By Augusto Sarmiento, MD
Six challenges that impact the future of orthopaedics
Groucho Marx once said, “Making predictions is a dangerous business, particularly if the predictions are about the future.” Ignoring the wisdom of his message, I venture to discuss what I consider challenges confronting our profession that may have a major impact on its future.
Tort reform is serious, frustrating, challenging, difficult, and complex. One aspect we often neglect to acknowledge, however, is that our actions, all too often, make us part of the problem, resulting in worsening the severity of the situation.
For example, a close friend of mine, a well-known spine surgeon, used to say that both laminectomy and fusion had a place in the treatment of disk disease. More recently, however, when asked about the subject, he replied, “The reimbursement for laminectomies has been so dramatically reduced in recent years that I now fuse them all.”
Is this what medicine is all about today? Unfortunately, this seems to be the message we are sending to medical students and residents.
We contribute to the spread of litigation in other situations as well. In published papers, for example, deviations from the normal that are not complications are often listed as complications. If we call these deviations “complications,” attorneys may surmise that their clients who experience these “complications” deserve compensation and the responsible surgeons, appropriate punishment.
When data in publications are deliberately distorted and embellished, we not only act unethically, but commit malpractice. When protocols are slanted in such a manner as to make the surgeon’s choice the only acceptable one, we commit malpractice. When we recommend a higher-risk treatment that gives us a greater financial benefit, we commit malpractice. Many other situations are daily temptations that some, hopefully a minority, cannot or wish not to resist.
Erosion of territory
Ignoring the erosion of our discipline is inexcusable.
In a number of institutions, no pathologic condition referable to the spine goes to orthopaedics. If orthopaedic residents do not get appropriate medical and surgical education in the care of spinal disorders, soon, by sheer numbers, the territory will totally belong to neurosurgery.
Plastic surgeons, within less than one generation, now not only perform cosmetic surgery and soft-tissue reconstructive procedures in the hand, but also internal fixation of fractures from the phalanges to the shoulder.
Today, podiatrists perform more major surgeries in the distal leg and foot than the orthopaedists. They staff emergency departments, so when patients with fractures of the foot, ankle, or tibia arrive, the podiatrist on call may be the one summoned to treat. I have personally seen fractures of the tibial shaft plated by podiatric surgeons in the Miami area.
The AAOS currently lists 26 different orthopaedic subspecialties. Excessive fragmentation has played—and will play—a role in the erosion of orthopaedics because it leads others to believe that our discipline is no longer a large and eclectic body of knowledge, but a splintered group in which one or a few surgical operations constitute the territory of its many subspecialties; it suggests those few operations can be mastered by virtually anyone with a modicum of surgical skills.
Is the body of orthopaedic knowledge larger today than it was 50 years ago? Or can we safely say that it is not larger, but different? That new knowledge has simply replaced old knowledge?
When I was a resident, the arthritic hip could be treated with femoral and acetabular osteotomies, tendon releases, intra- and extra-pelvic neurectomies, forages, synovectomies, capsulectomies, and at least six different intra-articular and extra-articular fusions. We also had to know how to do Smith-Petersen mold arthroplasties and Austin Moore prosthetic replacements.
Currently, for all practical purposes, all that is needed to surgically treat an arthritic hip, regardless of etiology, is total hip replacement. In other words, less clinical knowledge and more limited surgical skills are needed.
The subspecialization trend also affects resident education. As residency programs modified their structures to accommodate the subspecialties, some rotations became too short to satisfy the resident’s needs. Cohesiveness in the approach to the care of musculoskeletal conditions was weakened.
Schools do not teach us to think, but to believe and imitate our teachers. It is not until later in life that some realize the absurdity of this trap. With increasing frequency, residents in many programs are not being educated to be scientist/surgeons, but trained to become first-class technicians, skillful cosmetic surgeons of the skeleton.
Some 25 years ago, by adding one year of fellowship, most residents voluntarily increased the length of their training from 5 to 6 years. At first, I thought it was a good idea that enabled residents who felt weak on a given subject time to address that deficiency.
Many residents, however, elect to take the fellowship year not in an identified area of weakness, but in the subspecialty most attractive to them or the one perceived at the time to lead to a more lucrative practice.
Many cities are already becoming saturated with fellowship-trained surgeons in some areas, leaving no room for new arrivals. If the trend continues, the number of subspecialists needed to take care of communities would grow exponentially. The income of these surgeons, however, will be significantly lower than expected, because there will not be enough patients for each of them to satisfy his or her economic needs.
I am not suggesting turning back the clock. My critical views of fellowships should not be misconstrued as a sweeping condemnation. I am keenly aware that pursuing fellowship training is valuable for those who anticipate an academic career and wish to enlarge the scope of their knowledge. Additional training in pathology, basic research, immunology, or other similar subjects makes the academician a better-prepared person to discharge his or her teaching and research responsibilities. This also applies to those in the private sector who wish to further expand their expertise on a specific area and to those who are offered employment providing the completion of specialized training.
Another issue rarely discussed concerns the performance of surgery by fellows rather than residents. In some rotations, residents only hold retractors and watch the attending staff cater to their fellows, who also have the opportunity to see patients preoperatively and during follow-up.
I believe the issue of orthopaedic fellowships needs to be addressed objectively before it becomes a real problem. A careful and serious study of the place and role of fellowships could be conducted by our representative organizations. Such a study should not be carried out exclusively by individuals who have long enjoyed the convenience of having their own fellows, but include other unprejudiced, unbiased people, so the social, educational, and economic components of the issue can be discussed.
Professionalism and the orthopaedic/industrial complex
I am convinced that the growing loss of professionalism in our ranks is, to a great extent, the result of a misguided and inappropriately conducted relationship between orthopaedics and industry, a relationship that is necessary and essential to both parties.
For all practical purposes, industry exercises an overwhelming control of our education, as evidenced by the thousands of annual educational ventures that are directly or indirectly under their control. Every dollar industry spends supporting our programs extends its reach into education and justifies increasing the cost of products.
Industry effectively manipulates the system to ensure that the faculty of continuing education courses comprises people who, from the podium, will help sell their products. Direct-to-consumer marketing will soon show additional harmful effects.
When I recently invited industry to display products in the lobby of a symposium, three companies asked how many speakers they would be entitled to select. This is why so often some courses look not like gatherings of sophisticated physicians but Persian bazaars.
The Justice Department investigation of the relationship between orthopaedists and industry has disclosed serious transgressions, some of which are considered to be of a criminal nature. I was hopeful that the investigation would be carried out to its logical conclusion, but now, I am not so sure. We are told that companies have taken steps to correct their inappropriate activities and revamped their practices. I fear this move will be nothing but a distraction.
I sincerely hope the investigation will continue until the current corrupted system is completely corrected—on both the physician side and the industry side.
Industry benefits tremendously from some orthopaedists who, obsessed with the idea of becoming famous and wealthy, serve as their lackeys and receive millions of dollars to develop or promote new implants that much too often represent nothing more than inconsequential gimmicky modifications of existing products.
The healthcare crisis
At a time when our discipline desperately needs a coherent response to the host of challenges it faces, some of our representative organizations seem to be mired in irrelevant parochialism dealing almost exclusively with growth and self-serving pocketbook issues. Growth is not an end in itself and is not synonymous with prosperity.
No matter how complicated the issue of healthcare reform may be, no party or segment of our society, other than the medical profession, is in a better position to be effective in addressing the serious consequences of leaving the crisis unresolved. Not taking action is an action, but the wrong action. Dante Alighieri, in his immortal Divine Comedy, said, “The hottest places in Hell are reserved for those who in time of crisis remain neutral.”
Although moral conduct cannot be legislated, we can promote it and inculcate it in the minds of the young, as well as the more mature individuals, who are, with increasingly louder voices, expressing concern over the deterioration of their chosen profession.
Evidence exists to support the fear of socialized medicine and the superiority of a capitalist system. In some highly advanced countries, however, medicine has thrived under a socialized system and steadily contributes to science and progress. An increasing number of articles are coming from overseas and being published in major orthopaedic journals.
I am not supportive of socialization of our profession; I am simply trying to look objectively at the big picture. Even under the best of circumstances, we must become active partners in the ongoing debate and accept that a carefully and realistically structured rationing of the use of technology is unavoidable and necessary. Without surveillance and oversight, the costs of nonessential expensive tests and the performance of unnecessary surgical procedures make patient care unaffordable and unsustainable.
Allowing medicine to continue to become strictly a business, while ignoring the basic tenets of altruism and professionalism, will do nothing but to expedite its further decline and the implementation of the radical changes hovering above us. Embracing a positive course of action will not guarantee success; not taking that course almost certainly guarantees failure.
The administration is rapidly moving healthcare reform to the front burner, capitalizing on the popular support for the new president, and building what appears to be an unstoppable Juggernaut. Some of the challenges we are confronting are paradoxically intimately entwined with technical progress.
We should remove our blinders and recognize that the rapid, unharnessed technical explosion in orthopaedics is partially responsible for the serious challenges we now face; that many technical developments, about which we are so proud and call expressions of progress, may not be progress at all but “madness on the loose,” as philosopher Michael Novak, referring to society in general, recently said.
Augusto Sarmiento, MD, is a past president of the AAOS. This is an abridged version of an address he presented to the Florida Orthopaedic Society.