What are the most critical issues facing orthopaedic surgeons today?

Members of the AAOS Leadership Fellows Program—which encourages leadership skills and mentors young orthopaedic surgeons—were charged with interviewing all of the Academy’s living past presidents. This article is the first in a four-part series drawn from these varied and frank interviews.

Perhaps it’s not surprising that the major issues facing orthopaedic surgeons and the Academy have not changed greatly over the past 2 or 3 decades. In interviews with AAOS past presidents, two issues of concern emerged time and again: (1) orthopaedic surgeon/industry conflicts of interest and (2) unity within the orthopaedic profession. Declining reimbursement and tort reform also were frequently cited.

#1 Concern: Conflicts of interest
Although unity, reimbursement, and tort reform have been priorities for the Academy for many years, the problem of greatest concern to past AAOS presidents—industry/surgeon conflicts of interest—has only recently come into focus.

Among the most passionate on this topic was Roby C. Thompson Jr., MD, (1986-1987), who said that the credibility of the orthopaedic surgeon, as it relates to the medical and pharmaceutical industries, is the most critical problem the AAOS faces today.

“The problem has grown to almost epidemic proportions,” Dr. Thompson said. “Nearly every day we pick up the newspaper and see some sort of conflict of interest in medicine being discussed. Almost every time such an article appears, someone in orthopaedics is mentioned because the profit margins are so high.

James D. Heckman, MD, (1998-1999), agreed that “the encroachment of industry into the practice of orthopaedics” is currently the greatest threat to the orthopaedic profession.

“It’s jaundiced the whole ethical milieu in which we practice,” Dr. Heckman said. “Surgeons have been compromised in the selection of implants; patients are receiving overpriced implants and perhaps unnecessary surgery.”

Bernard A. Rineberg, MD, (1993-1994), noted the tremendous number of different implants that are available today, many with only minor variations. “Their development is often in the interest of entrepreneurs, not patients,” he said. Dr. Rineberg is also concerned about orthopaedic surgeons making money in a deceitful way. More than any other, he believes the conflict of interest issue has the potential to tarnish the Academy’s image.

While acknowledging there is no easy way to move beyond the current situation, Dr. Heckman recommended that orthopaedic surgeons actively maintain an arms-length relationship with industry whenever possible.

Newton C. McCollough III, MD, (1989-1990), also finds the relationship between orthopaedists and industry to be “troublesome,” stating that the situation “has been poorly addressed and is in need of fixing.”

Professionalism, ethics
According to Augusto Sarmiento, MD, (1991-1992), the same five problems he faced during his presidency still remain, the first of which is the “growing loss of professionalism and ethical infractions.”

Although many surgeons would agree that the business aspect of medicine occupies more of their attention than they would prefer, Robert W. Bucholz, MD, (2004-2005), argued that medicine is the “premier profession in the world” and that “we are privileged to be able to practice our profession.”

Thus, “the biggest challenge to our profession is that many practices are approaching orthopaedic surgery as a business, not a profession,” he said.

Fragmentation of orthopaedic surgery
Many AAOS past presidents expressed concern about the fragmentation of orthopaedic surgery. In fact, Vernon T. Tolo, MD, (2002-2003), said that subspecialization presents the greatest threat to our profession.

“Specialty groups such as the American Orthopaedic Society for Sports Medicine (AOSSM) are getting as big as the AAOS was 20 years ago and are capable of putting on annual meetings and producing publications, etc., that sometimes supersede what the AAOS provides,” he noted. If these organizations are not kept within the umbrella of the AAOS, Dr. Tolo fears that the unique power of the Academy to speak as the voice of orthopaedics will be lost.

John B. McGinty, MD, (1990-1991), agrees that a united position within the field of medicine—particularly in the political arena—is essential to orthopaedic surgery. “The AAOS would serve as the best liaison to other medical specialties as well as to the government itself,” Dr. McGinty said.

Robert D. D’Ambrosia, MD, (1999-2000), broadens the scope of unity to “avoiding town-and-gown” issues. “Striking the right balance between academics and community orthopaedists at the local, state, and national levels is critical,” he said.

Declining reimbursements, tort reform
Not surprisingly, the twin issues of declining reimbursement and tort reform came up several times, beginning with Charles A. Rockwood, MD, (1984-1985), who emphasized financial concerns.

Dr. McGinty agreed that declining reimbursements and increasing overhead are major obstacles for today’s orthopaedic practices. Further, he believes that tort reform is essential and that “the current medico-legal environment no longer fosters the expert care that the Academy outlines as essential.”

Dr. Tolo noted that the number of residents becoming fellowship trained in arthroplasty and pediatrics is declining at an alarming rate due to waning reimbursement. “We need to address these reimbursements, level the playing field, and get these specialties on a better track,” he said.

Declining reimbursement has also driven the development of today’s very high-volume specialties, according to James W. Strickland, MD, (1995-1996). Dr. Strickland views this as the most significant issue facing orthopaedics because it has reduced collegiality among groups and damaged the doctor-patient relationship. “Medicine, particularly orthopaedic surgery, cannot be done on an assembly-line process,” he said.

Trauma coverage, recruiting women
The past presidents identified many other important looming problems.

S. Terry Canale, MD, (2000-2001), cited emergency department and trauma coverage as among the most critical problems confronting our profession today.

Another challenge is the ongoing difficulty in recruiting women into orthopaedics, as Robert N. Hensinger, MD, (1992-1993), noted.

“We have to adjust to the changing face of medicine,” Dr. Hensinger said. “Women make up 52 percent of the incoming class at the University of Michigan Medical School, and we in orthopaedics are attracting women at a rate of only 5 percent. So essentially we’re recruiting from 50 percent of the classes, which means that half of the best and brightest aren’t really coming our way.”

As this brief survey shows, many of the most significant problems facing orthopaedics today are not particularly new. This may seem disappointing to some, who, with their orthopaedic surgeon’s knack for problem solving, might expect these issues to have been resolved. Clearly, however, resolving the most intractable problems requires cooperation among a united profession, government, and even industry. We should, therefore, heed the advice of our past leaders, and seek to work together whenever possible. A dose of patience and a recollection of our history may help a little, too.

Felasfa M. Wodajo, MD, is a member of the 2006-2007 class of the Leadership Fellows Program.