Bruce S. Miller M.D., M.S. guests on “5 questions with CJSM”

November 25, 2013 by sportingjim

Thanksgiving Day is near and, on a personal note, my twin children celebrate their tenth birthday this week. But here in Columbus, all celebrations fade in the face of “Hate Week.”

No it’s not something out of Orwell’s 1984. It’s what my fellow citizens of this fair city call this week when their beloved Ohio State Buckeyes (OSU) play their northern rivals, the Michigan Wolverines (U of M), in their annual college football game. It’s one of the oldest rivalries in the sport.

Having grown up in Grand Rapids, Michigan, with family members and multiple friends all attending the University of Michigan, I’m something of a Judas here in Columbus. My paycheck comes from OSU and I even received my MPH from the school, but in the words of the Beatles, those things “Can’t Buy Me Love.” My sporting allegiances will stay maize and blue regardless of the fact that I will surrounded by a sea of scarlet and grey (and hatred) this week.

I thought it high time then to track down one of my dearest friends and have him answer ‘5 questions with CJSM.’ I need help from a fellow supporter of the Wolverines.

Dr. Bruce Miller is an Associate Professor in the Department of Orthopaedics at the University of Michigan, and is a Team Physician for the U of M football team as well as USA Rugby. He publishes regularly, with a particular focus on rotator cuff pathology. His accomplishments are legion (including being an All-American in rugby when he was in college), but I know him best as the man with whom I studied helminths back in medical school. From worms to one of the premier positions in sports medicine, my how far he has come.

Here is what he had to say in answer to the questions we posed him:

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1) CJSM: You are a busy orthopaedic surgeon and team physician, how did you get involved in clinical research?

At the beginning of my academic career, I was doing more basic science research, primarily focusing on articular cartilage and some biomechanical interests. However, I soon learned that the world of basic science can be quite “competitive”, especially in terms of securing funding. I recognized that as a busy clinician, I was at a competitive disadvantage in competing with full-time scientists. In addition, I enjoyed following my patients functional outcomes after surgery. I eventually came to the realization that I could be more successful in pursuing clinical research in the sense that my established clinical practice could serve as my “laboratory” . . . I simply needed to acquire some new research skills. I was fortunate that the University of Michigan School of Public Health offered a Masters program for clinicians, which allowed me to gain a new skill set while allowing me to continue with my clinical practice. I attended classes four days every month for roughly 18 months, and ultimately earned a Masters Degree in Clinical Research Design and Statistical Analysis. Through this program I gained a valuable skill set that allowed me to launch a successful clinical research program.

2) CJSM: We understand your research is focused on clinical outcomes in sports medicine surgery. Can you briefly describe the specifics or what you are looking into (maybe talk about the registry you’ve developed here, any specific clinical outcome measures you use, etc.)

The primary focus of my research program is in rotator cuff disease. As common as rotator cuff tears are (most people will have one in their lifetime), there is surprisingly very little high-quality evidence to guide the clinician in the management of this disorder. I am following a large cohort of patients with known rotator cuff tears in a “pragmatic” clinical trial in order to help determine treatment allocation (indications for operative versus non-operative management) and functional outcome after treatment. We use a number of patient-reported outcome measures, but I favor the Western Ontario Rotator Cuff Index as my primary outcome measure for most research questions regarding functional outcome.

3) CJSM: You are a team physician for the U of M football team. You have to compose a 140 character tweet on twitter to share your experience of being the team doc for U of M. What does it say?

Dr. Miller: It is a great privilege to be a part of this storied football program and to work with a world-class team of ATCs in providing care for this group of elite athletes – GO BLUE!

(CJSM: Um, Dr. Miller, you’re 35 characters long on that one. How about, “GO BLUE!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!” ?)

4) CJSM: We’ve heard you speak at conferences about the differences between outcomes that are ‘statistically significant’ and those that are ‘clinically significant’ What measures do you use in your research to distinguish between those concepts?

Dr. Miller: Great question! One of my pet peeves in reading our literature is the blind assumption that if something is statistically significant it must be true and/or important. Not true! I think it is important that we all get more familiar with evidence-based medicine and the concept of the “minimal clinically important difference” or MCID. In short, the MCID is the smallest difference or change in health status that a patient would consider meaningful. A study could report a statistically significant difference after an intervention, but if that difference is so small that it is clinically meaningless to a patient, then we should think twice about adopting the intervention. Many of our validated outcome scores now have established MCIDs –authors should be held accountable for reporting both the clinical and the statistical relevance of their work.

5) CJSM: You are a team physician for USA rugby as well as U of M football. What do you find to be the chief differences in those two roles?

Dr. Miller: Let’s start with the similarities. In both roles, I have the opportunity to work together with skilled and experienced ATCs and PTs to help manage the medical needs of a group of elite athletes. As Team Physician for USA Rugby, the venue for competition is often international. As much as I enjoy international travel, providing medical care in a foreign country certainly poses a unique set of challenges, including language barriers and occasionally different styles of medical management. I am working together with a PT and ATC, but as the only physician I wear many medical “hats” – in addition to musculoskeletal injuries, I am expected to manage all medical issues that might arise, including, coughs, colds, skin conditions, concussions, etc. Providing medical coverage at an international rugby match is a thrill. Unlike American football, the play often continues in the face of an injury, so I have free range to enter the field and evaluate and manage injuries during live play. In a recent competition, I wore my GPS watch and logged in nearly 2 miles during a single match! In addition, I am in direct radio communication with the coaching staff as we need to make quick decisions and clear communications regarding an injured player’s disposition.

My role as Head Orthopaedic Team Physician for University of Michigan Football is quite different. The player roster is significantly larger than rugby, as is the medical staff – in addition to a veteran ATC staff, we also have an internal medicine physician and even a neurologist on board. In this role, I focus exclusively on the diagnosis and management of musculoskeletal injuries. The patterns of injuries between the two sports are roughly similar, which facilitates my ability to make the quick “game time” decisions that are necessary in this role. Supporting University of Michigan football is a year-round job, as the athletes have significant commitments to training before, during, and after the season. This allows for greater “continuity of care” of our athletes. A unique aspect of this role is the opportunity to observe an injury as it occurs, evaluate the injury in the acute setting, and then provide definitive (often surgical) care. It is a remarkably rewarding professional experience to have the opportunity to perform a surgical procedure and then guide an elite athlete through rehabilitation and ultimately back to competition.

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Thanks Bruce, you covered a lot in 5 questions! Good luck at ‘The Game,’ and to everyone in the blog world, Happy Thanksgiving!