Dr. Peter Millett is an Associate Surgeon at the Steadman Hawkins Clinic in Vail, Colorado. He directs their shoulder team and specializes in shoulder, knee and sports medicine. He is an Assistant Professor of Orthopaedics at Harvard Medical School, and was formerly co-director of the Harvard Shoulder Service, and co-director of the Harvard Shoulder Fellowship. He was on the staff at the prestigious Massachusetts General and Brigham & Women's Hospitals, where he specialized in disorders of the shoulder, knee, and elbow as well as sports-related injuries. He was also the director of the Musculoskeletal Proteomics Research Group at Harvard.
A native of Pennsylvania, Dr. Millett received his medical degree from Dartmouth Medical School in Hanover, NH and served as a research scholar at the University of Cambridge in England, where he was awarded a master's degree in science (M.Sc.) for his work in skeletal biology. Dr. Millett performed his orthopaedic residency training at the Hospital for Special Surgery in New York City, part of Cornell University's Medical School. He has received numerous awards for his work including the Lewis Clark Wagner Award for excellence in orthopaedic research, the American Orthopaedic Association - Zimmer Travel Award for orthopaedic research. Recently, his research has been awarded the Caspari Award and the Scientific Exhibit Research Award from the American Academy of Orthopaedic Surgeons. His work has twice been nominated as a Finalist for the Neer Award from the American Shoulder and Elbow Society. Dr. Millett has written more than 50 peer reviewed publications, numerous book chapters, and has co-authored a textbook of orthopaedics. He serves as a team physician for the U.S. Ski Team and has been the associate physician for the Denver Broncos professional football team and the Colorado Rockies Major League Baseball team. More information can be found at www.drmillett.com.
Shoulder 1: When did you know that you wanted to be a doctor?
Dr. Millett: For as long as I can remember I have I have wanted to be physician. Since early childhood, it has been a real calling for me. I have always been inspired to try to help others. Then, when I was a young teenager I actually had a brother who was ill, he had pediatric cancer, and I think that experience really solidified my desire to go into medicine.
Shoulder 1: How did you end up in the Orthopaedics field?
Dr. Millett: I’ve always been interested in how things work. I grew up in a rural part of Pennsylvania on a small farm, so I had to do a lot of things with my hands. I have also been quite active in sports throughout my life. When I entered medical school, orthopedics was just a natural fit: Being able to use my hands and applying mechanical principles to repair damaged joints and ligaments really inspired me. Taking care of people who want to remain active and dramatically improving people’s quality of life is really an awesome responsibility and truly a privilege for me.
Historically Orthopaedics has been very mechanical in nature, but there has been quite a revolution in the last few decades. It’s gone from being very mechanical to being much more focused on the biology of the joint. I’ve always been very interested in the biologic aspects, and I actually spent some time at the University of Cambridge in England studying how bones cells work and some of the basic mechanisms the body uses. That’s been a focus on mine as well and I continued that at Harvard where I directed the Musculoskletal Proteomics research group. We were recently able to establish a molecular “fingerprint” for osteoarthritis, the most prevalent of all musculoskeletal diseases.
Shoulder 1: What is the primary concern when a patient comes in for their first consultation?
Dr. Millett: I don’t think I can give one generalized answer for that. Everyone has different needs and expectations. You may have an elderly woman with a massive rotator cuff tear in her shoulder and she can no longer raise her arm. That patient wants pain relief and restoration of function, so she can sleep comfortably and care for herself. You may have an elite athlete who can’t throw through a baseball at 90 miles per hour, and he wants to know what can be done so he can get back to that activity. It really depends on the situation. Then you may have someone who has had an acute injury, a bad fracture, for example, and that person just wants to know what can be done to fix it so one can resume life again.
Shoulder 1: How knowledgeable are your patients. Do you need to spend a lot of time educating them?
Dr. Millett: Well you have the whole spectrum. But overall, most patients are fairly well informed. Some patients truly have researched everything. I have a number of physicians and other health care providers in my practice who are obviously very knowledgeable. I have also noticed an increase in the number of people who have researched their problem. Often time they come in with a fairly sophisticated understanding and a high level of information. Web sites like “shoulder1.com” help with patient education. On the other hand, there are those patients who just say “fix it doc.” I see the whole spectrum.
Shoulder 1: What kinds of resources do you direct them to when they want to learn more?
Dr. Millett: One thing I have developed is a series of online patient modules that’s available on my web site (www.drmillett.com). It has pictures with additional information and can help them learn more. We also have some teaching videos we can show the patients and a variety of other things that really help them understand their problem, what to expect after the surgery and what to expect with the rehabilitation. I think we offer the whole gamut for education.
Web sites such as shoulder1.com are also an excellent online source for information. The chat groups on various topics help patients get answers from a patient’s perspective. I think this is very helpful.
Many of my surgical patients are also very generous and volunteer their time so that they can speak with other patients who are contemplating surgery. This one on one conversation between patients is really reassuring and helps patients considering surgery get the information they need.
Shoulder 1: How do you develop a treatment plan with your patients?
Dr. Millett: It’s sort of a step-wise approach. I first try to assess their expectations and objectives – why are they coming to see me? Do they understand the problem and is it something I can address either with surgery or non-surgical treatment? Once the diagnosis is made I usually tell the patient the treatment options, both surgical and non-surgical, because they usually have several options. I then try to give them a recommendation about what I think is the best treatment based on my experience that will meet their expectations and allow them to return to the lifestyle, functional level and pain relief that they desire. My specific recommendation is based on my experience treating others and what I know we can actually achieve through surgery or non-operative treatment. I use a shared decision-making model. I give them the options and my recommendation, but ultimately the decision is up to the patient. I do my best to try to match the treatment and outcome with their expectations.
Shoulder 1: Do you think patients’ expectations have changed because of the new technology out there?
Dr. Millett: I think so. Patients want to be more active. They want less invasive and less painful treatment options for their problems. I use the latest technology and try to do as much as possible using arthroscopic or minimally invasive approaches. I am not however tied to one approach. If I think I can provide a better outcome with an open approach or a more invasive approach, then I may recommend that option. As a surgeon you have to be flexible. You have to weigh the risks and benefits of each option and really try to figure out what that individual patient wants and go forward from there. At the end of the day, most patients want the best outcome and that is what I try to offer.
Shoulder 1: You are one of the physicians for the U.S. Ski team. How does your treatment change for a star athlete who perhaps doesn’t want to accept any limitations and wants a fast-tracked recovery?
Dr. Millett: It certainly changes things – elite athletes have different needs, goals, and timetables that need to be considered. You have to weigh all the factors and try to come up with a plan that meets all the needs and expectations. It’s a unique situation with elite athletes and there are several factors to consider: (1) they typically are very healthy which is very favorable; (2) they usually cannot tolerate a disability (that an average person might find perfectly acceptable) since the disability limits the ability to participate in sport, which is their livelihood; (3) they have seasonal timetables that vary with the sport and may influence the timing of an intervention. In many instances, elite athletes have a lower threshold for surgery, accepting the risk but at the same time being less tolerant of small issues, like subtle weakness or minor joint stiffness, because they need to participate at such a high level. With elite athletes, you really have to find the right balance. You have to do just the right amount to allow them to participate at that high level of athletic performance.
Shoulder 1: It sounds really challenging.
Dr. Millett: Yes. Sometimes we would be more aggressive with the surgical approach than with others. The timing of the season also influences things. For example many baseball players will have surgery in October or November after the season is over in preparation for the following season. Whereas a player in mid-season might wait and try a non-operative or rehabilitative approach to get through the season. The problem could then be addressed at the end of the season. For example, a football player who dislocates his shoulder may elect to participate in the rest of the season and then have the problem fixed end of season. So you have to consider all these issues: The sport, the position, the timing of the season, and the injury that has been sustained. All those factors come into consideration and you have to weigh each individually.
One thing is certain - you can never justify allowing someone to return to play if there is significant risk of permanent or severe damage with continued participation. Sometimes these are the most difficult conversations to have.
Shoulder 1: Do you see more shoulder injuries than knee or elbow injuries?
Dr. Millett: Well my focus has really been on the shoulder, particularly complex problems such as failed surgeries or difficult problems. I do take care of a number of people with knee problems and have written quite a bit on the topic of athletic knee injuries, ligament tears and arthrofibrosis, a process where scar tissue blocks knee motion and causes pain. I also do some elbow work in athletes, but I would have to say my principal focus has been the shoulder.
Photo courtesy: Dr. Peter Millett
Most of my research, particularly over the last five years, has been focussed on the shoulder. I’ve developed some new techniques for shoulder replacement and for rotator cuff repair. I have a number of research projects under way involving shoulder replacement surgery, new arthroscopic techniques for rotator cuff repair, and shoulder stabilization surgery for people with unstable shoulders. My team has done research on different post-operative pain management, transfusion studies for predicting blood loss and the need for pre-donating blood. I have received several research awards in the last year for these projects including, the Caspari Award, the Award for the Best Scientific Exhibit from the American Academy of Orthopaedic Surgeons, and the Kilfoyle Award.
Shoulder 1: Have you seen a change or increase in the types of injuries you are treating?
Dr. Millett: Diseases of the shoulder haven’t changed that much, they have always been around, but our ability to diagnose them along with our ability to recognize and treat them is rapidly improving and constantly changing. There is a real revolution under way in shoulder surgery. Presently, we have a much better understanding of the biomechanics, anatomy, and diseases of the shoulder than we did even five years ago. As the population ages, particularly as the baby boomers reach their 50s and 60s, we are seeing an increase in a number of problems, such as rotator cuff tears and arthritis of the shoulder. These existed before but there are just more people with these problems. Furthermore, as people remain more active into later ages, we see more of these problems. Expectations are changing as well – individuals demand more and don’t want to live with disabilities that may have been acceptable to past generations. Fortunately we can offer treatment options that weren’t available even five years ago. Most of the procedures I do today were not available five years ago. So you can see that the changes that are going on in the field of shoulder surgery are quite rapid.
Shoulder 1: What types of procedures have changed the most?
Dr. Millett: There are really two areas – advanced arthroscopy and shoulder replacement surgery. Arthroscopic surgery is a minimally invasive technique where a camera is placed inside the shoulder to see. It has been used for some time to look inside but now we can actually operate through the scope as well. This allows us to repair torn tendons, to restore stability to unstable shoulders, and to repair torn cartilage – all through tiny incisions. Because the pain is minimized, this often allows patients to go home the same day. These surgeries are less invasive because we can do them through much smaller incisions. It’s really amazing what has been happening; it let’s us become much more precise.
As for shoulder replacement, we have been using new, innovative, anatomically correct designs which we believe will improve outcome, durability, and longevity of the implants. Another development has been the introduction of the "reverse shoulder replacement", which has been designed for those individuals who have a no functional rotator cuff, a severe fracture, or a bad shoulder for a variety of other reasons. These are often used in the setting of a failed procedure or revision setting. This is an implant that allows us to salvage many of those otherwise previously untreatable conditions. Last year alone I did over 50 of these new procedures.
Shoulder 1: What kinds of major breakthroughs have you seen in the field in last few years?
Dr. Millett: I think that the largest breakthrough in my field has been the arthoscope, which is a camera that allows us to operate through very small incisions. Rather than looking through a keyhole, which analogous to a regular incision, where it sometimes is difficult to see, we go inside with the "scope", look around and see everything! It’s allowed us to identify injuries that we didn’t even know existed. We now can offer innovative treatments, which minimize pain, allow for a faster recovery, and decrease the risk of complications that you often had with more traditional procedures. It’s really amazing.
Shoulder 1: What other exciting developments are going to be seen in your field?
Dr. Millett: I think the big area for development is going to be in the biologic enhancement of tissue healing, which is the ability to improve healing using growth factors which are special proteins that will speed up the healing process. For example, in the future if someone tears their rotator cuff – which is an important group of tendons in the shoulder – we will be able not only to repair it but we will also be able to place growth factors in at the same time which will speed healing. Normally it would take three or four months for the tendon to heal sufficiently to allow return to activity, but in the future we will be able to cut that time in half or more. We will have stronger repairs with less pain, fewer complications, and a tendon which is as good as new!
In the future we are also going to have computer assisted surgery, surgical navigation where we can look at a video monitor and see the patient in 3-D. By linking with MRI and x-ray, we will have “x-ray vision” to see into the patient and will be able to rotate the images, just like you see in science fiction. It’s not however that that far off. I am currently utilizing it for research purposes and as the technology gets better it will become more widely implemented.
Shoulder 1: That’s sounds very exciting.
Dr. Millett: Yes, particularly with the virtual reality. You will be able to take someone’s imaging study like their MRI or x-ray of their shoulder and put it into a computer program. The computer will be able to generate a specific model of that patient’s shoulder or knee. Then you will be able to see it on a video screen or monitor and see your instruments working, where you are putting implants or where your sutures will be precisely placed. The surgeon can rotate the image and manipulate the screen as needed. This technology will allow for increased precision, less invasiveness, and ultimately better outcome for our patients.
Shoulder 1: Do you have a favorite piece of technology or piece of equipment that makes your job easier?
Dr. Millett: I don’t think I have one favorite piece! I have different “favorites” for different procedures. With increased specialization, I have developed specific instruments that help me address specific problems. For example, I have special arthroscopic instruments that allow me to work through tiny incisions and even to work remotely. I have also helped develop special positioners for shoulder surgery, which allow us to position the patient in an optimum position very securely with lots of exposure. The patient can be awake while I do the surgery, and both of us are very comfortable!
Shoulder 1: How do you balance having a practice with finding the time to learning the new technologies?
Dr. Millett: I think it’s so exciting that I personally want to be at the cutting-edge and be doing innovative things and being able to translate that into better results for the patients. So I think there are a couple of key factors. One is the personal desire to improve, which I personally have and which I think most surgeons have. I am always trying to do it better. The passion has to come from within. Another motivating factor occurs when we see patients that have problems that cannot be treated by current technology. Fortunately, it’s fairly rare that nothing can be done, but it remains one of the most frustrating situations - when a patient has a problem and there really isn’t currently a good solution to that problem.
Shoulder 1: Would you say that was your biggest challenge right now?
Dr. Millett: Yes. I would say that it’s identifying those key areas where we need to improve and then developing creative ways to actually treat them. I find this creative side of orthopaedics and shoulder surgery personally quite satisfying. We need to keep working to improve and making the technology better so that we can address some of these problems, improve healing, and hasten recovery for our patients. I have invented several new techniques and methods for shoulder surgery and have discovered new “fingerprints” for arthritis which will help us diagnose and treat patients better. New discoveries always lead to new questions and new challenges!
Shoulder 1: What do you find most rewarding about your profession?
Dr. Millett: Probably the most gratifying thing about my specialty is that Orthopaedic surgery is about improving people’s quality of life. The results are frequently striking and dramatic. We really make a big difference in our patients’ lives.
Photo courtesy: Dr. Peter Millett
I work in a referral environment so many of my patients come in with difficult problems or with a failed previous surgery that hasn’t worked out for them. I enjoy the challenge of those difficult cases. Often these patients are frustrated and are looking for a solution to their problem. Fortunately there are many things we can do. For example, I remember a delightful woman who hadn’t been able to comb her hair since the 1980s because she had massive rotator cuff tears in both her shoulders. Otherwise, she was vibrant and healthy. I was able to offer her a solution and performed a new type of shoulder replacement. She is now pain free and can comb her hair and raise her arm over her head. She said she hadn’t been able to take care of herself for two decades! The surgery changed her life.
I can recall another gentleman who is almost 70 who has had arthritis in his shoulders for 30 to 40 years. He had severe pain on a daily and ongoing basis. I replaced both his shoulders and within a few weeks he was pain free. He recently called me to say that he feels better now than he felt in his twenties! These are not unique occurrences – they happen every day in my practice. So it’s things like that – allowing people to get back to their lives – that I really find most rewarding. It’s a nice feeling to be able to impact people’s lives so markedly. In my job, I’ve meet people from all over the world, from all walks of lives. To be part of their life, hear their stories, and help them with their problem is incredibly rewarding.
Shoulder 1: Do you collaborate with other professionals?
Dr. Millett: I work with physical therapists, radiologists, and other orthopaedic surgeons on a daily basis. Because of the nature of my practice, I see patients from near and far. At times it’s hard to standardize the rehabilitation process because my patients come from all over the country and the world. So, I have developed rehabilitation protocols that can help the therapists and guide the recovery. I have also written educational articles to help update physical therapists on innovative strategies for rehabilitating the shoulder. I’ve given lectures at educational meetings for physical therapists and for radiologists to help them understand what I do at surgery so that we can have better outcomes for our patients.
I like the collegiality of orthopedic surgery. Although my practice is focused and highly specialized, I enjoy the relationships I have developed with orthopedic surgeons who practice in the community and who may not have the type of specialized practice that I have. I have very good relationship with the general orthopaedists with whom I work because I can often provide help or advice when they have difficult problems. I have tried to foster an open attitude where they feel free to call me and ask me questions. When they have difficult problems or problems beyond the scope of their practice, they can send the patient over for a consult confident that we are all working toward the common goal of solving the patient’s problem. I have been fortunate to develop excellent working relationships with the other doctors and caregivers in my community, and I’ve really enjoyed that as well.
Shoulder 1: Did you have any mentors that inspired you?
Dr. Millett: I’ve had a series of wonderful mentors who have helped me. First and foremost would be my parents. My father instilled in me a strong work ethic. I can still hear him say “Work hard, it will pay off!” My mother instilled in me an insatiable love of knowledge and of respect for others. I was also fortunate in that I worked with many of the true pioneers of orthopaedics, sports medicine, and shoulder surgery. These people have been the thought leaders over the last few decades and they helped shape and mold my career. Some of them have already been featured as shoulder1.com heroes. Men such as Russell Warren, David Altcheck, Edward Craig, and Thomas Wickiewicz looked after me while I was a resident at Cornell / Hospital for Special Surgery, an institution which is clearly one of the pillars of orthopaedic surgery. I then did a fellowship with Richard Steadman and Richard Hawkins, in Vail, Colorado. These two are considered world-renowned for their expertise in shoulder and sports injuries, and from them I learned how to provide cutting-edge care in a personalized environment, where listening to the patient is paramount to a successful outcome. In the spring of 2005, Dr. Steadman was kind enough to invite me back to the Steadman Hawkins Clinic in Vail, where I now direct the shoulder service.
For the last five years, I have been on staff at Harvard and have been co-director of the Harvard Shoulder Service, with my mentor and friend Dr. J.P. Warner. Without question, Dr. Warner had the most profound influence on my understanding of shoulder disorders and their treatment. He has been an invaluable teacher, mentor and friend. I consider him among the top shoulder surgeons in the world.
So as I move along my career path, I find that each of these people has influenced me in unique ways. I’ve tried to incorporate the “best practices” from each into my style, my surgical approaches, and my treatment of patients. One of the really important things for me has been for me has been to focus on where I am going but also to remember to give back to those who follow. You can’t forget your history, where you came from, and whose coming behind you.
Shoulder 1: So being a mentor is also an important part of your orthopedic career?
Dr. Millett: I think being able to give back is an important part of this for me. I’ve been part of the fellowship training program at Harvard and now am part of the training program at the Steadman Hawkins Clinic in Vail. We have trained a number of surgeons who have now gone out around the world, taking the principles we have taught them and implementing them in their own practices. As Director of the Shoulder Services at the Steadman Hawkins Clinic, I’m going to focus on making our fellowship training program as strong as it can be so the next generation of orthopedic surgeons will have a strong foundation built on the principles and skills, research and the clinical care that we use every day. Although I have a busy practice and care for many, many patients, I’m only one physician and I can only realistically care for a limited number of people. But if I take these principles and skills and transfer them to other surgeons through educational programs such as our fellowship program, academic publications, or lectures, then the information if amplified and multiplied so that it cascades on itself. By these avenues, I then have the ability to affect and impact many thousands and millions of people around the globe. So the educational aspects of my practice are an extremely piece of what I do.
Shoulder 1: What advice would you give to a young physician about to start out in this field?
Dr. Millett: I think it’s incredibly exciting right now, and I think medicine is still very much an art and a science. As a physician you absolutely need skills in both. It’s been called the “youngest science” and “noblest profession”, and I really believe that is the case. We have so much to discover, and we have the ability to impact people’s lives so dramatically. I would encourage anyone who is interested to look at medicine and orthopaedic surgery in particular, very closely.