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New Technology? This past weekend, I went to a patient screening event at Western University with some of my students. We periodically have interprofessional “open houses” at the clinical center on campus, as a means to generate increased business and serve the community in a meaningful way. I’ve always enjoyed attending screenings, even when I was in private practice, and more so now that I’m teaching. I enjoy interacting with patients, but now I have the added dimension of having students along. For our preclinical students, these are some of the first true patient contacts they have. In addition to our examinations, we also bring the clinic’s pressure mat sensing system. Demonstrations of cool technology like this is always a very popular part of our screening events, but during this past Saturday, I had to ask myself, “When should we use this new technology in podiatric medicine and surgery?”
Patient 1 - Making the Diagnosis
One of our screening patients was a 50 year old lady complaining of pain in her right first intermetatarsal space for about 3 months. During her examination, I elicited pain plantar and just distal to the 2nd metatarsal head with no edema and a negative modified Lachman’s test(also known as the vertical stress test) of the 2nd MTP joint. Additionally, I found a structural hallux limitus bordering on rigidus. She was suffering from a 2nd MTP joint predislocation syndrome secondary to her hallux limitus. When she stepped on the pressure sensing mat, I was unsurprised to find increased pressure under her 2nd metatarsal head and very little pressure under the 1st metatarsal head. The scan managed to confirm exactly what I’d found on my examination. Is There Value in Confirming the Diagnosis? Now, here’s my conundrum. I’m usually pretty opinionated about things and tend to fall squarely on one side of a debate or the other. But in this case, I’m of two minds. Although the pressure scan confirmed what I was already thinking, the patient found it very informative. It also reaffirmed in a very clear and concrete way what I’d already told the patient. From an educational as well as marketing standpoint, this technology was a home run! So, although the technology wasn’t strictly necessary from a diagnostic standpoint, it did come in very useful for overall care. The other side of the argument is this. Wasn’t I using the pressure mat sensing system the same way we’re taught to use any laboratory test or imaging study, as a confirmatory test to my clinical judgment? If that’s the case, one could only argue against use of this technology from an overutilization standpoint. Patient 2 - Performing the Treatment
I contrast the use of this technology with that used on a different patient. A second patient complained to me about a painful verruca plantaris on her right heel. She’d tried a few over the counter medications and then went to a dermatologist who used a laser to remove the wart. Unfortunately, her wart had recurred. My issue here is with the use of lasers for wart removal. I know it’s common to use various types of lasers to remove warts on the foot, but I’m not convinced they work better than electrocautery and curettage. I see the use of laser as more of a marketing tool to show how high tech your practice is. After a quick search of the Cochrane database as well as Medline, I was unable to find any quality studies that show laser has better outcomes than conventional therapies. In fact, a recent study by Togsverd-Bo and colleagues found no difference between pulsed dye laser and paring alone for verruca plantaris, after a head-to-head prospective randomized controlled trial.1 Similarly, Robinson, et al. compared pulsed dye laser with cantharidin or liquid nitrogen in a randomized controlled trail, and similarly, they found pulsed dye laser was not superior to conventional therapy.2 If the mechanism of laser therapy is selective destruction of dermal capillaries in the papillary layer and thermal damage to the HPV particles themselves, then why not use electrocautery? Does the newer technology have a place in treating this entity? I’m not convinced. New Technology that is Clearly Superior In the majority of new technologies, a void is filled and a need satisfied. Compression screws have replaced Kirschner wires (in most cases). Digital radiography is replacing conventional radiographs. In some cases, though, technology is not necessarily better than its precursor. It’s our job as clinicians to rigorously test the merits of all new technologies. We can then feel free to allow those new technologies to flourish and move our profession forward. Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum. Best wishes.
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