Published 6/1/2008

Readers question leaders, CDHC, PA articles

I am a member of the next generation of orthopaedists. I have expended a great deal of time, energy, and, frankly, money to reach this point. I have paid particular attention to the way I handle and present myself, listening to the teachings of my professors, mentors, and professional society leaders. My peers and I know the importance of evidence-based learning and practice, how to appropriately judge the rigors of published research, and the definition of professionalism and its relation to medicine and law.

In a recent AAOS educational resources catalogue, one of the offerings was a surgical technique video, and one of the co-authors is known to me. Despite multiple years in private practice and opportunities to resolve the issue, this author has not been certified by the American Board of Orthopaedic Surgery and is not an AAOS fellow. Given the emphasis on certification, and the figurative and literal price to earn this distinction, it is unimaginable to me how such an individual could be awarded an honor like representing the Academy in its educational arm. It forces me to pause and question why I have dedicated so many of my efforts to meet the requirements of my Board and Academy, when clearly one can still achieve professional success and satisfaction by simply fostering personal relationships with the “right” people.

As a young orthopaedist, [I find] it difficult to swallow such direction from leaders when I know that their professional and personal lives have been, and continue to be, improved by the activities discussed [in the Standards of Professionalism on Orthopaedist-Industry Conflicts of Interest]. Already, we are forced to deal with issues of falling reimbursement, lack of emergency call coverage, and patient distrust. The truth is that many of these issues have been brought on and exacerbated by more senior physicians who have historically enjoyed larger paydays and lax regulation. The cumulative effect of leaders telling us to “do as we say, not as we do” is terribly frustrating.

I take my role as an orthopaedic surgeon very seriously, and I know that it is an honor to have this opportunity. I am currently involved in resident education, and I aspire to become more involved in the Academy and the subspecialty societies. I know that politics and networking play a significant role in determining who does and does not ascend these professional ladders. At the risk of drawing the ire of persons in positions of authority, I write to you in hopes of bringing these issues to greater light. As a body, we are unlikely to deliver real change unless we have reliable disclosure and oversight from our governors. I hope [for] help to guide me, my peers, and the residents we teach, as we continue our efforts to better ourselves, our societies, and our Academy.

Robert R. Gorman III, MD
Kalamazoo, Mich.

AAOS President Tony Rankin, MD, responds:
Regarding the participation of non-members in the development of Academy continuing medical education (CME) programs and educational resources: Each year the Academy undertakes an Annual Meeting call for participation and a selection process that includes video and multimedia programs produced by members and others interested in contributing to the Annual Meeting. A peer-review process is undertaken for all of the submitted video and multimedia material, similar to the scientific papers, and accepted programs are shown at the Annual Meeting and sold through the Academy’s educational resources catalog. Further, any Academy-produced, accredited electronic media CME program undergoes a rigorous peer-review process in which two Academy fellows comment on the educational material using a prepared set of questions developed by the Academy’s Electronic Media Education Committee.

Education department staff tell me that we do not have a policy restricting nonmembers from participating as editors of or contributors to our electronic media programs. However, we do have a policy that at least one member must be listed as an editor. Further, I understand that for the Annual Meeting call for participation, for [submitting] scientific papers the only membership requirement is that at least one member must be listed as one of the authors. Annual Meeting multimedia program participation has no membership requirement. From time-to-time, nonmembers have submitted award-winning programs. For each of these activities, the peer-review process represents the Academy’s effort to ensure that our educational programs are accurate, effective, consistent with generally accepted orthopaedic practice, and supported by orthopaedic science.

Dr. Gorman, thanks for writing us. The issues you raised are important and worthy of further discussion. I look forward to your participation in future Academy programs.

Downsides to CDHC
The recent “Ahead of the Curve” article (April 2008) devoted to consumer-directed health care (CDHC) and health savings accounts (HSA) was incomplete and failed to mention the obvious downsides to these programs.

CDHC depends on the assumption that the healthcare economy operates as a free market, as the computer or aircraft industry does. As long ago as 1963, healthcare economists (Kenneth J. Arrow, for one) have shown this assumption to be false, for the following very good reasons:

  • Injury or illness occurs randomly and unpredictably. Orthopaedic surgeons should know better than most people that acute injuries often are accompanied by factors of time and/or geography that preclude intelligent “shopping around” for a cheaper doctor, hospital, or treatment option.
  • Healthcare consumers must depend on professional guidance for their decisions. Studies have shown that the Internet is a fountain of misinformation and direct-to-consumer advertising is biased.
  • A free market depends on price competition. I don’t see this in place to any great extent.

CDHC and HSAs, because they depend on high-deductible health plans, will obviously lower healthcare costs to the employer by shifting costs to the patient. But they place an unfair burden on two very vulnerable groups: the poor and the unhealthy. The main principle of insurance is to share the risk equally—not to divert precious healthcare resources into retirement accounts for healthy people.

William H. Salot, MD
Grosse Pointe Shores, Mich.

Clarifying the PA’s role
The practice management article, “How to use physician extenders: Four ways to integrate PAs into your practice” (March 2008), contained excellent information regarding physician assistant (PA) utilization. In particular, the pointers for avoiding problems showed great insight and understanding of PA practice.

To be completely accurate, however, the phrase “independent practice,” which was used throughout the article in reference to PA practice, warrants clarification from practical, philosophical, and regulatory standpoints.

Although PAs may practice with a great deal of autonomy and the physician is not necessarily required to be on site while the PA is treating patients, a physician assistant may not engage in independent practice.

Physician supervision is the hallmark of PA practice. The American Academy of Physician Assistants (AAPA) definition of PA states, in part: “Physician assistants are health care professionals licensed ... to practice medicine with physician supervision. ... Within the physician-PA relationship, physician assistants exercise autonomy in medical decision making and provide a broad range of diagnostic and therapeutic services ...” (www.aapa.org, accessed 04/17/08). Although the distinction between independence and autonomy may be subtle, it is a distinction that is the cornerstone to the physician-PA team.

Tricia Marriott, PA-C, MPAS
AAPA liaison to the AAOS

New name for Now?
Wow—the April issue of AAOS Now could be renamed PEOPLE: Orthopaedics Edition.

All the gossip, plus exposed flesh (albeit in the surgical ads). Renew my subscription!

Janaleigh Hoffman, MD
Fremont, Calif.