Advisories and bylaw amendments also considered during NOLC

Since the establishment of the AAOS Professional Compliance Program in 2005, new Standards of Professionalism (SOPs) have regularly been added, at a rate of one or two per year. During the recent National Orthopaedic Leadership Conference (NOLC), the joint AAOS Board of Councilors (BOC) and Board of Specialty Societies (BOS) Professionalism Committee held open hearings and developed recommendations on two new proposed SOPs.

Orthopaedic Surgeons Treating Athletes
The first draft SOPs—Orthopaedic Surgeons Treating Athletes—focused on the role of orthopaedic surgeons who serve as physicians to organized sports teams. Among the issues discussed was what might constitute inappropriate agreements between sponsoring sports organizations and the surgeons who provide medical services to patient-athletes.

Champ L. Baker Jr., MD, president of the American Orthopaedic Society for Sports Medicine (AOSSM), raised concerns about ambiguous language in the draft. Deciding whether a surgeon had violated the mandatory standards would be difficult without specific definitions. As an example, he cited the term “payments” in a passage reading “An orthopaedic surgeon or his or her professional corporation shall not make payments of any kind for the exclusive privilege of providing care to the patient-athlete, teams or institutions.” Of particular concern was whether the term would apply to a small-town practice that provided trainers or equipment to a local school, as a cooperative gesture to ensure continuation of the sports program at the school.

During the discussion, the difference between these SOPs and one of the initial SOPs—Providing Musculoskeletal Services to Patients—was raised. One suggestion was to narrow the focus of the sports-medicine SOP to two issues: the disclosure of conflicts of interest with sports teams and any quid pro quo agreements that might limit a patient-athlete’s choice of health care.

Later, in a joint meeting of representatives from the BOC/BOS and the AOSSM, the complex relationships inherent in the selection of team physicians were discussed and parallels with other relationships between physicians and groups of patients were suggested, such as agreements with corporations. Under a compromise agreement, the SOPs on Orthopaedic Surgeons Treating Athletes were withdrawn; instead, the existing SOPs on Providing Musculoskeletal Services to Patients will be amended. In addition, it was recommended that AAOS endorse the AOSSM’s Principles for Selecting Team Medical Coverage (see bottom of page).The BOC/BOS approved these recommendations with a 95 percent vote of support.

On-Call Professional Responsibilities
The second draft SOPs—Orthopaedic Surgeons’ On-Call Professional Responsibilities—also generated considerable debate. Jeffrey Anglen, MD, president of the Orthopaedic Trauma Association, discussed the genesis of these SOPs, which were developed in response to the Institute of Medicine report The Future of Emergency Care. That report raised the issues of providing timely emergency department (ED) care to patients and the unavailability of specialist care.

Because many people believe that orthopaedic surgeons are best able to take care of orthopaedic problems, the reluctance or unavailability of orthopaedic surgeons to take call may lead people to believe that orthopaedic surgeons are failing to meet their responsibilities. Dr. Anglen clarified that the draft SOPs are not an attempt to require orthopaedists to provide trauma care; a tool for hospitals, government, or patients to force orthopaedists to take call; or an expectation that all orthopaedic surgeons will take all types of orthopaedic call cases. The work group on proposed SOPs will continue to refine the wording and will return with a revised version at a later time.

No orthopedic surgeon left behind
Also during NOLC, the BOC/BOS Resolutions Committee held an open hearing on a proposed advisory opinion to require new fellows to join their state orthopaedic societies and to present “ongoing evidence of professional responsibility through participation in the key contact program, PAC membership, or activity in state or national orthopaedic organizations” to maintain fellowship status.

Although many agreed that it is critical for orthopaedic surgeons to be strongly involved in advocacy efforts and their state orthopaedic societies, they also expressed concern over whether this would be an appropriate way to encourage advocacy and participation. The BOC/BOS Resolutions Committee recommended—and the BOC/BOS membership approved—a substitute advisory opinion, requesting the AAOS Board of Directors to establish a project team on a unified membership between AAOS and the state orthopaedic societies. The project team’s report would be considered at the fall BOC/BOS meeting.

Proposed changes to the Nominating Committee
The Nominating Committee Review Project Team, established in response to recommendations passed at the 2006 BOC/BOS fall meeting, presented its report for discussion. The Project Team was charged “to conduct a thorough review of all aspects of the AAOS Nominating Committee and AAOS officer election process.” The team made the following recommendations, which were adopted by the BOC/BOS and will be presented in the form of bylaw amendments to the AAOS in the fall:

• Keep the size of the Nominating Committee at seven, including the individual appointed as the Chair by the Board of Directors.
• Change the composition of the Nominating Committee so that one member is elected by the BOC, one member is elected by the BOS, and four members are elected by the fellowship.
• Announce the members of the Nominating Committee in September so the committee can meet in the fall.
• At least 60 days before the Annual Meeting, the Nominating Committee would announce its nominations for various positions.
• Allow any 20 fellows to nominate other individuals to serve, up to 10 days before the Annual Meeting.
• Present the committee’s slate—as well as any others nominated—during the Annual Business Meeting at the Annual Meeting. No nominations from the floor would be allowed.
• Hold the election during the Business Meeting at the Annual Meeting.

G. Jake Jaquet is executive editor of AAOS Now. He can be reached at jaquet@aaos.org

Principles for selecting team medical coverage
The following principles were adopted by the American Orthopaedic Society for Sports Medicine (AOSSM) in 2005. The guidelines were developed so that “physicians, teams, and, most of all, athletes can use them to ensure they enjoy the highest standard of quality medical care possible.”

1. The selection of a team physician should be based fundamentally on the physician’s credentials and ability to provide the highest level of care. The AOSSM recognizes that there likely will be multiple qualified groups in any given area that can provide the requisite level of care required, but that certain relevant considerations should be included when selecting medical coverage:
• The physician’s experience with caring for teams, especially at the level of competition for which they are competing
• The physician’s formal training, including postgraduate sports medicine fellowships
• The physician’s support network, including other specialists and ancillary personnel that can provide the required coverage
• The quality and depth of facilities at the physician’s disposal in being able to tend to the team’s needs
2. The process of selecting the team physician should include input from multiple parties that have an interest in the well-being of the players. AOSSM believes that opening the process (if not the decision) to a broader circle of individuals who will interact with the team physician(s), especially when commonly accepted criteria are established, the team is likely to make a stronger, more informed, and less controversial decision about who will provide coverage.
3. The selection of team medical staff should not be based on financial incentives offered by the physician and/or his or her institution. The AOSSM feels that the practice of bidding for team contracts establishes an inappropriate criterion for selecting medical coverage and leaves the physician and team management susceptible to conflicts of interest under those circumstances. At the same time, AOSSM recognizes that there may be appropriate financial concessions that a physician or institution may give in arranging a contract and believes there needs to be latitude for negotiations.
4. The team should fully disclose any sponsorship, advertising, or financial arrangement that the medical staff (or their institution) has made with the team. The AOSSM recognizes that there are instances where some level of sponsorship may be appropriate, and the leadership realizes the impracticality of attempting to parse every conceivable financial relationship. It is the AOSSM’s sentiment that disclosure will have the largest sentinel effect on any type of inappropriate incentive.
5. The team and medical staff should ensure appropriate communication (within legal limitations) to players, other medical providers, and management to provide for a more open understanding regarding the healthcare environment.