive than the doctors at Great Ormond Hospital who had to make the decision to remove care.

But there is a side that is not represented in the discussion, and that is Charlie’s. The parents should have the right to make decisions for their child but those decisions should be based on what might be best for him and what the best medical information reveals about his disease course. It cannot be enough to say they want to keep him alive and will love him through whatever life gives him. Charlie, were he to survive, would have no ability to report pain or hunger or thirst. He would have limited independent movement. He would probably never develop speech. If he could see, he would be unable to interpret images beyond the flashing of lights. And he would most likely die at a very young age.

Charlie’s parents have been put in an impossible position. The ethics committees, the doctors and the courts have provided a support for them to make the unimaginable choice, to allow their child to pass away. They, and all of us who are engaged by this case, must look at all the resources and think what is best for the small and voiceless soul that is Charlie's.

Wednesday, June 28, 2017

Fundaments I: The Essence of Healthcare

In general, I steer clear of overt political statements. This in itself is a political stance in a time of hyperpolarizaion. Politics is not what this post is about.

The problem with Healthcare (capital H) is that the term has been politicized to the point that you almost have to shade the word red or blue whenever you write it. Like many words today ("liberal" and "conservative" being two obvious ones in this context) it has lost its meaning in the jumble of policy and polemic that usually accompanies discussion. Talking about the Dread Healthcare means taking a stand for or against one administration or the other; one law or another; one belief system or another.

None of this could be further from the fundamental definition of healthcare. There is nothing political about giving or receiving medical or wellness assistance - it is a normal human activity and in all probability has always been so. Ancient Egyptian mummies show signs of medical intervention and even earlier human remains show that the species has always tried to fix what was physically wrong.

Skull from Early Dynasty Egyptian tomb showing cranial trepanation during life.

In point of fact, the actual act of providing health care is no different now than it was in past centuries. An ailing soul presents to an individual who has some interest (if not expertise) in medical care. The provider assesses, diagnoses and lays on hands in an effort to cure. The laying on may be surgical or prescriptive or acupunctural or spiritual. The essence is the same.

The controversy is not about how the care is done or whether it is done at all. It lies in who can access the care and how it will be paid for. I'm quite sure our earliest ancestors felt the same way as we do, arguing about how long they had to wait in a drafty cave and how many bird eggs the shaman demanded in payment for the intervention. Humans always will question value.

But to lose the essence of medical care as we are now doing in the convolution of policy and economics is both short sighted and dangerous. Any law or any regulation should be written for the express purpose of facilitating the basic practice of medicine. Any law or regulation that interferes with this process or makes it harder to attain the care needed must be discarded.

Tuesday, June 20, 2017

Singing A New Song

About a year ago, my wife accepted a new position in Dallas, TX. It was an academic dream job for her. Once it was apparent that Dallas was a great city to live, there was no hesitation in supporting her career and making the move.

As with any major change, the move brought me to a branching point in my career. Would I open up another solo practice? Would I try to join one of the many established groups in my new city? Or would I take the leap into a different career focus - one of consulting on practice implementation and teaching on healthcare?

Several important factors led to my decision to follow the latter path. First, I am not quite the ingénue I used to be. Pediatric specialties require a long start up time. One needs to earn the trust of the community and of the parents before a practice is seasoned and established. At my age, I wasn't sure I would have time to devote myself to a building process, not to mention for the long-standing attachments that inevitably develop.

Another factor is Dallas's saturation with excellent pediatric orthopaedists. I know them all well and can unfailingly recommend them all. Although I flatter myself to think I would have been welcomed in their numbers, I could hear them say, "But where will you find your patients?"

The final and probably most compelling factor was an opportunity to embrace the role of teacher and mentor. I have always been academic at heart and the siren song of instructing was too great to ignore.

So here I am - same voice but singing a different song.

My consulting service is focused on returning providers of all stripes to the joy that they once had in working in healthcare. I can safely and boldly say that I loved every minute of my clinical practice. and I believe that everyone who chooses to enter the service of medical care feels that or felt that way at one point. Now, in an age of noise and uncertainty, politics and polemics, it is difficult to remember. Why did we choose to become doctors? Nurses? Therapists? Surely it was not to satisfy some policy written by a remote and monolithic government. It was to reach out and help others. As corny and as idealistic as that sounds, it is nevertheless the truth. What other reason would anyone have to devote so much time and sacrifice to such a difficult undertaking.

I am happy to have a platform to give voice to my ideas, even if only a few are listening. I have the opportunity to talk with providers and patients and policy makers - to learn and teach what medical care is all about. As such, this blog has been revitalized to serve as a place to record what I've learned. And hopefully a place to engage in dialogue with others.

Welcome back to my blog. I hope you enjoy the song.


Listen to my podcast at www.peerspectrum.com
 

Tuesday, January 20, 2015

TREATING IN THE FOURTH DIMENSION

At lunch the other day, a friend asked me about surgical indications.  The discussion turned to how treatment of kids differed from that in adults with similar problems.  I discussed the obvious things, like the relative size of the child, the anesthesia and other medical concerns, the relative strength of bones and soft tissues and the presence of growth plates.  But as I talked, it occurred to me that the biggest difference in operating on children vs. adults is the effects of time.

We teach our students to learn anatomy and surgery in all three dimensions.  It is not just the flat shape of a structure that is important, it is also its alignment in space and its relationship to the structures next to it on all sides.  But it seems to me that pediatric specialists bring a unique perspective to the operating table.  We also have to look at things in the fourth dimension – time.

All structures change with time.  Human anatomy and physiology is by no means immune to the effects of the passing years.  But once adulthood is reached, the changes in the body are less dramatic.  A thirty year old is almost the same anatomically as her forty year old self, barring disastrous pathology.  The opposite is true with children.  Small increments of even a few months during the growth spurt can change the length, the breadth and even the shape of an anatomic structure in a child.


Consequently, when we as pediatric providers make a decision on treatment, we are not only looking at the child in the clinic on that given day.  We are also calculating the passage of time, reading the tea leaves and consulting the crystal ball to determine what that child will be like – with and without treatment – in a month, in six months, in six years and in sixty years.  Our decision is not only based on the two dimensions of an x-ray or even the three dimensions of the alignment on the clinical examination.  That fourth dimension, the effect of time, is also of paramount importance.


Tuesday, October 21, 2014

Out Of the Garden: When Scoliosis Is Not Just Scoliosis



Earlier this month, I had the privilege of presenting a talk at the Chiari and Syringomyelia Foundation regarding scoliosis other than the adolescent idiopathic variety.  It was fun and liberating to talk about all the unusual causes of the disorder, something that I rarely get to do since the idiopathic variety accounts for 90% or so of scoliosis cases.  Researching and considering the topic was also eye-opening, because it reminded me of the fact that complex causes of spinal curvature may not be as uncommon as we suppose and so-called Garden variety scoliosis may be far more complex than we imagine.

The talk is archived at this address: : http://csfinfo.org/videos/physician-lecture-videos/carolinas-chapter-physician-lectures/

Please enjoy, and as always, I welcome your comments.

Thursday, September 4, 2014

CLUBFOOT AND GLOBAL MOTOR DEVELOPMENT: SOME PRACTICAL CONSIDERATIONS

Along the lines of my Tummy Time essay comes this reflection on the treatment of clubfoot.  As I note, our understanding of clubfoot is very much under evolution.  I have tried to discuss the larger picture of childhood development with clubfoot rather than specifics of clubfoot treatment.  Please let me know your take on this and all of my posts.  ~KPM


The foot is undeniably the pedestal for human balance and ambulation.  Humans depend on the complex interaction of the many joints and ligament structures in the foot to hold up their weight, propel them forward, stop their momentum and cushion their landings.  The emphasis on proper foot function is so strong that it has fostered a billion dollar footwear and orthotics industry that governs what we wear (and don’t wear) and how we play and live.

Because of this overarching significance, great care is placed in early childhood in getting the foot to grow as “normal” as possible.  This care is especially seen in the congenital deformities of the foot, such as talipes equinovarus, also known as clubfoot.

The understanding of clubfoot continues to evolve.  Most experts no longer think that clubfoot is simply a positional abnormality from months of in utero molding.  Although a small subset may be due to extrinsic issues like multiparous conditions, breech positioning and fibroid uterus, the vast majority of clubfeet are now recognized to be a true disruption of the neural axis into the foot, probably arising from the brainstem or even the brain itself.  In other words, clubfoot is a true neuromuscular condition.

The treatment of clubfoot is evolving as well.  Not so many decades ago, the emphasis of early treatment was on loosening the ligaments up so that a child could be more easily repositioned during surgery.  Mixed long-term functional results from surgery as well as the need for non-surgical options in developing countries led to the advent of rigorous casting and bracing protocols, sometimes lasting for many months or longer.  Although there is no clear consensus that the casting techniques are the final word in treatment, nevertheless most children with clubfoot now have an extended course of casting and/or bracing.
 
The issue at hand is that clubfoot itself may pose challenges to a child’s development, even after the foot is realigned.  The treatments themselves are time-consuming and by definition happen during the period of utmost importance in the early motor development of a child.  The casts may span the first six to nine months of life, when a child is typically starting to grapple with crawling and other forms of locomotion and beginning to assay the challenge of upright stance and walking.

It is important to give special attention the motor development in these children throughout the treatment process.  There is a tendency to keep the children lying on their back throughout the treatment to “protect the casts”, but this is both unnecessary and potentially harmful. Parents need to understand not only that milestones may be somewhat delayed by the treatment, but also that they should not be passive about the child’s positioning and function during the treatment.  It is essential, despite casting to allow as much of the child’s general function to develop as possible.

There are a number of strategies which I have incorporated into my treatment protocols which hopefully will minimize the developmental effect of the casting.  First and foremost, I have tried to engage the parents in the child’s positioning as much as possible.  A lot of the early postural development need not be lost to the casting regimen.  Since the casts are typically placed with the knees bent, the all-important curving forward of the body and limbs into what is termed the flexor position need not be disturbed.  Also, the child will still be able to explore side positioning and rolling, although the parents may have to be more active in helping the child position and in clearing the casts over the other leg during rolling.

Since positioning on the baby’s stomach (prone-lying) is so important for the development of arm and hip/ pelvis position and function, I try to place the casts so that there is some active movement available in the knees.  The child should be able to bring the legs under while in the prone position and push off with the arms and hips to get the full benefit of the ground reactive force.   

Another important point is to make full use of whatever time out of the casts might be available.  In point of fact, since it is not the casting, but the interval stretching before casting that is the actual treatment, I find that these timeouts are actually very important in the regimen.  I try to encourage the parents to take full advantage of the time away from immobilization to have the child rolling and prone and to do as much facilitating as possible in the brief respites.  In the early stages of the casting, I will use a material that the parents can remove the day before the next stretching/ casting treatment.  This not only allows the parents to bathe the child thoroughly but also give an extended period of attention to motor stimulation.  I have also talked to parents about specific techniques like brushing to stimulate the child’s awareness of the feet during the periods out of the casts.  These same techniques can also be done while the child is the cast since the toes and forefoot are exposed.

An interesting technique I have incorporated recently has been cast application in a bouncy seat.  Not only does this help the child to relax during the cast application.  It also allows the child to maintain a flexor posture better than placement of the cast in the fully flat position typically used.  My hope is that the child will accommodate to the cast as part of the more natural flexor positioning.  Early results in terms of acceptance of the cast by the child and maintenance of leg function have been encouraging.

In summary, the most important point is to not allow the casting regimen to dominate the child’s function.  The parents can and should be instructed to be as active in the child’s development as they would be if the child were not casted.  And special exercises and activities should be used to take advantage of every moment that the child is freely mobile.

Monday, July 28, 2014

The Hip and Tummy Time

(Although this blog has long been devoted to pediatric spine topics, I feel like I reserve the right to branch out a little and touch on some general pediatric orthopaedic areas and maybe even on some issues in society pertaining to medicine and the care of kids.

Along these lines, I offer this essay which I wrote in regards to an early motor development program that I am helping develop.  Please let me know if the topic is of interest.  There a many more essays like this one in this feverish brain of mine. -  KPM)




There is an ancient Greek fable about a dreaded creature called the Sphinx who used to waylay travelers with a riddle.  Answer the riddle (as none did) and you could pass safely on your path.  Fail to answer and you were torn apart by the ravenous beast.  The riddle, made simple by the repetition of the years, was “What walks on four legs in the morning, two at midday and three at night?”  The answer or course is a human – crawling in infancy, walking tall in midlife and using a cane in dotage.

What makes this riddle true is the remarkable changes that occur in the structure of the child to go from a fetal ball to a walking youth and nowhere are they more evident than at the hip joint.  The hip is the only joint in the body to actually change its whole structure, positon and anatomy as it develops, and it is these changes that allow humans to eventually stand and walk on two feet in a way that no other creature can.

One of the major changes that the hip undergoes between birth and walking is the alignment and rotation.  When first born, a child has hips that are very flat with respect to the pelvis (the technical term is retroverted).  This allows the hip and legs to retract out of the way without undue stress as the child is delivered through the maternal pelvis and the birth canal.  But it means that, at first, the child cannot bring the hips in front.  We see that in the newborn alignment of the hips with the legs splayed out in what we call the frog position, bent up and rolled out.  A newborn cannot (and should not) be able to bring the hips in to the midline and care should be made in the very early days of life not to pull the legs together to swaddle since it drives the hips into an unnatural position.

Over the course of the first few months of life, the hips begin to roll forward into what is called anteversion.  Ultimately, this lets the child bring the hips straight in front and gives them the stability to start bearing weight and even to push the body forward into crawling.  Ultimately the anteversion provides the child with a secure, forward directed center of balance that will allow upright stance and walking.  Finally, as the child gets more secure and the balance and ambulation muscles develop fully, the posture becomes more upright and the hips assume their adult position.

As with all bone development, the hip realignment cannot happen in a vacuum.  Bone shape follows function, so the bone will shape and position according how it is used.  In children with neuromuscular disease who never walk or crawl, the hips stay retroverted.  If the muscle forces don’t balance during early walking (as in some types of cerebral palsy) then the hips end up too anteverted by late childhood and adulthood.

Which brings us to Tummy Time.  There was a trend through the 1980’s and early 90’s to avoid stomach lying as much as possible.  Genuine fears about protecting the child’s airway led to this well-meaning but ultimately misguided conservatism.  The prevailing feeling was that children ultimately roll over and crawl, so we will protect them until they figure out how to do those actions safely on their own.  Added to the advent of car-seats and other important safety measures, we saw a generation of kids who were essentially told to figure it out on their own.

Many did, but we did see an increase in delayed walking and in some cases the loss of important milestones, like rolling, arm push up and other actions which help develop normal patterns of gait and balance.  Although it is still early to tell, we seem to be seeing an increase in early joint problems in this protected generation.

We seem to have finally figured out that prone lying, or Tummy Time, is safe and vitally important to the development of upright function.  It promotes the awareness of weight bearing and transfer.  It leads directly to experimentation with arm and leg movements which facilitate crawl.  And ultimately, it is from the prone position that humans learn to lift up and become upright walkers.

As for the all-important hip joint, which seems to govern all of propulsion, Tummy Time provides the ground and reactive forces necessary to start the process of realignment of the joint.  The baby feels the ground below the pelvis and reacts with muscular contraction.  The muscle function starts to reshape the hips.  As the hips reshape, pulled inward and forward by the muscle function, they become stronger and better positioned to lift the body and to start forward propulsion.  And ultimately, these functional changes lead to increased strength and balance which lift the child upward into stance and walking.

The Sphinx would be so proud!

Monday, May 5, 2014

"VALUE" IN HOLLYWOOD - Notes from the Pediatric Orthopaedic Society 2014 (part 1)


I recently traveled to Hollywood for the annual meeting of the Pediatric Orthopaedic Society of North America (POSNA).  I am always bemused by LA and especially Hollywood, packed as it is with an odd mix of tourists and denizens, the former trying to snap photos of Marilyn Monroe’s footprints, the latter trying to shill lurid stories about the stars’ dwellings and demises.


The meeting was held in the same facility that hosts the Oscars, and as expected, they did their best to schmaltz it up, complete with a Red Carpet Banquet, which I missed.  It would have been fun to see what some of my colleagues came up with as Hollywood formal.

On the serious side, amidst the usual presentations about hip reconstruction and clubfoot (to operate or not, that is always the question), there were some curious trends that I noticed in the overall thought process of the group, mostly change for the better although some of it remains to be seen.  The watch cry for the whole meeting was “Value”, which is the newest in a long line of buzzwords in the medical community.  In past the issue has always been to define the word in a practical manner so that it can be measured, duplicated (and I guess hopefully rewarded).  The working definition that interlaced a lot of the conversation was the quasi-mathematical expression [Value=Outcome/Cost].  So simple – plug in the numbers and you will have the secret value score.  The problem remains as always: what are the numbers to plug in?

Cost, one would think, is an easy variable to define.  All things have a finite price after all, and there must be some way to find and report that price.  But as we all know, medical economics defies even the simplest logic.  In fact any medical occurrence has multiple prices.  There is the price for the actual treatment (brace or implant or what have you), the price for the treating doctor’s visit, the price for any hospital service, the price for anesthesia, and so on.  About the only one of those that is easy to obtain is the charge of the treating physician, and even that is complicated by the fact that the actual number may have little or nothing to do with the actual fee that a patient or an insurer pays.  Don’t even try looking for hospital or implant costs – that way lies madness.

What about outcome?  By definition, this is a non-numerical factor which wiser heads than mine have been trying to arithmetize for decades.  As such, there are complex surveys and instruments which are supposed to come up with a useable score to plug into this kind of formula.  Although some of these may work in some settings (the Harris Hip Score is elegant for simple arthritis of the hip but not so good for hip impingement), these tools are bulky and hard to implement.

The emphasis at POSNA was on bolstering awareness of the need to understand cost and outcome, so that a value can be derived.  The insurers and the government conflate value with cost alone, but the mere cutting of costs may not enhance the value of anything.  Ultimately, the goal is to bolster the value to such a degree that it overrides any effect that the cost may have.

An excellent point made was that value must be determined in communication with the patient and family, not just by some measurements on an x-ray.  Even if a hip implant lasts for 25 years, it is still not valuable if the patient is in constant pain for every day of that span.

So, finally and at long last, surgeons (and I presume all doctors) will be forced to speak to their patients before, during and after their care.  They will need to go beyond the superficial questions (“Any pain?”) and delve into complex interactions like “How has this affected your life?”, “Did the surgery match your expectations?” or the all-important “Are you satisfied with your care?”  Although these factors will be hard to quantify, they are the true measurements of value.

Monday, March 31, 2014

THOUGHTS FROM THE EAST - My visit to Korea

Last week, I had the estimable pleasure of being one of the invited speakers at a symposium on Patient Care in Spinal Surgery at SoonChunHyang University Medical Center in Seoul, Korea.  The faculty, led by Dr. B-J Shin, was made up of some of the leading orthopaedic spine experts in that country.  Despite the obvious language barrier (the talks, besides mine, were exclusively in Korean), I was able to learn a tremendous amount, not only about the art of treating spine patients but also about the nature and the character of my colleagues in this delightful and mysterious country.

This was my first visit to Asia and from first to last I found my hosts charming and welcoming.  They all seemed delighted to try out their English speaking skills, which to my great fortune were uniformly excellent.  The curious nature of the medical field is that many of the words used in talks are not translated into the native tongue, so despite the balance of the talks being in Korean, many of the words and phrases were understandable.  Combined with the tone of voice, the frequent laughter and the body language, I was able to understand the gist of almost all the lectures, although there were some in which I wish I could have gleaned the details.



The symposium ran from preoperative evaluation to postoperative and chronic pain management.  There were a number of talks on blood loss and transfusion, which is one of my special areas of interest.  I presented my work on Blood Conservation In Scoliosis Surgery which fit in very well with the overall scope of the conference.  The audience asked me a number of insightful questions and the whole interchange made it clear that my message had been delivered.  In fact, the talk was well enough appreciated that I was 'hi-jacked' by Dr. K-Y Ha, another prominent spine professor, to give Grand Rounds the next morning at another University Hospital, Seoul St. Mary's for the orthopaedic residents.  Despite being Saturday morning and my talk again being in the non-native language, I only put two of the residents to sleep, which is an excellent ratio.




After a whirlwind city tour of the magnificent and exotic city - think New York skyscrapers mixed with Buddhist shrines and ancient palaces - I spent the final day in the city observing the surgery of Korea's preeminent deformity specialist, Dr. C-S Lee.  I was impressed by his flair and elegance as well as the fascinating process that had gone into the development of his technique.  As with all my other hosts, he was friendly and welcoming and genuinely interested in my thoughts on everything from his screw placement and curve reduction to the skating of Yu Na Kim (I agree with him and his whole country that she was cheated out of Olympic Gold, but that is a conversation for another time).

Dr. C-S Lee and me

I was thoroughly enchanted by my visit to Korea.  I was treated with fantastic courtesy and amazing hospitality.  But more importantly, I was impressed by the dedication and the skill of the spine community in that country.  I hope that I can continue to interchange ideas and to learn from them and I certainly hope that my future includes another visit.