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InSpine 3-10 Volume 6 The International Journal for Spine Care Professionals

The growing business of

medical tourism ISSN 1662-3282

Kenneth Kamler



Tondo interactive table Focus 20 Posterior atlanto-axial dislocation without dens fracture Soft wool for hard bones Technology 34 How to solve problems creatively At Work 42




Imprint All rights reserved. Any reproduction, whole or in part, without the publisher’s written consent is prohibited. Great care has been taken to maintain the accuracy of the information contained in this publication. However, the publisher, and/or the distributor and/or the editors, and/ or the authors cannot be held responsible for errors or any consequences arising from the use of the information contained in this publication. Some of the products, names, instruments, treatments, logos, designs, etc. referred to in this publication are also protected by patents and trademarks or by other intellectual property protection laws (eg, “AO”, “ASIF”, “AO/ ASIF”, “AOSpine”, “InSpine”, “TRIANGLE/GLOBE Logo” are registered trademarks) even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name, instrument, etc. without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

Editor-in-Chief Michael E Janssen, USA Managing Editor Chi N Lam, USA Deputy Editors Michael Dittmar, Mexico Michael Daubs, USA Editorial Committee Chi N Lam Monroe Levine Urs Rüetschi Jane Wiedler Michael Fawcett Copyright © 2010 by AOSpine Stettbachstrasse 6 8600 Dübendorf Switzerland Contact InSpine is published four times per year.

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InSpine | Volume 6 | Issue 3


Michael E Janssen, DO

Table of contents 5

OPINION Spine surgeons today: too many meetings, too little time

6 10

PINBOARD COVER STORY Medical tourism: seeking treatment anywhere


PROFILE Kenneth Kamler



A world without borders “Global” seems to be the new buzzword of the day. Even healthcare—traditionally a local or regional enterprise— now competes on an international level. Patients who require specialized care like spine surgery are looking more and more outside their homeland for medical treatment—cost savings is just one of many reasons. That’s why in this issue of InSpine we examine some of the emerging trends in medical tourism and the motivating factors that have spawned this new, global industry (p 10).

Tondo interactive table


CENTERPOINT Harbourview Hospital, Seattle


CASE REPORT Posterior atlanto-axial dislocation without dens fracture

29 30

WHAT NOT TO DO RESEARCH Cervical nucleoplasty using coblation technology


FOCUS How true are medical dramas?


TECHNOLOGY Soft wool for strong bones


AT WORK Can your practice RAP?


EXCELLENCE Creative problem solving. Thinking your way ahead





Cultural boundaries have also become more blurred nowadays. In the earlier days of medical dramas, TV series such as “M*A*S*H” were created in a fictitious setting. Today’s medical dramas, however, are of a different caliber. Worldwide syndicated shows like “House” or “Grey’s Anatomy” portray the behavior of doctors, nurses, and their patients in such realistic settings, that many viewers may have trouble drawing the line between reality and fiction. Several studies investigate this phenomenon, we give a brief overview on page 32. On a more practical note, we discovered a new and rather unknown method to organize powerful, productive meetings as they happen in every medical practice. How the Reflective Adaptive Process (RAP) works and can be put to best use is explained on page 38. And as surgeons have to tackle all kinds of problems every day—not just medical ones—we include a hands-on guide to “creative problem solving” in this issue (p 42).

Enjoy this issue!

Comments to the editorial board:


Tondo Ž interactive table: enabling collaboration and efficiency in clinical audits Identifying the cause of medical errors, both human and systemic, requires collaboration and openness as well as the efficient sourcing, retrieval, and analysis of clinical data. In reality, defensiveness and inefficiency often block the path to clarity and understanding. To help remove these barriers, Italian graduate student Valeria Donati created TondoŽ, an interactive table with a user-friendly interface that helps clinicians and administrators get to the root of medical mistakes so they don’t happen again.

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InSpine | Volume 6 | Issue 3

Every year in the United States alone an estimated 98,000 patient deaths can be attributed to medical error thus making clinical audits that accurately identify and help to rectify the root cause of these mistakes more essential than ever. [1] Yet the fears and insecurities of clinicians and administrators who par ticipate in the auditing process often make for results that are anything but clear cut and conclusive. Communication, not confrontation This unfortunate reality became evident to Valeria Donati, 30, a graduate student in Interaction Design at IUAV University of Venice while she was conducting research at a local hospital in order to identify a suitable topic for her thesis.

“I came to understand that medical mistakes are like an epidemic and that many people die from every year,” she recalls. With the encouragement of hospital staf f, she read up on the issue in medical journals, magazines, and PowerPoint presentations, and she recognized that negative interpersonal behavior during clinical audits often exacerbated the investigation. “I interviewed doctors, facilitators, and clinical auditors and they all said that defensiveness during audits is a really big problem because participants start to fight,” Valeria says.

“Tondo® aims to analyze the whole medical history of a person and to plan concretely how to avoid errors in the future.”

Her solution to the problem—and the subject of her thesis project—is Tondo ® [‘round’ in Italian], an interactive table that helps to take confrontation out of communication during the auditing process so that par ticipants can concentrate on the task at hand.

Valeria Donati, Interactive Designer “Tondo”

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Tondo ® interactive table Error form



Il!documento!delle!analisi!clinichè!stato disegnato!con!caratteri!troppo!piccoli.


Electrical recordings

Casi!simili Paziente:!! Martina!Albertin!! Reparto:!! Ortopedia Errore:!! ! Misdiagnosi





Paziente:!! Luca!Scanu Reparto:!! Chirurgia Errore:!! ! Misdiagnosi



Radiology exams


956789083 956789083 8


Surgical reports
























ERROR ARCHIVE ICONS Large, easy-to-use icons on Tondo’s® interface provide for the immediate retrieval of a patient’s medical data for a detailed analysis of how, when, and why a diagnosis or treatment went wrong.

INTERACTION Tondo’s® tabletop screen allows clinicians and administrators to closely analyze every detail of a patient’s hospital stay, including medical reports, x-rays, blood tests, and ECGs. If an error has occurred, it can be seen and studied onscreen whereas in conventional audits this data, as well as the means to view it, may not be readily available.

Clinical audit results are filed in an error archive stored in Tondo’s® internal memory. These results can be quickly retrieved, viewed on the tabletop screen, and edited using a touch-sensitive keyboard. In the above fictional case example, the misdiagnosis of two patients was attributed to illegible clinical analysis data.

DOCUMENTATION Date-specific retrieval of patient case files, medical reports, x-rays, and blood and other tests.

Efficient retrieval of medical data The table’s round shape and the fact that Valeria has designed a user-friendly interface that enables tabletop visuals and typography to be legible from all sides encourages a sense of equality among participants.

Tondo’s® illuminated surface features a rotating ‘timeline’ that allows for date-specific retrieval of patient case files, medical reports, x-rays, and blood and other tests so that the details of a patient’s diagnosis and day-to-day treatment can be clearly seen, reconstructed, and reviewed.

Tondo’s® intuitive features are disarmingly playful and easy to use, contributing to a collaborative approach of investigation, discovery, and analysis. Large, round, touch-sensitive icons function to retrieve, open, and copy documents that with simple hand gestures can be distributed, rotated, magnified or minimized for better viewing. A finger can be used like a pen to ‘draw’ on an image and the drawing is simultaneously transferred to everyone else’s display.

This visual approach together with the quick and easy access to all medical data makes for a far superior identification and analysis of what and who went wrong than is possible from studying excel spreadsheets, which was the conventional auditing method that Valeria observed being used.

“The visuals are very moveable,” Valeria explains, “so while the facilitator still has the main control of the situation and chooses which documents to open and who can speak, everyone can see everything that’s on the screen.”

Tondo® also has an internal memory where case notes are stored in an ‘error archive’ so that case reconstructions, conclusions and recommendations can be retrieved for future reference.

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InSpine | Volume 6 | Issue 3

“With this new approach you can see the error on screen, its not just on paper or verbal, so everything is more clear,” Valeria explains.

Test groups approve Valeria developed Tondo® with scientific support from the Clinical Risk Center of Tuscany, which provided regular feedback to ensure the prototype corresponded to a medical setting and met the requirements of a clinical audit. An emphasis on round shapes in the table’s design was evidently the right choice. Test groups have found that Tondo’s® shape contributes to a more open, relaxed, and collaborative ambience and that its features are so intuitive and easy to use that participants require almost no training.

In healthcare, also designers can contribute to saving lives, a great reward for any young person. Professor Gillian Crampton Smith, IUAV University, Venice

On many fronts Tondo® holds great promise and makes a strong case for greater involvement by designers in the areas of medical and healthcare devices. “The knowledge that designers have (information design, interaction design, service design) is not often applied to the design of systems or equipment in hospitals, though there are notable exceptions,” says Professor Gillian Crampton Smith, co-director of the Interaction Design programme at IUAV University of Venice, who supervised Valeria’s thesis project. She believes that designers can offer healthcare: “logical design that makes errors difficult or impossible and that eases the cognitive load for people using complex machinery (eg, surgeons).” Valeria concurs with this assessment. “The medical field has to be really technical, but clinicians need more intuitive interfaces to work with because the existing interfaces are always designed by engineers. A designer without an engineer can’t do anything, but I think that the opposite is also true.” Crampton Smith agrees that at the moment, Valeria’s interest in designing for the healthcare sector may be the exception to the rule among young interaction designers, but she thinks this could change. “This is a field where designers can contribute to saving lives, which is a great reward for any young person. And problems in medical design are complex, which is challenging and enjoyable.”

“Corri! corri!” Valeria attributes her interest in healthcare to the three years she spent working as a radiology assistant at a hospital in Rome, her hometown, before she began her studies in design some six years ago. Having now graduated cum laude from her Masters program in Interaction Design, Valeria is in the early days of an internship with Siemens Corporate Research in Princeton, New Jersey. “It’s perfect, really challenging, and interesting,” she reports.

In among her professional obligations she needs to find time to complete the Tondo® prototype and to consider the various offers from commercial developers that are quickly coming her way. “I’m trying to understand what could be the next best step,” she says, sounding just a bit under pressure, which is probably not unusual for her. “My personal ‘aka’ is “corri! corri!” meaning “run! run!” because since starting my studies I’ve had to run a lot,” she says with a laugh. She agrees this could be taken as an indication of having found her true vocation. “I think I’m on the right way,” she says. “I would like to go ahead with interaction design for medical and healthcare devices. I want to do something to improve the quality of people’s lives.” References [1] L Toni Lewis, MD, President, Committee of Interns and Residents, December 2, 2008

Web resources To see Tondo® in operation go to:

Valeria Donati Valeria Donati, 30, is a native of Rome, Italy. She studied product and graphic design at Universidade Lusiada in Lisbon for one year, followed by three years at La Sapienza University of Rome where in 2007 she earned a Bachelor’s degree in industrial design. In 2008, she and her team won first prize in the mobile category of the Adobe Design Achievement Awards for their project “What’s Cooking?” She has completed internships at Studio Ruggieri Poggi in Rome, and at Prospect Design in London, England. In 2010, Valeria graduated cum laude with a Masters degree in Visual and Multimedia Design, specializing in Interaction Design, from IUAV University of Venice. She is currently working as interaction design intern at Siemens Corporate Research in Princeton, New Jersey. Her strengths are idea generation, problem solving, and graphic and video development, and she is now discovering her interest in strategic thinking. She can be reached at

Science 23

Tondo article on InSpine medical magazine  
Tondo article on InSpine medical magazine  

An article from an interview I made in june 2010 about my Thesis project Tondo.