Kent Hagan MD

Physician. Physiatrist. Sports Medicine. Finance and Business of Medicine. Twitter and medicine should be fun. Tweets and opinions are my own.

[Dr. Longissimus @DrLongissimus]

MSK ultrasound is all fun until you realize that abnormal is an itty bitty different shade of gray compared to normal and normal can be an itty bitty different between people and that abnormal on MSK MRI is usually 🚨🚨🚨➡️

[Ramp Capital @RampCapitalLLC]

When someone with no kids working less than 40 hours a week tells me they have stress, debt, and trouble sleeping at night

[White Coat Investor @WCInvestor]

What Order to Fund Your Investing Accounts 👇

It's difficult to dictate an exact order that will be appropriate for everyone, but there are some general guidelines that most agree on.

1. Obtain any available employer match. Missing out on this is leaving part of your salary on the table.

2. Eliminate high-interest rate (8%+) debt. This risk-free “investment” provides a guaranteed return that you will need to take significant risk to beat.

3. Fund a Health Savings Account (HSA) if a High Deductible Health Plan is right for you.

4. Fund all available retirement accounts. This includes 401(k)s, 403(b)s, Individual 401(k)s, profit-sharing plans, SEP-IRAs, SIMPLE IRAs, Backdoor Roth IRAs etc. Remember you may be able to have multiple 401(k)s. Fund the tax-free (Roth) ones first unless you are in your peak earnings years and don't expect to be able to max out both tax-deferred and tax-free accounts for the year.

5. Consider 457b and other deferred compensation plans, if available.

6. Consider a defined benefit/cash balance plan.

7. Pay off moderate interest rate debt (4-8%).

8. Invest in a taxable account in high expected return investments.

9. Pay off low interest rate debt (<4%).

10. Invest in a taxable account in low expected return investments.

[Howard Luks MD @hjluks]

Orthopedic Truths #4
The ACL:
The ACL is important for some people to remain active.
Others tolerate its loss very well.
ACL tears are too common in sports.
ACL tear prevention programs exist... they work, yet community/ school sports don't utilize them.
ACL tears are more common in athletes participating in the same sport year-round.

ACL surgery, despite years of research and practice, remains an imperfect solution to a complex problem.
Do all ACL tears require surgery?
No
But yours might.
Your child should probably have it.
It's the secondary injuries we worry about.
What about adults?
Many do fine without ACL surgery.
Some don't.
But it often pays to wait and see.
Everyone's knee feels unstable initially.
Very often, that stability improves with time and physical therapy.
Therefore, for adults, you might want to wait before booking that surgery date.
Why is the surgery an imperfect solution?
Because the native ACL isn't a straight, single-diameter structure, but our reconstruction is.
Secondary injuries can include meniscus tears and cartilage injuries.
Those will increase the risk of developing arthritis.
The history of reconstruction is wild... and somewhat circular.
Back in the 80's and 90's we argued about which graft worked well.
We still have those arguments.
Now, we added the quad tendon graft to the argument.
Would I take hamstrings from a sprinting athlete... no, not really.
Am I a quad enthusiast? Not yet.
When the MOON group announces their data, then I might.
But it took 20 years for that to come out for hamstrings vs BTB.
BTB remains the gold standard... and will for a while.
But we tried Goretex.
We tried other things, too.
Those didn't end well.
Oh. We have this scope thing. Let’s keep reconstruction via one tunnel. Evolution be damned.
The ACL has had the same femoral footprint (attachment) for millions of years. But heck.
Let’s put that tunnel here.
It worked for some... but many failed.
We tried to repair them, but they failed.
We developed tools to place the ACL where nature intended it.
But going too distal seemed to increase the risk of re-rupture, too.
Now we cheat a little back up the wall on the lateral condyle.
We tried reconstructing both bundles—certainly, that would work better. I tried them, too, but that didn't work.
Fixation... we need screws. The metal screw worked very well. It was predictable and easy to remove.
Oh.. I hate seeing screws on the x-ray. Let’s use these awesome bioscrews.
Wow…, I haven’t seen a cyst that big before 😩
Sadly... those screws dissolved the bone around the graft, too.
Then, we devised some wild, stupid ways to secure the graft that make revision surgery challenging.
Thankfully, most of those are gone now.
Along the way, we thought we would save our patient's tissue by using cadaveric tissue or allograft.
There were disease-spreading issues early on.
But that got better.
Oops... they fail very often in kids.
We don't use them in kids anymore.
We can use them in adults.
(But your own tissue is better.)
Hey... It's been 30 years, so let's repair them again.
That still didn't work.
Hey... let's put this little sponge in the repair.
Okay... That might work... the jury is still out on this.
"ACL tears never heal without surgery."
But it appears that they do!
Enter the cross-brace protocol.
It's annoying for the patient.
It doesn't pay the surgeon as well.
But it appears to work. For some.
The jury is still out. More research is needed.
But... ACL tears can heal.
Rehab. “I let my patients return to sports in 6 mos”. 🙄.
Just don't!
Don’t mess with the biology of healing.
Kids should wait 12-24 mos to return to sports.
I don't think that most parents understand the recurrent tear rate.
Most kids I see out there are not properly/fully rehabilitated after surgery.
It's hard when our lovely insurance companies approve 8 PT visits for an ACL patient.
Multinational/well-researched protocols exist for the rehab of an ACL athlete.
But they're not used often.

Ah... this messy little ligament has generated reams of "research" over the years. Much of it is nonsense, but some solid data exists.
The controversies around how to manage these athletes persist.
I would have thought we would have been further along, but here we are.
Stay tuned... I imagine we are still having the same conversations in 20 years.
Ask your school to implement ACL tear prevention programs.

[Kent Hagan MD @HaganMDMBAMSF]

My favorite paper to bring to journal club and share with med students. 😂🤌🏼

[Michael Justus @mhjrad]

when it’s my turn to lead journal club

[Kent Hagan MD @HaganMDMBAMSF]

300 x 5 was a challenge this morning.
#docswholift

[Kent Hagan MD @HaganMDMBAMSF]

Not a bad view for an Arkansas Friday night.
#NorthernLights #Auroraborealis

[Kent Hagan MD @HaganMDMBAMSF]

Take your family to your local NASCAR track. You won’t regret it.

[Mark Lewis, MD, FASCO @marklewismd]

In medicine we don’t drop diss tracks, we make comments into the conference mic meant for questions

[Kent Hagan MD @HaganMDMBAMSF]

Snatchin’ after clinic. #exercise #sportsmed

[nascarcasm @nascarcasm]

Attaching a pit sign to cover up a hole in the quarterpanel is the most deliciously awesome ARCA moment in the history of ARCA moments.

[RKendallPMR @mtnfreek]

It’s interesting how people looking for a “permanent” fix for their spine problem come in bunches. Always hate to disappoint them with nothing is permanent in the human body.

[Kent Hagan MD @HaganMDMBAMSF]

Clean complexes after clinic. Physicians need exercise and movement too!

[Ali A. Baaj MD @AliBaajMD]

We can always do spine surgery but we can’t undo it. I encourage patients to consider all options, exhaust non-operative therapy, and not rush to non-urgent spine surgery. #neurosurgery

[Ummey Hani @u_htar]

@AliBaajMD Have you read “When the air hits your brain” Dr Baaj? The author has described this as one of the 5 cardinal rules of neurosurgery! 😋
It’s an amazing read!

[Kent Hagan MD @HaganMDMBAMSF]

Greatly enjoyed my two weeks each of retina and optho-plastics. Blinded many techs with the slit lamp.

[Dr. Glaucomflecken @DGlaucomflecken]

We’re entering the most magical time of year, post match ophthalmology elective season! Come one, come all. Ortho, psych, OB/GYN, anesthesia. Have a seat and apartment shop while we talk at you. Do you have afternoon plans? Well keep them, you’re gonna need something to do.

[Dr. Glaucomflecken @DGlaucomflecken]

We’re entering the most magical time of year, post match ophthalmology elective season! Come one, come all. Ortho, psych, OB/GYN, anesthesia. Have a seat and apartment shop while we talk at you. Do you have afternoon plans? Well keep them, you’re gonna need something to do.

[White Coat Investor @WCInvestor]

The main problem with investing is that people don't do it.

[Kent Hagan MD @HaganMDMBAMSF]

Elite podcast! Dipping into the healthcare world. Very well done. https://t.co/FSG9i5GQlr

[White Coat Investor @WCInvestor]

Most children of white coat investors will deal with shadow syndrome to one degree or another. Shadow syndrome refers to children growing up in the shadow of hyper-successful parents. Start preparing now to deal with it.

Here are 8 ways to empower your children in the shadow of YOUR success.

1. Live Well Under Your Means
Artificially lower your kids' lifestyle. It does not have to be the very best that you can afford. The problem is that sometimes that feels like you're punishing yourself. There's no reason you can't drive a Tesla while they drive a Civic. You can fly coach when you take the kids and First Class when you don't.

2. Communicate
ASK your kids how they feel about growing up in your shadow and start talking about it while they're young. You can let them know how some people in their situation feel and what they have done about it. You can have them talk to therapists or advisors who specialize in dealing with this kind of thing.

3. Don't Force Kids into a Particular Career or Major
Point out the pluses and minuses of a given career and how their attitudes toward work and income and lifestyle might change over the next few decades. But don't force them.

4. Lighten Their Burden
"Lighten their burden but do not remove the struggle." That requires a very careful, individualized balancing act. You've got to be really careful not only how you use your wealth to benefit them, but also how, when, and under what conditions you pass it on to them.

5. Help Them To Be Grateful
The children of the wealthy have a lot to be grateful for, but it doesn't happen naturally. What will happen naturally is called entitlement or "out-of-touch-ness." Gratitude has to be taught. This can be done by emphasizing how fortunate their lives are, through travel, through giving, and particularly through service to others.

6. Learn Where the Wealth Came From
Your kids need to understand the sacrifices you made and the work you put in to build your fortune. They should know where you got lucky and about the important decisions you've made in your career and with your investments. This knowledge will help them to have a more realistic view of their parents, the family wealth, and their own place in the story.

7. Build Financial Literacy
Wealthy heirs often have money dumped in their laps without any significant preparation. At a minimum, make sure they have general financial literacy.

8. Help Them to Be Wealth Creators, Not Wealth Consumers
If generation 1 is the only generation that ever creates any wealth, your family is highly likely to be one of those that goes "shirt sleeves to shirt sleeves" in 3 generations. But if that second and third generation can also learn to be wealth creators, that will go a long way toward building generational wealth.

Do you have experience with shadow syndrome?

What do you plan to do about it in your family?