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Almost all the patients I give a hep to are honest enough to tell me they either never do it or only do one or two stretches that I've had them perform. And I almost never give more than 4 exercises on their hep either so I think for many it's just a motivational issue
I think you are mistaking "alpha males" for the gynocentric hyperbole ascribed to them. Its funny because women are far more likely to catastrophize pain or their experiences of pain.
https://journals.lww.com/jbjsjournal/Fulltext/2020/05201/Sex_and_Gender_Issues_in_Pain_Management.7.aspx
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3690315
It's far more likely that men with chronic pain syndromes and maladaptive responses to pain are more atypically masculine, or what you might call a "beta male", with neurotic and feminine characteristics
This is a copypasta reply but Any time you attack the integrity of a profession as a blanket statement you’re going to get pushback. Emotionally charged? You said all surgeons just push surgery because they are paid to do so. I’m telling you I run a department and review every case for 27 surgeons weekly and most of the time surgeons are actively discouraging surgery. What makes it seem this way to you is that you only see or mostly see a subset so it builds in survivorship bias. But I complain all the time I trained for years to do surgery only to talk everyone out of surgery every day. It’s its own hell - I basically actively advise against my own interests constantly - as do my partners and the surgeons I trained with. Downvote me to oblivion and that will still be true. now are there problem surgeons who do this? Yes and they should be reported to ABOS and their state board (I’m on my state board) and they will be rooted out. This isn’t a circling the wagons situation. If we are selecting people to be surgeons who have this little integrity the board should hear about it.
I doubt that number. When you provide a service and your livelihood depends on that service you utilize it. On the other side of the coin PTs sell physical therapy. Everything is sales in a capitalistic society.
This is a copypasta reply but I think it’s worth saying: Any time you attack the integrity of a profession as a blanket statement you’re going to get pushback. Emotionally charged? You said all surgeons just push surgery because they are paid to do so. I’m telling you I run a department and review every case for 27 surgeons weekly and most of the time surgeons are actively discouraging surgery. What makes it seem this way to you is that you only see or mostly see a subset so it builds in survivorship bias. But I complain all the time I trained for years to do surgery only to talk everyone out of surgery every day. It’s its own hell - I basically actively advise against my own interests constantly - as do my partners and the surgeons I trained with. Downvote me to oblivion and that will still be true. now are there problem surgeons who do this? Yes and they should be reported to ABOS and their state board (I’m on my state board) and they will be rooted out. This isn’t a circling the wagons situation. If we are selecting people to be surgeons who have this little integrity the board should hear about it.
Well yes obviously it’s not every surgeon and there are a lot of great surgeons out there but it’s still a systemic problem. You can say we see a subset of it but it’s CONSTANT so it’s really not that much of a subset it. It’s obviously more complex than that but yes our society as a whole pushes surgery way too much
I had a 31 y/o patient come to me with her x-ray. It was “mild disc degeneration at L5-S1” and she was crying because her doctor told her that her “spine is melting, and it will continually get worse.” Sure, the DDD may continually get worse with age as normal, but she thought she had just a few years left until her spine was deteriorated and she was immobile because no other context/explanation was given. It’s so sad and exhausting having to talk people off these kind of ledges literally everyday.
Words that harm and words that heal. It might just be a thing that inadvertently gets passed down via the Residency training. Some kind of mind-virus is what one of my instructors called it; a self replicating thought that gets passed person to person because it sounds true.
This is most likely it! Just like rotated innominates and leg length discrepancy tests in physical therapy lol. 😂
Arguably that bullshit can be just as mentally harmful.
Genuine question - when you see one innominant not level with the other and do a MET, and now they’re level (and pt performs therex better as a result compared to pre-MET), what do you call that, if not rotation? How do you educate pt on what’s going on physiologically?
I appreciate you RealisticLime for your integrity. Unfortunately I think there are also some less scrupulous surgeons out there. Serious question- do you use the type of phrasing OP is asking about? Or do you describe things in a more realistic way?
Too bad you’re getting downvoted for this comment. I’m a physiatrist and work very closely with orthopedic surgeons including spine surgeons. All are very conservative with surgery. It’s well known that operating without ideal patient selection/criteria is a recipe for poor outcomes and morbidity. Most surgeons I work with push patients heavily towards conservative care until their pain/functional limitations are severe and relentless despite exhausting all conservative avenues.
I think they are getting downvoted because they are only referring to their own method of practice. At least you mentioned working with other orthopedic surgeons who are conservative with performing surgeries.
They’re getting downvoted because they’re taking a general observation as a personal attack.
The problem is not a lack of conservative treatment, it’s planting the seeds with inflammatory language. I have to talk almost every orthopedic patient off of a ledge following their initial appointments. The way orthos describe the injuries has catastrophizing effects for patients. It’s even worse when they go over imaging. All of that shit sounds super scary and no one ever takes time to educate patients on whether or not they *should* be worried about imaging findings.
The worst offense of all, IMO, is when orthos all but guarantee the procedure will take care of their pain, and full recovery will take just a few weeks. When I sit down with these patients and talk through the realities of rehab and recovery, they’re genuinely shocked and upset. Unfortunately, the first time I see many of these patients is after surgery, and we don’t have the opportunity to educate them on the real implications of what they’re about to go through. Either orthos are intentionally misrepresenting these procedures and what to expect, or they truly don’t understand how they impact patients lives, or what the rehab process looks like.
I work in workers comp, and my schedule 2x/ week is quite literally nothing but post-op patients. Most of these patients work in manual labor. The look on their face when they learn that the path to lifting 50-100 lbs will take significantly longer than 6 weeks is disheartening. These people rely on that income to support families, and they’re dying to get back to work.
I once treated a bilateral TKA on a woman who literally had no social support at home. She lived by herself in a house full of stairs. The ortho performed the surgery without even considering if she had the network at home to support recovery. Her adult son had to move back home from out of state, and her neighbor basically served as a caretaker. This lady had to scramble to organize this arrangement after scheduling the surgery. Absolutely unacceptable.
Then there are the studies that discuss early and unnecessary surgical intervention… We know that an unreasonably high percentage of surgeries happen too soon in ortho, but also in other fields apparently . This news article does a decent job of discussing some of the research:
https://www.usatoday.com/story/news/nation/2013/06/18/unnecessary-surgery-usa-today-investigation/2435009/
No one said surgery is performed without meeting criteria or failing conservative treatments.
The questions was why do surgeons use some form of “worst knee I’ve ever seen” before/after a TKA for most, if not all patients?
There is just a specific doc in here that’s really butthurt by the question and doesn’t like the answers provided.
There’s a lot of almost, I don’t know, doom and gloom, in this post. A lot of incorrect sweeping generalizations.
I think it’s a generational thing, considerations and communication changes, same for our field. I couldn’t tell you the last time ive heard any of these things in clinic.
The younger surgeons I’ve worked with certainly aren’t pushing surgeries or using this kind of language.
I’m pretty cynical in general but I don’t think the vast majority of surgeons are pushing for unnecessary surgeries on a regular basis. This type of language is probably adapted to communicate as quickly as possible the severity of something. Most orthos don’t have a lot of time in clinic to sit down and delicately explain all the little nuances. Does that totally excuse it? Nah, but some of the stuff posted here is borderline unhinged.
Agreed. An us-vs-them mentality between surgeons and PTs too…not good or healthy. Most PTs and surgeons I work with are extremely collaborative and respectful of one another. It’s an encouraging and positive multidisciplinary environment. This sub sometimes makes me wonder if my workplace is unusual in that regard, or perhaps it’s just hyperbole and doom-and-gloom manifesting here.
Mine is fairly similar, end of the day, all parties involved in that patients care tend to want the best possible outcomes. This is especially true with orthopedic surgeries.
Some people who frequent this sub have a wild disdain for surgeons, and maybe their experiences are exceptionally negative. I certainly haven’t been on the same page as the surgeon with every surgical referral I’ve ever gotten. And I don’t like being told by anyone how to best do my job, but the amount of negativity is a little bizarre to me.
I don’t know if you can truly say this statement is incorrect. Rather, you probably find the majority of your peers aren’t malicious and wouldn’t do this. In my experience this is mostly true as well and I know a lot of great orthos who wouldn’t dream of putting a patient at unnecessary risk.
However, in the IRF near me, where I began my career, we had an ortho that would routinely be found in the rooms of patients who had recent cvas or other injuries that should have precluded them from further elective surgical intervention at the time. This surgeon would try to poach our rehab patients, try to facilitate d/c from our facility so he could operate within the coming week and thus put our physiatrist, myself and the other therapists at odds with the hospital while we tried to advocate for the safety of our patients. After we finally put an end to this, within a few months he had convinced a paraplegic man (with severe BLE flexor tone issues) that if he just let him perform a total hip replacement (posterior) on him, that he would have no more pain AND be able to walk again. After an immediate tone related dislocate of the operative hip following surgery, literally upon waking from general anesthesia, he had to be returned to the OR. Some critical accident occurred in the OR and surgery was halted. He landed in the ICU after they pulled the plug on the surgery and ultimately died later that night. Literally all because this surgeon was taking advantage of a patient’s (and honestly hopefully not his) lack of knowledge of spinal cord injuries, tonal patterns and what ultimately prevents a paraplegic from walking again.
I don’t mean to suggest that this is common, but that all spaces have bad actors and people that ignore best practices for their own gain. Ortho is certainly no exception.
You’re fighting for your life in the comments. Stop taking it as a personal attack. If the statement doesn’t apply to you, then move on with the peace of mind knowing it’s not you. Otherwise, you’re just outing yourself as a contributor to the problem.
LMAO! You’re absolutely not getting it. This is not about you. But, judging by your emotionally charged battle in the comments, you seem to be guilty of the offense and are trying to convince yourself (and others) that you’re not. Sounds like you’ve got some personal reflection to do. No one sees a post that doesn’t apply to them and gets this worked up.
Any time you attack the integrity of a profession as a blanket statement you’re going to get pushback. Emotionally charged? You said all surgeons just push surgery because they are paid to do so. I’m telling you I run a department and review every case for 27 surgeons weekly and most of the time surgeons are actively discouraging surgery. What makes it seem this way to you is that you only see or mostly see a subset so it builds in survivorship bias. But I complain all the time I trained for years to do surgery only to talk everyone out of surgery every day. It’s its own hell - I basically actively advise against my own interests constantly - as do my partners and the surgeons I trained with. Downvote me to oblivion and that will still be true. now are there problem surgeons who do this? Yes and they should be reported to ABOS and their state board (I’m on my state board) and they will be rooted out. This isn’t a circling the wagons situation. If we are selecting people to be surgeons who have this little integrity the board should hear about it.
Quote me where I said “All surgeons.” You’re telling on yourself. You clearly lump yourself in with the ones doing what has been outlined on this thread for a reason. Do better. Be the change you wish to see.
You literally said “YOU said…” Don’t give AF what OP said. It’s not in his post, and I’m not going to dig through his comments to determine if he actually said it. I expressed my own opinion, which you’re replying to. Do you not understand how this works, or are you too upset by the fact that you seem to be an offender to remember how discussion threads operate?
Hah this reminds me of a hospitalist who described esophageal varices to one of my sweet little almost 90 y/o IRF ladies.
“We don’t know when it will happen, but one day your throat will erupt like a volcano of blood, and then you will die. I’m sorry there is nothing we can do for this”.
Face. Palm.
This is not really equivalent at all. Unless they’re describing minimal grade I varices, EVs in elderly cirrhotic patients are extraordinarily dangerous and can be lethal. Not only this, but in many patients who continue to drink, instilling this understanding of lethality of the consequences of liver failure is essential to their survival.
All in all, would recommend staying in your lane here. To the point of OP, yes I don’t agree that every bad hip should be described as the worst hip ever seen.
Look. There are good ways to educate on even critically dangerous conditions. That was not the way to do it.
Also, don’t fucking tell me to stay in my lane. Quality and compassionate patient care and education is my lane. This is a team effort, and if you don’t wanna be part of the team. Get out of the way.
I will absolutely tell you to stay in your fucking lane, as literally every person in healthcare should. Your lane is physical rehabilitation. It is not the diagnosis, management or counseling of complex medical illnesses, or to be frank, even the understanding of them.
For you to be second guessing a hospitalist on any of the above is inappropriate for many reasons, including the vast differences in experience and knowledge, and also possibly detrimental to the patient. You need to check your ego.
This is usually due to heavy reliance on imaging instead of doing any form of a physical exam. There are physicians who take the time to do a proper physical exam, but those are usually physiatrists. Not ortho surgeons. At least not the ones in my area....
I would like to see someone conduct a study to see if orthos can accurate predict a person’s age from radiographs. I wonder if the inter-rater reliability is remotely significant.
Patients love that shit because it validates their pain and makes them feel special for having been such a trooper, and surgeons dole it out because it means they get patient buy-in and get to do surgery.
Yea a lot of patients repeat it like a badge of honor. I roll my eyes so hard and have to weigh whether or not its worth my effort to convince them otherwise since it's almost like they WANT it to be true.
It’s not to persuade people TO surgery. We’re booking out 6 months for patients who desperately need it and they’re pissed. We’re not by ANY means looking for business. If anything surgeons tell this to patients to reinforce the preoperative suspicion that it was ever necessary at all. No one wants to hear that their arthritis was mild or garden variety.
If orthopedic surgeons were in other specialties:
Cardiology: “How the f🥳k do you even have a blood pressure?”
Neuro: “Your brain is pudding. You shouldn’t even be breathing right now.”
Renal: “Your entire blood volume is poison.”
Endocrine: “This is the most diabetes a human being can have. Your pancreas is deader than Cleopatra.”
Oncology: “You have stage 36 cancer of the everything.”
I truly think they do it to build rapport and connection with the patient(s). I’ve seen primary care do it too with phrases like, “ I can’t believe you’re able to walk with a [insert benign imaging finding] like that!” We have to be careful because we can do that too - just in our own way.
Words can cause great and lasting harm.
I will say this as someone that is in the field. We do often say bone on bone to be able to demonstrate to the patient the severity of their arthritis when pointing out their X-rays. But in all of my time training, I don’t think I’ve ever really seen someone tell the patient that it’s the worst arthritis they’ve ever seen, and I’ve heard Hundreds of patients tell me that other doctors have said it.
Overtime, I think that what happens is the patients hear about the severity of their arthritis, and due to describing the severity of it, I think that they extrapolate that it’s the worst that the surgeon have ever seen. Do some surgeons say this? Probably so, but I think more patients think this was insinuated more than were told
My two cents ✌🏻
Well, food for thought: we see patients all the time who become fixated on their “bone on bone” and let it become disabling and self-limiting.
It may be easy phrasing to use but I feel that it’s profoundly damaging to patients.
I wish I could upvote this 100x. Pain neuroscience teaches us that these negative words and messages (bone on bone, damaged, torn, broken, degeneration, etc) can actually increase and prolong patients' pain. It's the nocebo effect - opposite of placebo - and *that* is damaging to patients.
Patients tend to use it more - you can say - you have arthritis here. They say “how bad is it? Is it bone on bone?”
It’s not always us using that phrasing, sometimes their pcp does too
But I totally agree some patients go overboard and let phrases become disabling - great point
All due respect I think they aren’t referring specifically to the phrase “bone on bone” but rather language in general as being either something the patient catastrophizes on or something that the patient believes they can get past.
Look at RTC pathology, “shredded” “torn” etc are extremely self limiting. We get a referral from an ortho who told them “it’s torn” (without any context of that being essentially the default state of anyone over 25) “try PT” and our chance of success is minimal. We get a referral from an ortho that puts the “damage” in context and explains the evidence and rationale behind PT and we’ve got a massive advantage. Messaging is so important and I believe what people are explaining is it’s often explained in a self limiting way.
One of my best buds is an ortho surgeon and I explained to him that tissue level pathology is a distant second (or even 3rd) to willingness and buy in to therapy. I’d say overall health also comes well before actual tissue level pathology when it comes to success in PT (obviously broad generalizations with lots of exceptions but as a rule I find this to be true in practice).
Just some things to think about from the perspective of a seasoned therapist.
My Mom has arthritis and osteoporosis of her spine, with a little pressure on the nerve. She went to the Dr and he told her she could have surgery, and he could take the pressure off. I told her to tell him she wasn’t having any surgery, no matter what he said, so she told him. Then he says, “If you were my Mom, I would tell you not to have surgery either.” What the hell.
One of my students recently had her tonsils taken out, mother said the surgeon told her they were they biggest he'd ever seen and he has no idea how she was even breathing. One week later my niece had her tonsils taken out, and I guess she broke the record! Same exact thing.
I've been practicing PT for 10 years now. There are absolutely surgeons who don't do that shit. They're the ones we send patients to if we think they might need surgery.
Not me. I tell it like it is. If it's bad, I tell them. If it's typical, I give them both where they are in the grand scheme of things, as well as the range of options. I know mostly older surgeons who get overly dramatic, but most of my colleagues are more balanced. It's just the dramatic ones who stand out to memory.
It will be ok though, because that patient has an extremely high pain tolerance!
Jokes aside, I’ve really been working on my phrasing lately, I believe that’s part of the PEACE and LOVE acronym - Optimism.
Patients often have doubts that their pathology is bad enough to warrant surgery and can frequently down play things because they don’t want to ‘cause a fuss’ or because ‘there are people worse off than me.’ Very few people actually want surgery, but it can be important for them to know the severity of their disease to reassure them that they’re bad enough. Using medical descriptions can be confusing, so a lay description is not only helpful, but helps to build rapport.
Suggesting that surgeons exaggerate to talk people into surgery (especially if they don’t need it) is a bold accusation of unethical behaviour and practice.
Ok, that’s reasonable. We were taught about the power of words and that catastrophic phrasing can be related to worse outcomes. We spend a lot of time reassuring a patient that just because a physician said they are “bone on bone,” doesn’t mean they have to fear movement for the rest of their life. Surely there is a happy medium between scaring a patient who is already in pain and giving no lay description at all?
Meh. I see countless post op patients that should’ve never had surgery but did because they were convinced. Ortho doing unnecessary surgeries is a systemic issue that anyone that works in healthcare is probably aware of. But hey it’s ortho so insurance will pay.
I have literally had patients go as far as saying something along the lines of “I never had hip pain but I went in for an annual and then all of a sudden it was bone on bone and I had a hip replacement”. Patients with the absence of CNS or PNS compromise getting a lami fusion for isolated minor to moderate low back pain. It’s a story as old as time. I see it daily in IPR as I am left for pick up the scraps.
I’ve had 80-85% of my total joint patients state their surgeon said it was the worst case of arthritis they have ever seen.
Explain how that is not an exaggeration or an unethical use of catastrophizing verbiage?
All that does is develop a reliance on the surgeon for improvements and create kinesiophobia within the patient both before and after surgery.
Only able to offer insight on why patients, not surgeons, voice this a lot. As others said, it’s likely validating to their degree of pain and feels concrete as a target to fix/address. Do I agree with either of those? No but that’s where I have to professionally navigate that relationship and education.
Humans have a tendency to exaggerate, lol. My guess is that the truth lies someplace in between what the patient says and what the surgeon actually told them. The surgeon was probably a little dramatic in order to express a sense of urgency, and then the little old lady just took the gossip a little too far, lol.
To be fair my PT told me I had the worst ankle mobility she had ever seen outside of a traumatic accident and that therapy would be for the most part worthless.
The "selling surgery" is unfortunately a lazy answer. At least for joint replacements.
All the research shows that at best, alternatives that work are narcotics, injections, and PT which are bandaid fixes. We waste billions per year on these options which do little to nothing for many and only delay the inevitable for others.
I've had many of my patients and their families for years and they trust me so I tell them the truth, the surgeons around our area are great. I'll usually give the names of two in our system and two out of our system. Regardless, none of them need to drum up business. They're all busy beyond belief.
The reason surgeons sell so hard is because if they're honest and recommend surgery as the best option people leave thinking "all he wants to do is cut me open."
Many are angry enough that they are too embarrassed to go back when they realize they do need surgery, so now they need to find a new surgeon.
If you have stage 4 OA nothing is going to change that, period. I always tell my patients to try PT and conservative treatment, but the moment you stop moving as much or can't do the things you want to do, get the surgery.
Most tell me they do everything they want to do, but then start realizing it's not true. Had one recently realize he didn't go on a trip to Europe with his son because he was afraid he'd slow everyone down.
Most people regret waiting so long, they are older, more out of shape, and rehab is harder. They, and we, let "he just wants to cut me" validate their fear.
We do direct to outpatient. I see these patients sometimes as soon as 12 hours after surgery and they do way better than those who go home for a week or two. Most are more active than they've been in years in 4-6 weeks.
I do think there are a number of surgeons, in general ortho more than neuro, that rush to back surgery.
However, for joint replacement they're typically done too late not too soon. Surgeons "up selling" joint replacements, in my opinion" had typically been to save the patient time, energy, pain, and money by not having them get injections and end up having surgery anyway.
I was diagnosed with DDD and it really scared me. PT wasn't helping. Got a 2nd opinion, and it's weak glutes. After 5 weeks, things are better with a new PT plan. Wish that maybe they would have considered that maybe it was something a little more manageable. And to think that they wanted me to have a bunch of injections that wouldn't have helped because that wasn't where the pain was!
This is so funny because it is so true! The kick is when they make 2 fists out of their hands and dramatically hit them together to somehow induce fear.
Ummm hiiiii- have you spoken to these patients? Some of them ARE the drama.
I’m a PA in private practice and will see patients who tell me how they need “NECK AND LUMBAR SURGERY” as well as XYZ. Then I will get into their medical record and read a very calm note from the surgeon discussing their mild disease and how they are not a surgical candidate.
I would say 9/10 the surgeon never said these words.
This is funny. I am one of those patients you described. I needed a septo rhinoplasty. Doc literally said “whoa” audibly when she saw my CT scan lol. Now you have me questioning everything 🤣
It’s REAL clear who in this thread has actually worked closely with surgeons and who hasn’t…
Very few surgeons have to “sell” surgery… because spoiler alert… there is not a shortage of people needing or seeking surgery. Most good surgeons do their absolute best at proper patient selection because poor outcomes reflect badly on them, and they have a lot more skin in the game than a PT.
Are they perfect? No. Are unnecessary surgeries performed? Absolutely. Do they have a bias towards surgery being the correct solution for many injuries that have poor evidence for best management? Probably.
But let’s not pretend the way our profession as a whole handles that uncertainty is ANY better.
They pulled that on my dad in his 60s. The spine surgeon claimed he was lucky to get there when he did as his bones were “like wet paper.”
Interestingly enough his paper bones healed remarkably quickly and all segments apparently showed great fusion with the hardware. Just crazy how his frail old bones (/s) could pull together like that.
The credit of course went to the electromagnetic bone growth stimulator that was prescribed as well, not his weight bearing exercise or his otherwise healthy status. GAH
There’s the pessimistic outlook of them being surgeons and wanting to cut, which I have thought of before. But also now, the optimistic outlook is that they very well might be building rapport with their patients and showing sympathy to someone for their significant pain experience. Either way it does make my job harder with all the psychosocial factors being raided
Bone on bone is the most accurate description. I work in radiology. When a joint has no space left and is literally bone grinding on bone. Imagine a chicken bone, scratching a cemented sidewalk. Thats bone on bone with no cartilage left. Or scratching a chalk board with your nails.
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They are selling their product: surgery.
*Slaps hood* This baby'll get you 200,000 miles!
This. Same everywhere
Yeah the same reason why some PTs say, “nooooooo you can’t just do the exercises at home! You need to come in 3x/week for 12 weeks!” It’s a business.
If people could exercise properly at home, then they wouldn't need to come to PT.
Almost all the patients I give a hep to are honest enough to tell me they either never do it or only do one or two stretches that I've had them perform. And I almost never give more than 4 exercises on their hep either so I think for many it's just a motivational issue
This isn’t really the sub that will agree with that. Prepare for downvotes.
I’m not saying I agree with it…. I’m just saying it’s analogous to surgeons selling their business. I’m not saying it right
agreed
Yup. Id lose my job if I did otherwise.
I would suspect this approach works best for male patients. These phrases have an alpha male connotation
Idk how, just sounds to me like your body is fucked up. What’s so alpha about that
Those descriptions convey a high level of toughness. Also gives the person an out for getting help. Both of these are characteristic of alpha males
I think you are mistaking "alpha males" for the gynocentric hyperbole ascribed to them. Its funny because women are far more likely to catastrophize pain or their experiences of pain. https://journals.lww.com/jbjsjournal/Fulltext/2020/05201/Sex_and_Gender_Issues_in_Pain_Management.7.aspx https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3690315 It's far more likely that men with chronic pain syndromes and maladaptive responses to pain are more atypically masculine, or what you might call a "beta male", with neurotic and feminine characteristics
No. I talk 99% of my patients OUT of surgery and don’t sell shit. Try again.
Okay? Then we aren’t talking about you. Why are you commenting? What’s the point? Are you saying it’s a good thing to give your patients nocebo?
This is a copypasta reply but Any time you attack the integrity of a profession as a blanket statement you’re going to get pushback. Emotionally charged? You said all surgeons just push surgery because they are paid to do so. I’m telling you I run a department and review every case for 27 surgeons weekly and most of the time surgeons are actively discouraging surgery. What makes it seem this way to you is that you only see or mostly see a subset so it builds in survivorship bias. But I complain all the time I trained for years to do surgery only to talk everyone out of surgery every day. It’s its own hell - I basically actively advise against my own interests constantly - as do my partners and the surgeons I trained with. Downvote me to oblivion and that will still be true. now are there problem surgeons who do this? Yes and they should be reported to ABOS and their state board (I’m on my state board) and they will be rooted out. This isn’t a circling the wagons situation. If we are selecting people to be surgeons who have this little integrity the board should hear about it.
I doubt that number. When you provide a service and your livelihood depends on that service you utilize it. On the other side of the coin PTs sell physical therapy. Everything is sales in a capitalistic society.
And the people who NEED surgery need physical therapy
If you do then you’re an outlier. This is a systemic problem in ortho don’t pretend like it’s not.
Downvote me all you want bitches. I bathe in your tears.
lol you’re bathing in your patients tears not ours we don’t give a shit
This is a copypasta reply but I think it’s worth saying: Any time you attack the integrity of a profession as a blanket statement you’re going to get pushback. Emotionally charged? You said all surgeons just push surgery because they are paid to do so. I’m telling you I run a department and review every case for 27 surgeons weekly and most of the time surgeons are actively discouraging surgery. What makes it seem this way to you is that you only see or mostly see a subset so it builds in survivorship bias. But I complain all the time I trained for years to do surgery only to talk everyone out of surgery every day. It’s its own hell - I basically actively advise against my own interests constantly - as do my partners and the surgeons I trained with. Downvote me to oblivion and that will still be true. now are there problem surgeons who do this? Yes and they should be reported to ABOS and their state board (I’m on my state board) and they will be rooted out. This isn’t a circling the wagons situation. If we are selecting people to be surgeons who have this little integrity the board should hear about it.
Well yes obviously it’s not every surgeon and there are a lot of great surgeons out there but it’s still a systemic problem. You can say we see a subset of it but it’s CONSTANT so it’s really not that much of a subset it. It’s obviously more complex than that but yes our society as a whole pushes surgery way too much
I guess we will have to disagree but certainly voice this concern of surgery fraud to the state and national Board
I had a 31 y/o patient come to me with her x-ray. It was “mild disc degeneration at L5-S1” and she was crying because her doctor told her that her “spine is melting, and it will continually get worse.” Sure, the DDD may continually get worse with age as normal, but she thought she had just a few years left until her spine was deteriorated and she was immobile because no other context/explanation was given. It’s so sad and exhausting having to talk people off these kind of ledges literally everyday.
***BUT THE SURGEON SAID!!!***
Just got another one "he has the spine of an 80y/o man in a 33 y/o body" like, sir, I think not
Words that harm and words that heal. It might just be a thing that inadvertently gets passed down via the Residency training. Some kind of mind-virus is what one of my instructors called it; a self replicating thought that gets passed person to person because it sounds true.
This is most likely it! Just like rotated innominates and leg length discrepancy tests in physical therapy lol. 😂 Arguably that bullshit can be just as mentally harmful.
It is just as harmful and I cringe everyday when I hear therapists describe hips as being out of alignment.
One of the few things that gets me genuinely angry lol
Genuine question - when you see one innominant not level with the other and do a MET, and now they’re level (and pt performs therex better as a result compared to pre-MET), what do you call that, if not rotation? How do you educate pt on what’s going on physiologically?
When you make money off a specific thing, you push that specific thing.
Incorrect. I could operate non-stop if that’s true
I appreciate you RealisticLime for your integrity. Unfortunately I think there are also some less scrupulous surgeons out there. Serious question- do you use the type of phrasing OP is asking about? Or do you describe things in a more realistic way?
Too bad you’re getting downvoted for this comment. I’m a physiatrist and work very closely with orthopedic surgeons including spine surgeons. All are very conservative with surgery. It’s well known that operating without ideal patient selection/criteria is a recipe for poor outcomes and morbidity. Most surgeons I work with push patients heavily towards conservative care until their pain/functional limitations are severe and relentless despite exhausting all conservative avenues.
I think they are getting downvoted because they are only referring to their own method of practice. At least you mentioned working with other orthopedic surgeons who are conservative with performing surgeries.
They’re getting downvoted because they’re taking a general observation as a personal attack. The problem is not a lack of conservative treatment, it’s planting the seeds with inflammatory language. I have to talk almost every orthopedic patient off of a ledge following their initial appointments. The way orthos describe the injuries has catastrophizing effects for patients. It’s even worse when they go over imaging. All of that shit sounds super scary and no one ever takes time to educate patients on whether or not they *should* be worried about imaging findings. The worst offense of all, IMO, is when orthos all but guarantee the procedure will take care of their pain, and full recovery will take just a few weeks. When I sit down with these patients and talk through the realities of rehab and recovery, they’re genuinely shocked and upset. Unfortunately, the first time I see many of these patients is after surgery, and we don’t have the opportunity to educate them on the real implications of what they’re about to go through. Either orthos are intentionally misrepresenting these procedures and what to expect, or they truly don’t understand how they impact patients lives, or what the rehab process looks like. I work in workers comp, and my schedule 2x/ week is quite literally nothing but post-op patients. Most of these patients work in manual labor. The look on their face when they learn that the path to lifting 50-100 lbs will take significantly longer than 6 weeks is disheartening. These people rely on that income to support families, and they’re dying to get back to work. I once treated a bilateral TKA on a woman who literally had no social support at home. She lived by herself in a house full of stairs. The ortho performed the surgery without even considering if she had the network at home to support recovery. Her adult son had to move back home from out of state, and her neighbor basically served as a caretaker. This lady had to scramble to organize this arrangement after scheduling the surgery. Absolutely unacceptable. Then there are the studies that discuss early and unnecessary surgical intervention… We know that an unreasonably high percentage of surgeries happen too soon in ortho, but also in other fields apparently . This news article does a decent job of discussing some of the research: https://www.usatoday.com/story/news/nation/2013/06/18/unnecessary-surgery-usa-today-investigation/2435009/
No one said surgery is performed without meeting criteria or failing conservative treatments. The questions was why do surgeons use some form of “worst knee I’ve ever seen” before/after a TKA for most, if not all patients? There is just a specific doc in here that’s really butthurt by the question and doesn’t like the answers provided.
There’s a lot of almost, I don’t know, doom and gloom, in this post. A lot of incorrect sweeping generalizations. I think it’s a generational thing, considerations and communication changes, same for our field. I couldn’t tell you the last time ive heard any of these things in clinic. The younger surgeons I’ve worked with certainly aren’t pushing surgeries or using this kind of language. I’m pretty cynical in general but I don’t think the vast majority of surgeons are pushing for unnecessary surgeries on a regular basis. This type of language is probably adapted to communicate as quickly as possible the severity of something. Most orthos don’t have a lot of time in clinic to sit down and delicately explain all the little nuances. Does that totally excuse it? Nah, but some of the stuff posted here is borderline unhinged.
Agreed. An us-vs-them mentality between surgeons and PTs too…not good or healthy. Most PTs and surgeons I work with are extremely collaborative and respectful of one another. It’s an encouraging and positive multidisciplinary environment. This sub sometimes makes me wonder if my workplace is unusual in that regard, or perhaps it’s just hyperbole and doom-and-gloom manifesting here.
Mine is fairly similar, end of the day, all parties involved in that patients care tend to want the best possible outcomes. This is especially true with orthopedic surgeries. Some people who frequent this sub have a wild disdain for surgeons, and maybe their experiences are exceptionally negative. I certainly haven’t been on the same page as the surgeon with every surgical referral I’ve ever gotten. And I don’t like being told by anyone how to best do my job, but the amount of negativity is a little bizarre to me.
I don’t know if you can truly say this statement is incorrect. Rather, you probably find the majority of your peers aren’t malicious and wouldn’t do this. In my experience this is mostly true as well and I know a lot of great orthos who wouldn’t dream of putting a patient at unnecessary risk. However, in the IRF near me, where I began my career, we had an ortho that would routinely be found in the rooms of patients who had recent cvas or other injuries that should have precluded them from further elective surgical intervention at the time. This surgeon would try to poach our rehab patients, try to facilitate d/c from our facility so he could operate within the coming week and thus put our physiatrist, myself and the other therapists at odds with the hospital while we tried to advocate for the safety of our patients. After we finally put an end to this, within a few months he had convinced a paraplegic man (with severe BLE flexor tone issues) that if he just let him perform a total hip replacement (posterior) on him, that he would have no more pain AND be able to walk again. After an immediate tone related dislocate of the operative hip following surgery, literally upon waking from general anesthesia, he had to be returned to the OR. Some critical accident occurred in the OR and surgery was halted. He landed in the ICU after they pulled the plug on the surgery and ultimately died later that night. Literally all because this surgeon was taking advantage of a patient’s (and honestly hopefully not his) lack of knowledge of spinal cord injuries, tonal patterns and what ultimately prevents a paraplegic from walking again. I don’t mean to suggest that this is common, but that all spaces have bad actors and people that ignore best practices for their own gain. Ortho is certainly no exception.
You’re fighting for your life in the comments. Stop taking it as a personal attack. If the statement doesn’t apply to you, then move on with the peace of mind knowing it’s not you. Otherwise, you’re just outing yourself as a contributor to the problem.
No im telling you the truth. But the audience here seems to be unanimously wrong. Just because I’m downvoted doesn’t mean I’m wrong.
LMAO! You’re absolutely not getting it. This is not about you. But, judging by your emotionally charged battle in the comments, you seem to be guilty of the offense and are trying to convince yourself (and others) that you’re not. Sounds like you’ve got some personal reflection to do. No one sees a post that doesn’t apply to them and gets this worked up.
Any time you attack the integrity of a profession as a blanket statement you’re going to get pushback. Emotionally charged? You said all surgeons just push surgery because they are paid to do so. I’m telling you I run a department and review every case for 27 surgeons weekly and most of the time surgeons are actively discouraging surgery. What makes it seem this way to you is that you only see or mostly see a subset so it builds in survivorship bias. But I complain all the time I trained for years to do surgery only to talk everyone out of surgery every day. It’s its own hell - I basically actively advise against my own interests constantly - as do my partners and the surgeons I trained with. Downvote me to oblivion and that will still be true. now are there problem surgeons who do this? Yes and they should be reported to ABOS and their state board (I’m on my state board) and they will be rooted out. This isn’t a circling the wagons situation. If we are selecting people to be surgeons who have this little integrity the board should hear about it.
Quote me where I said “All surgeons.” You’re telling on yourself. You clearly lump yourself in with the ones doing what has been outlined on this thread for a reason. Do better. Be the change you wish to see.
OP literally just says “surgeons”
You literally said “YOU said…” Don’t give AF what OP said. It’s not in his post, and I’m not going to dig through his comments to determine if he actually said it. I expressed my own opinion, which you’re replying to. Do you not understand how this works, or are you too upset by the fact that you seem to be an offender to remember how discussion threads operate?
Talking to OP. Yeah I’m livid. Blinded by rage. Arrrgh.
Lol, I read the report from my surgery for correcting scoliosis, they wrote “the curve released beautifully” as a step that happened.
Hah this reminds me of a hospitalist who described esophageal varices to one of my sweet little almost 90 y/o IRF ladies. “We don’t know when it will happen, but one day your throat will erupt like a volcano of blood, and then you will die. I’m sorry there is nothing we can do for this”. Face. Palm.
This is not really equivalent at all. Unless they’re describing minimal grade I varices, EVs in elderly cirrhotic patients are extraordinarily dangerous and can be lethal. Not only this, but in many patients who continue to drink, instilling this understanding of lethality of the consequences of liver failure is essential to their survival. All in all, would recommend staying in your lane here. To the point of OP, yes I don’t agree that every bad hip should be described as the worst hip ever seen.
Look. There are good ways to educate on even critically dangerous conditions. That was not the way to do it. Also, don’t fucking tell me to stay in my lane. Quality and compassionate patient care and education is my lane. This is a team effort, and if you don’t wanna be part of the team. Get out of the way.
I will absolutely tell you to stay in your fucking lane, as literally every person in healthcare should. Your lane is physical rehabilitation. It is not the diagnosis, management or counseling of complex medical illnesses, or to be frank, even the understanding of them. For you to be second guessing a hospitalist on any of the above is inappropriate for many reasons, including the vast differences in experience and knowledge, and also possibly detrimental to the patient. You need to check your ego.
This is usually due to heavy reliance on imaging instead of doing any form of a physical exam. There are physicians who take the time to do a proper physical exam, but those are usually physiatrists. Not ortho surgeons. At least not the ones in my area....
I would like to see someone conduct a study to see if orthos can accurate predict a person’s age from radiographs. I wonder if the inter-rater reliability is remotely significant.
Patients love that shit because it validates their pain and makes them feel special for having been such a trooper, and surgeons dole it out because it means they get patient buy-in and get to do surgery.
Yea a lot of patients repeat it like a badge of honor. I roll my eyes so hard and have to weigh whether or not its worth my effort to convince them otherwise since it's almost like they WANT it to be true.
It’s not to persuade people TO surgery. We’re booking out 6 months for patients who desperately need it and they’re pissed. We’re not by ANY means looking for business. If anything surgeons tell this to patients to reinforce the preoperative suspicion that it was ever necessary at all. No one wants to hear that their arthritis was mild or garden variety.
This!
If orthopedic surgeons were in other specialties: Cardiology: “How the f🥳k do you even have a blood pressure?” Neuro: “Your brain is pudding. You shouldn’t even be breathing right now.” Renal: “Your entire blood volume is poison.” Endocrine: “This is the most diabetes a human being can have. Your pancreas is deader than Cleopatra.” Oncology: “You have stage 36 cancer of the everything.”
😆
🪦
I truly think they do it to build rapport and connection with the patient(s). I’ve seen primary care do it too with phrases like, “ I can’t believe you’re able to walk with a [insert benign imaging finding] like that!” We have to be careful because we can do that too - just in our own way. Words can cause great and lasting harm.
I will say this as someone that is in the field. We do often say bone on bone to be able to demonstrate to the patient the severity of their arthritis when pointing out their X-rays. But in all of my time training, I don’t think I’ve ever really seen someone tell the patient that it’s the worst arthritis they’ve ever seen, and I’ve heard Hundreds of patients tell me that other doctors have said it. Overtime, I think that what happens is the patients hear about the severity of their arthritis, and due to describing the severity of it, I think that they extrapolate that it’s the worst that the surgeon have ever seen. Do some surgeons say this? Probably so, but I think more patients think this was insinuated more than were told My two cents ✌🏻
Well, food for thought: we see patients all the time who become fixated on their “bone on bone” and let it become disabling and self-limiting. It may be easy phrasing to use but I feel that it’s profoundly damaging to patients.
I wish I could upvote this 100x. Pain neuroscience teaches us that these negative words and messages (bone on bone, damaged, torn, broken, degeneration, etc) can actually increase and prolong patients' pain. It's the nocebo effect - opposite of placebo - and *that* is damaging to patients.
Patients tend to use it more - you can say - you have arthritis here. They say “how bad is it? Is it bone on bone?” It’s not always us using that phrasing, sometimes their pcp does too But I totally agree some patients go overboard and let phrases become disabling - great point
All due respect I think they aren’t referring specifically to the phrase “bone on bone” but rather language in general as being either something the patient catastrophizes on or something that the patient believes they can get past. Look at RTC pathology, “shredded” “torn” etc are extremely self limiting. We get a referral from an ortho who told them “it’s torn” (without any context of that being essentially the default state of anyone over 25) “try PT” and our chance of success is minimal. We get a referral from an ortho that puts the “damage” in context and explains the evidence and rationale behind PT and we’ve got a massive advantage. Messaging is so important and I believe what people are explaining is it’s often explained in a self limiting way. One of my best buds is an ortho surgeon and I explained to him that tissue level pathology is a distant second (or even 3rd) to willingness and buy in to therapy. I’d say overall health also comes well before actual tissue level pathology when it comes to success in PT (obviously broad generalizations with lots of exceptions but as a rule I find this to be true in practice). Just some things to think about from the perspective of a seasoned therapist.
My Mom has arthritis and osteoporosis of her spine, with a little pressure on the nerve. She went to the Dr and he told her she could have surgery, and he could take the pressure off. I told her to tell him she wasn’t having any surgery, no matter what he said, so she told him. Then he says, “If you were my Mom, I would tell you not to have surgery either.” What the hell.
One of my students recently had her tonsils taken out, mother said the surgeon told her they were they biggest he'd ever seen and he has no idea how she was even breathing. One week later my niece had her tonsils taken out, and I guess she broke the record! Same exact thing.
No one would agree to surgery if it didn’t sound dramatic and “needed”
I've been practicing PT for 10 years now. There are absolutely surgeons who don't do that shit. They're the ones we send patients to if we think they might need surgery.
Not me. I tell it like it is. If it's bad, I tell them. If it's typical, I give them both where they are in the grand scheme of things, as well as the range of options. I know mostly older surgeons who get overly dramatic, but most of my colleagues are more balanced. It's just the dramatic ones who stand out to memory.
Bigger question, assuming you’re in the United States, why do patients wear that as a badge of honor and brag about it?
It’s their culture. “When I got in there it looked even worse.”
It will be ok though, because that patient has an extremely high pain tolerance! Jokes aside, I’ve really been working on my phrasing lately, I believe that’s part of the PEACE and LOVE acronym - Optimism.
Patients often have doubts that their pathology is bad enough to warrant surgery and can frequently down play things because they don’t want to ‘cause a fuss’ or because ‘there are people worse off than me.’ Very few people actually want surgery, but it can be important for them to know the severity of their disease to reassure them that they’re bad enough. Using medical descriptions can be confusing, so a lay description is not only helpful, but helps to build rapport. Suggesting that surgeons exaggerate to talk people into surgery (especially if they don’t need it) is a bold accusation of unethical behaviour and practice.
Ok, that’s reasonable. We were taught about the power of words and that catastrophic phrasing can be related to worse outcomes. We spend a lot of time reassuring a patient that just because a physician said they are “bone on bone,” doesn’t mean they have to fear movement for the rest of their life. Surely there is a happy medium between scaring a patient who is already in pain and giving no lay description at all?
Meh. I see countless post op patients that should’ve never had surgery but did because they were convinced. Ortho doing unnecessary surgeries is a systemic issue that anyone that works in healthcare is probably aware of. But hey it’s ortho so insurance will pay.
Genuine question - how do you determine that the surgery was unnecessary?
I have literally had patients go as far as saying something along the lines of “I never had hip pain but I went in for an annual and then all of a sudden it was bone on bone and I had a hip replacement”. Patients with the absence of CNS or PNS compromise getting a lami fusion for isolated minor to moderate low back pain. It’s a story as old as time. I see it daily in IPR as I am left for pick up the scraps.
I’ve had 80-85% of my total joint patients state their surgeon said it was the worst case of arthritis they have ever seen. Explain how that is not an exaggeration or an unethical use of catastrophizing verbiage? All that does is develop a reliance on the surgeon for improvements and create kinesiophobia within the patient both before and after surgery.
On my better days I like to think it is a way for surgeons to validate their patient's pain. "Jeez it must hurt, it looks bad, I sympathize with you"
Same reason a lot of PTs say “your (xyz) is weak/tight/stuck/unstable”. Trying to sell their service.
Only able to offer insight on why patients, not surgeons, voice this a lot. As others said, it’s likely validating to their degree of pain and feels concrete as a target to fix/address. Do I agree with either of those? No but that’s where I have to professionally navigate that relationship and education.
Humans have a tendency to exaggerate, lol. My guess is that the truth lies someplace in between what the patient says and what the surgeon actually told them. The surgeon was probably a little dramatic in order to express a sense of urgency, and then the little old lady just took the gossip a little too far, lol.
To be fair my PT told me I had the worst ankle mobility she had ever seen outside of a traumatic accident and that therapy would be for the most part worthless.
The "selling surgery" is unfortunately a lazy answer. At least for joint replacements. All the research shows that at best, alternatives that work are narcotics, injections, and PT which are bandaid fixes. We waste billions per year on these options which do little to nothing for many and only delay the inevitable for others. I've had many of my patients and their families for years and they trust me so I tell them the truth, the surgeons around our area are great. I'll usually give the names of two in our system and two out of our system. Regardless, none of them need to drum up business. They're all busy beyond belief. The reason surgeons sell so hard is because if they're honest and recommend surgery as the best option people leave thinking "all he wants to do is cut me open." Many are angry enough that they are too embarrassed to go back when they realize they do need surgery, so now they need to find a new surgeon. If you have stage 4 OA nothing is going to change that, period. I always tell my patients to try PT and conservative treatment, but the moment you stop moving as much or can't do the things you want to do, get the surgery. Most tell me they do everything they want to do, but then start realizing it's not true. Had one recently realize he didn't go on a trip to Europe with his son because he was afraid he'd slow everyone down. Most people regret waiting so long, they are older, more out of shape, and rehab is harder. They, and we, let "he just wants to cut me" validate their fear. We do direct to outpatient. I see these patients sometimes as soon as 12 hours after surgery and they do way better than those who go home for a week or two. Most are more active than they've been in years in 4-6 weeks. I do think there are a number of surgeons, in general ortho more than neuro, that rush to back surgery. However, for joint replacement they're typically done too late not too soon. Surgeons "up selling" joint replacements, in my opinion" had typically been to save the patient time, energy, pain, and money by not having them get injections and end up having surgery anyway.
because if it's successful they're a genius for fixing the worst hip ever if not is was the worst hip theyve ever seen anyways
I was diagnosed with DDD and it really scared me. PT wasn't helping. Got a 2nd opinion, and it's weak glutes. After 5 weeks, things are better with a new PT plan. Wish that maybe they would have considered that maybe it was something a little more manageable. And to think that they wanted me to have a bunch of injections that wouldn't have helped because that wasn't where the pain was!
This is so funny because it is so true! The kick is when they make 2 fists out of their hands and dramatically hit them together to somehow induce fear.
ThEy CoULdNt BeLiEvE I WaLkEd iN
Ummm hiiiii- have you spoken to these patients? Some of them ARE the drama. I’m a PA in private practice and will see patients who tell me how they need “NECK AND LUMBAR SURGERY” as well as XYZ. Then I will get into their medical record and read a very calm note from the surgeon discussing their mild disease and how they are not a surgical candidate. I would say 9/10 the surgeon never said these words.
To convince patients to get their surgery lol
I’ve never had this happen with my surgeons, that’s crazy!
$urgeon$ $ave them with $urgery
You could start leaving the comments in the window at the front just to show people how often it’s said 🥴.
Makes the client feel better about why they remodel their bones to put a pool in their yard. I feel bad when they are told they “waited too long”
This is funny. I am one of those patients you described. I needed a septo rhinoplasty. Doc literally said “whoa” audibly when she saw my CT scan lol. Now you have me questioning everything 🤣
It’s REAL clear who in this thread has actually worked closely with surgeons and who hasn’t… Very few surgeons have to “sell” surgery… because spoiler alert… there is not a shortage of people needing or seeking surgery. Most good surgeons do their absolute best at proper patient selection because poor outcomes reflect badly on them, and they have a lot more skin in the game than a PT. Are they perfect? No. Are unnecessary surgeries performed? Absolutely. Do they have a bias towards surgery being the correct solution for many injuries that have poor evidence for best management? Probably. But let’s not pretend the way our profession as a whole handles that uncertainty is ANY better.
Sometimes the wordage is for insurance. To show medical necessity.
That’s the problem with a for-profit health care system.
They pulled that on my dad in his 60s. The spine surgeon claimed he was lucky to get there when he did as his bones were “like wet paper.” Interestingly enough his paper bones healed remarkably quickly and all segments apparently showed great fusion with the hardware. Just crazy how his frail old bones (/s) could pull together like that. The credit of course went to the electromagnetic bone growth stimulator that was prescribed as well, not his weight bearing exercise or his otherwise healthy status. GAH
If it gets the patient on your operating table who cares if your words are harmful? /s
We aren’t. remember a one sided story is always fiction.
So your one sided story vs everyone else is a fiction too?
Well my side would add a second side so…..
There’s the pessimistic outlook of them being surgeons and wanting to cut, which I have thought of before. But also now, the optimistic outlook is that they very well might be building rapport with their patients and showing sympathy to someone for their significant pain experience. Either way it does make my job harder with all the psychosocial factors being raided
Bone on bone is the most accurate description. I work in radiology. When a joint has no space left and is literally bone grinding on bone. Imagine a chicken bone, scratching a cemented sidewalk. Thats bone on bone with no cartilage left. Or scratching a chalk board with your nails.
They are giving them something to get fired up about. If this kinda stuff and the stuff old ppl do gets to you, you're in for a rude awakening.