Orthopaedic heroes set an example to follow

Last year, the AAOS celebrated its 75th anniversary with many events, including the publication of a history of orthopaedics. It highlights many seminal figures—visionary men and women who built the foundation for our current professional lives. As we face intense financial challenges and consider our responses, let us remember these pioneers and the circumstances under which they practiced and loved orthopaedics.

Our current medical system is unsustainable, and we are quite likely to feel downward pressure on our incomes for several years. The federal government, through Medicare and its participation in Medicaid, simply cannot continue to support the medical establishment as richly as it has in the past. The current global banking crisis has greatly exacerbated the problem by requiring large capital outlays by the federal government. The Congressional Budget Office estimates a deficit of $1.2 trillion for the current fiscal year, which does not include the costs of the pending stimulus plan.

In an interview with the Washington Post, President Obama stated that “the big problem is Medicare, which is unsustainable…” and called on all Americans to be ready to sacrifice to save Medicare.

Inspiration from the past
Fortunately, we have the example of our orthopaedic ancestors for inspiration. Their achievements, outstanding patient care, and love of orthopaedics all took place in environments where they made considerably less money than today’s typical orthopaedist, whose mean salary of $394,000 is approximately 10 times the salary of the average American worker.

In 1931, when the AAOS was first envisioned, the average orthopaedic salary was just under 3 times the pay of the average American worker or less than $120,000 in today’s dollars. Despite this, the legacy of the Academy’s founders reveals that they enjoyed their orthopaedic practice and the life-changing treatments just as much as we do today.

Jump to the 1958 AAOS Annual Meeting. Despite fierce criticism, Paul Harrington, MD, persevered in using instrumentation to correct spinal deformity. His perseverance, determination, and dedication revolutionized spine deformity care and enabled us to treat spinal deformity patients in a way not previously imagined.

At that time, orthopaedic salaries were approximately 5 times those of the average American worker or significantly less than $200,000 in today’s dollars. But we do not question that Dr. Harrington enjoyed his work any less than today’s spine surgeons who receive many multiples of that income for comparable work using procedures that are entirely dependant on his original ideas.

Another example of an individual whose love of learning and caring for patients can still inspire is Abraham Colles. Born of humble origin in Ireland in 1773, he began his career in 1797 as a teacher of anatomy and surgery, with a practice of his own for “the sick poor.” In his first year, he earned 8 pounds (about $500 today), and he never earned more than 421 pounds ($32,500 in today’s dollars).

Elected president of the Royal College of Surgeons, he wrote “On the Fracture of the Carpal Extremity of the Radius” in 1814. It described the fracture named in his honor and discussed principles of its treatment—decades before the advent of radiographs. In retrospect, his work and insights are amazing and his humble beginnings and middle class earnings did not tarnish his love of medicine.

Riches aren’t always monetary
Orthopaedics is rich with stories of innovation, intellectual exploration, teaching, and compassionate care for the sick or injured. Our predecessors, those giants in orthopaedics, worked diligently and with astonishing achievement for much lower incomes than we expect today.

Not until the 1970s, after the advent of Medicare and Medicaid, did physicians’ salaries begin to grow exponentially compared to median household income, and this growth has been largely confined to physicians practicing in the United States.

We should be thankful that we have had the opportunity to enjoy such a large income from the practice of orthopaedics but also understand that it has always been unsustainable. Maintaining the economic status quo in medicine will eventually bankrupt the country; simply not enough money is available.

Although this is discouraging, we can all draw strength and inspiration from our orthopaedic heroes. They loved their work, their patients, and their profession, and they made astounding innovations while working for far less money than almost any of us enjoy today. They clearly found fulfillment in their work from nonmonetary sources, and we must do the same. We can start by remembering every day the joy that comes from realizing the improvements that we are making in the lives of others. Few others have been able to help their fellows as much, and that is a blessing to all of us.

In the coming years and budget battles, we can choose to squabble and scratch for every dime of reimbursement, or we can turn our collective attention to protecting our patients by making the sacrifices that President Obama requested. It will be quite tempting to rationalize protecting our income as a patient-centered goal—to preserve their access to us. This, however, may lead to work stoppages or the refusal to treat certain classes of patients.

We must never harm our patients in the name of fighting for them. In reality, we can accommodate large reductions in our reimbursement and still earn the historical average for orthopaedists while continuing to provide the same excellent care to our patients that our predecessors provided to their patients.

The AAOS mission statement is to “serve the profession, champion the interests of patients, and advance the highest quality musculoskeletal care.” We can choose to view these goals in harmony with each other, or we can see our interests as sometimes diverging from those of the patients we serve. If we recognize that patient interests must come first and foremost, even when this will cause us disappointment or loss, then our Academy can continue its high mission. If we place our own interests equal to or above those of our patients when they inevitably clash in the coming years, then our Academy will become just another interest group.

The choice is ours and, just as we rely on the inherited knowledge and the pioneering techniques of orthopaedists who have gone before us, let us also reconnect with their motivation and love for orthopaedics as we wade into an uncertain economic future.

James B. Rickert, MD, is an orthopaedist in private practice.

He can be reached at jbrickertmd@comcast.net

Sources:

AAOO 75^th Anniversary Timeline
U.S. Bureau of Labor Statistics
AAOS member survey
Sources for Abraham Colles from the Royal College of Surgeons (Ireland)
Sources for converting pounds circa 1800 to modern dollars:
The Economic History Services query services (http://www.eh.net)