And here is the article that above said letter is referring to:
The orthopaedic community is deeply concerned about the changes brought about by health-care reform. The primary concerns seem to be centered around the increasing loss of autonomy, the reduction in reimbursement for services provided, the overwhelming number of regulations that border on the irrational, and the perception that there are too many orthopaedists. The entire scenario almost seems to be designed to break the spirit of the medical profession in the hope that physicians, in frustration, eventually will accept a system of controlled National Health Insurance in which they are salaried employees.
While I do not question the legitimacy of those concerns, I believe that efforts to offset the real or perceived trends will be futile unless we acknowledge that we are, to some extent, willingly or unwillingly responsible for many of the problems that we now confront. I suspect that, unless we make a major effort to modify a number of deeply rooted attitudes and practices, we will lose the battle and, in the not-too-distant future, the discipline of orthopaedics will cease to exist.
Economic considerations prompted the government to initiate health-care reform. Organized medicine responded not by officially agreeing that the escalating cost of medical care was a problem that needed to be addressed, but by bemoaning the possible personal financial implications of the proposed plans. We assumed that our fortress was impenetrable and that the discipline was too well entrenched for anything of a draconian nature to happen to us. We refused to acknowledge that we may have played a role in the creation of the escalating cost of medical care, and we continued to indulge in practices that any observer could readily identify as contributing to the problem.
In clear and loud terms, we were told that specialty medicine was too expensive, that specialists relied too heavily on technology, and that too many operations were being performed. Rather than initiating a process to determine whether the charges were valid, we proceeded to indulge in an orgy of technology, to create more subspecialties within our profession, and to treat a greater number of conditions with more expensive operative means. All of these actions contributed to the problems that others were trying to address.
Our actions did not go unnoticed. When the fees for services were reduced, we responded by complaining about it and increasing the volume of our services. Many conditions that previously had been treated successfully with simple non-operative means began to be treated operatively instead. This pattern reached the educational institutions, and, within a very short time, new graduates from orthopaedic residency programs were completing their training with only a modicum of understanding and respect for non-operative approaches to diseases and injuries of the musculoskeletal system. Today, the diagnosis and treatment of musculoskeletal conditions nearly always involve the use of expensive technology. For example, tendinitis and bursitis demand not just a physical examination but magnetic resonance imaging as well. A sprained joint is thought to require, in addition to magnetic resonance imaging, an arthroscopic procedure followed by expensive and prolonged physical therapy. Low-back pain, even in the absence of a neurological deficit, is approached with a battery of costly tests followed, once again, by prolonged physical therapy. Although many graduates finish their residency seeming to know little about how to reduce a fracture and immobilize it in a cast, they do know how to insert an intramedullary nail, secure a plate, and apply an external fixator. In fact, I believe that many orthopaedic residents are being trained to be skeletal cosmetologists rather than physicians. An unjustified and unreasonable obsession with perfect anatomical restoration recently has dominated the minds of many, particularly in the field of fracture care. Inconsequential abnormalities are considered to be indications for operative treatment because of the fear of undocumented undesirable sequelae.
Some individuals in academic medicine suggest that orthopaedists should treat only fractures that necessitate an operation and leave the closed treatment of fractures to others. This, I believe, would be professional suicide. Once others become responsible for the non-operative care of fractures, they will instruct the orthopaedist as to which fractures are to be treated with operative means, rather than the other way around.
The emphasis on cost containment has given those outside our profession an opportunity to extend the scope of their disciplines. Today, the neurosurgeon not only performs stabilization procedures on the spine but is often the one who is identified by the medical profession and the public at large as the expert in that area. Similarly, the plastic surgeon is considered by many to be the true hand surgeon, and his or her presence in the orthopaedic operating room is thought to be essential for the care of patients who have a fracture associated with soft-tissue damage. Pediatricians and family physicians treat so-called simple fractures with increasing frequency. Podiatrists now consider the operative treatment of tibial fractures to be part of their armamentarium. Third-party payers welcome the involvement of non-orthopaedists because of the perception that it generally reduces the cost of care.
Thus, the field of orthopaedics has become an attractive prey; it has been easy for others to move in and capture a large portion of our territory. I suspect that other practitioners no longer view orthopaedics as a comprehensive body of knowledge that requires long and rigorous training but rather consider it simply as a series of operative procedures that anyone with surgical skills can readily master. Having reasoned in that manner, these other practitioners only needed to request instructions on how to use the instrumentation from the orthopaedic manufacturing companies. Industry saw a new market opportunity and readily accommodated their desires.
To complicate matters, orthopaedists became infatuated with subspecialization and the prestige that subspecialty societies offered. New and often superfluous societies were established for many specific bones and joints as well as for several operative techniques and diseases. I believe that the large number of operations required for membership in some societies can be an inducement to perform unnecessary procedures. Many of these societies publish their own journals and hold educational meetings in isolation from the rest of the profession. They also established lobbying offices in Washington in the hope of gaining a direct and more effective voice in the halls of Congress. In doing so, they have weakened the cohesiveness of our profession.
Some twenty-five years ago, academicians began, with the best of intentions, to structure orthopaedic departments to fit the subspecialty trend. Educational institutions recruited faculty who limited their practices to smaller and smaller areas of the body. As the faculty had to be accommodated with residents, rotations through the various sections became shorter and shorter.
Soon thereafter, fellowships began to receive greater emphasis, and it did not take long for them to become status symbols. Most residents completed a fellowship, regardless of whether or not they needed additional education. However, in the current health-care environment, many physicians never have the opportunity to practice in the area in which they have received additional training. Managed care and government regulations now discourage rather than encourage referrals to specialists.
To identify problems without offering answers is unwise. Therefore, I will present some possible solutions. I recognize that most will be difficult to implement because of existing practices and long-held beliefs, inherent conflicts of interest, and the natural inclination to accept the status quo.
I suggest that the current system of resident rotations through every subspecialty be replaced with a system that encourages greater exposure to general orthopaedics throughout the entire training program. In that manner, the resident would feel comfortable managing the operative and non-operative aspects of orthopaedics on the completion of training. The frustration and insecurity that short rotations generate would be assuaged. Rotations that are limited to one specific area, such as pediatric orthopaedics, could be preserved, whereas those that focus on more esoteric and highly specialized areas, such as scoliosis and oncology, could be deemphasized.
One could argue that a structured exposure to subspecialties is imperative because of the explosion of knowledge and technology during the last few decades. My answer to this argument is that, to a large extent, the body of knowledge in orthopaedics is not necessarily greater. Instead, new knowledge has replaced old knowledge. Other professions and trades have clearly demonstrated that point.
I also suggest that orthopaedic postgraduate fellowships be deemphasized. Such fellowships should be offered only to those who truly need additional education, either because of deficiencies in the program that they completed or because they have a clear interest, and hope to carry out future research, in one particular subdiscipline. Additional criteria could be established as well. In my opinion, there is little doubt that five years of training in a well balanced program provides the orthopaedic resident with sufficient education to practice good orthopaedics in the operative and non-operative arenas.
The Council of Musculoskeletal Specialty Societies (COMSS) could help to accomplish these goals by restructuring itself in a manner that would preserve the existence of groups that focus on specific areas of orthopaedics while eliminating the perceived elitist nature of the system as it is today. The existing barriers to membership in subspecialty societies should be lowered, and unreasonably restrictive criteria should be eliminated. It is not necessary to issue certificates of membership or certificates of additional competency. The field of orthopaedics has a well structured mechanism to ensure that its members are competent to practice in all areas of the discipline. The rigorous and extensive period of education along with board certification and recertification should suffice. There is no evidence that the addition of new, artificial barriers has enhanced the quality of care.
The composition of the Board of Directors of The American Academy of Orthopaedic Surgeons also should reflect the proposed new philosophy. This goal can be achieved by having all Board members elected by the fellowship. At this time, there are a number of appointed representatives on the Board. Such preferential treatment sends a message to the orthopaedic community that there are some individuals who, for reasons of subspecialization or positions held in certain societies, belong to a higher level in the hierarchy of the profession. This unhealthy perception should be dispelled.
The American Academy of Orthopaedic Surgeons could set a good example by changing its name to The American Academy of Orthopaedics. Such a move would deemphasize the operative aspect of the discipline and would indicate to the public that members of The Academy have been educated to provide the best non-operative as well as the best operative treatment of conditions of the musculoskeletal system. To my knowledge, no one has ever questioned the competence of urologists, ophthalmologists, and others regarding their operative and non-operative expertise. The names of their Academies do not include the word surgeons. Ours should not either.
A major step in paving the way to success would be for the body of orthopaedists to carefully assess its relationship with industry. Our organizations must make it clear that the postgraduate education of orthopaedists should be determined and controlled by the profession itself. This can and should be done without belittling the important role that industry has played, and should continue to play, in the development of the specialty.
We must agree that the cost of orthopaedic care is high and reject the argument that, because this country is very wealthy, it does not matter whether the health-care component of the national budget is 8, 10, or 20 per cent. The medical profession is an important component of society, and it is obligated to use its privileges and to discharge its responsibilities in the most prudent manner. To claim that we should be free to spend as much as we want is not a good argument. We should be allowed to spend as much as is necessary, provided that the approach is unselfish, reasonable, and objective. Society cannot, and should not, tolerate abuse simply because there is money to pay for it.
I sincerely believe that these issues should greatly concern us and suspect that, unless current trends are tempered or modified, our specialty will be in serious danger of ceasing to exist.
I will accept criticism for this commentary if criticism is to come. My ideas on these issues are the product of the careful observation and study of my profession during my long tenure in the practice of orthopaedics, in education as well as in research and medical administration.
Augusto Sarmiento, M.D.
