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Orthopaedists have long had a love affair with tinkering, “toying with,” engineering, and inventing in all aspects of biomechanic (biomechanical engineering) endeavors. This romance has brought them close to orthopaedic device manufacturing companies, which I believe is okay because it’s resulted in benefits to our patients and has fostered some extremely important inventions and innovations in our field.

AAOS Now

Published 10/1/2010

Romance and finance

In today’s world, most problems are related either to romance or to finance…and some are tied to both.

S. Terry Canale, MD

But this editorial isn’t about romance; it’s about finance. It’s (all) about (the) money, money, money, money—enough already!

Being paid fairly for the goods and services you provide has always been a tenet of our democracy. But lately, money’s gotten a bad rap. It’s not only the Wall Street bonuses, or the government buy-outs, or the national debt. There’s an underlying current that people who are paid “big bucks” are somehow at fault.

Take orthopaedic surgeons, for example. An article in the Archives of Internal Medicine last month focused on the disclosure—or lack of it—among authors of scientific articles in a number of orthopaedic journals, including the Journal of the AAOS. That’s triggered a number of reactions, mostly unfavorable to orthopaedists, and even among orthopaedists.

As William Renda, MD, wrote me: “I am personally tired of having to defend my profession and tens of thousands of fellow hard-working orthopaedists because of the greed and avarice of the few. This leaves a clear impression of systemic and widespread corruption of medicine and, in particular, orthopaedic medical literature.”

Now, I don’t know that the individuals who received those payments are greedy and avaricious. They may very well have worked just as hard as I do and earned every cent that they were paid. What I do know—particularly as the editor of a news magazine—is that every story, including this one, has at least two sides.

It’s more complicated than a coin flip
Orthopaedists are currently facing a “heads, I lose; tails, you win” situation. It may be that nothing we do can turn around the bad press that’s fallen out of the Department of Justice investigation. But here are some points that I think are just non-negotiable:

  • Collaboration between surgeons and orthopaedic industry is essential in continuing the progression of medical science and continued improvement of patient care. When transparent, relationships between physicians and industry can create innovative medical advances that benefit patients and improve both health care and people’s overall quality of life.
  • Orthopaedic surgeons—indeed all physicians—have an ethical duty to disclose any and all consulting relationships. They should be scrupulously honest, especially when the credibility of scientific and academic research, which can advance patient care, is at stake.
  • Studies have shown that the dollar amount doesn’t really make a difference. Whether it’s $10, $10,000, or $10,000,000, it’s the relationship that needs to be disclosed—to colleagues in the case of a journal article and to patients in every case.
  • “Relevance” isn’t the issue; disclosure is. The royalties an author receives from a shoulder implant design may not have anything to do with the article he or she is writing on the use of plates in upper extremity fractures, but readers still ought to know that he or she has a relationship with XYZ company.

That all being said, I can understand the problem that journal editors face. Even if they require that all authors submit disclosure statements with their manuscripts, by the time the manuscript is printed, the disclosure information may be out of date. An author may have severed relationships with one or more companies, and signed on with others. So do you print the old disclosure information or the new? Do you combine the information? How far back can you go…and how do you explain it to readers? How much time and effort does the journal have to devote to verifying the information?

According to James D. Heckman, MD, who was editor of The Journal of Bone and Joint Surgery (JBJS) during the study period, “The editors are totally dependent on disclosure by authors. Editors don’t have the resources to police disclosures.”

Dr. Heckman also points out that the move is toward full disclosure, including dollar amounts. JBJS presently demands disclosure of any relationships lasting longer than one year and the sources of funding for studies, regardless of when obtained.

We’re the example
Until all medical companies disclose all payments to all physicians—cardiologists, radiologists, internists, and so on—orthopaedists are the example. Our payments were out there first, and we’re blazing the trail and occasionally getting caught in the thicket of things.

That’s why the Academy’s disclosure policy continues to evolve, mainly in the direction of mandatory disclosure of all potential conflicts and relationships—related or not—for everyone involved in educational and leadership efforts. We urge other medical groups to move in a similar direction.

Physician-industry relationships—and the responsible and complete reporting of them—are a top priority and a challenge across the U.S. healthcare system. It’s in everyone’s best interest to get it right.

If we can get the whole disclosure issue right, we can fall in love again with our ability to be inventive and have our orthopaedic colleagues be proud of the accomplishments of innovative orthopaedists. For more information visit the AAOS disclosure policy.