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AAOS Now

Published 5/1/2012

From Patient Responsibility to PSAs

Responsibility
The discussion of the current guidelines for physician/patient interaction by the American College of Obstetrics and Gynecology (ACOG) (
“Does Patient Responsibility Still Exist?” March) ignores the obstetric role in which ACOG members have an additional responsibility to the unborn child. Surely, that is an important concern in follow-up.

Pediatric orthopaedists like myself, who routinely deal with children younger than age 18 years, are in a parallel situation. Parents are the responsible party. The child (patient) may be at risk when parents don’t follow through with treatment recommendations. As the child’s doctor, we have a responsibility to our patients, even though their parents may not comply. This is both a legal and ethical issue. 

All orthopaedists, when they care for children, should be aware of this responsibility. I think this article does a disservice by not including the unique aspects of the physician’s responsibility when caring for children. 
Robert N. Hensinger, MD

Ann Arbor, Mich.

Reimbursement
I wanted to reassure my fellow orthopaedists who may be alarmed after reading the article about the address presented by John Cerf, MD, during the Practice Management Symposium (“Expect Fundamental Changes in Reimbursement,” February). He is anxious about the one percent drop in spending on physicians services compared to total health spending. Actually spending on physicians services grew 2.5 percent between 2009 and 2010. It’s just that spending on other categories grew faster; for instance, hospital spending grew 4.9 percent. So to all those trying to make ends meet, don’t give up hope.
Robert E. Liebenberg, MD

Philadelphia

Telephones
I thoroughly enjoyed Dr. Canale’s editorial article regarding calling office practices (
“Please Hold…Your Call Is Very Important to Us,” March). Nothing is more frustrating or “consumer unfriendly” than trying to get through to someone and getting an answering system.

I especially enjoyed the “if you are still alive, press 1 or call back later” option. Keep up the great commentary....they make us all realize how idiotic some of our attempts at practice efficiency really are!
Jack M. Bert, MD

St. Paul, Minn.

Public service?
After much thought, I must raise concerns about the story regarding Ms. Dominique Gambale (
“Academy Rolls Out New Public Service Messages,” February). To the layperson (the target audience) this campaign could easily send the message that this approach (limb salvage) is not just the “right” thing to do, but is also the “best” thing to do. Most orthopaedic surgeons would recognize that this is not necessarily true.

Additionally, given that she needed nine additional surgeries, that she is only now walking, and that she continues to experience “pain and swelling in her leg,” one might make the case that this was possibly the wrong decision for both the patient and the healthcare system; what has been the financial cost of her treatment to date?

In my own practice, I treated a high-profile case of a teenager with a mangled extremity due to a shark bite sustained while bodyboarding. He was treated with just two procedures—a preliminary guillotine amputation at the referring facility and the definitive amputation by me a couple days later. One year later, he was not only fully functional, but he was also completely painfree and made headlines again when he was back in the ocean bodyboarding at the same spot where the shark attack occurred.

Despite his excellent outcome (which I could reasonably argue is much better than Ms. Gambale’s at the same point in time), I would similarly argue that this case should not be presented by the AAOS as a shining example of what should be done. Although it could never be proven, I would guess that, with proper counseling and support, had Ms. Gambale instead undergone a primary amputation she might reasonably be playing tennis today rather than hoping to one day do so.

Although I believe those involved in selecting and producing Ms. Gambale’s case for the campaign had the best of intentions, I also believe that the emotion and “attractiveness” of her story overwhelmed the scientific rigor that should have been applied in the decision-making process. At the very least, I believe the Academy owes members a follow-up to this story a year from now. Failing to do so would make a mockery of all that has been done to improve the validity of our scientific efforts over the last several years.
Byron Izuka, MD

Honolulu, Hawaii

Editor’s Note: Amputation vs reconstruction of the “mangled” (salvageable) extremity is a controversial subject among orthopaedists and orthopaedic trauma surgeons, and we appreciate Dr. Izuka’s insightful comments. The intended message of the public service announcement (PSA) was not that reconstruction was the recommended, correct, and right procedure; the message was that, since the Iraq war, advances in orthopaedics and orthopaedic surgery, particularly in limb salvage and amputation surgery, have broadened the choices for patients. In this particular case, the patient was fully informed of the prognosis, procedures, and probable outcome, and a shared decision was made to proceed with reconstruction. Limb salvage may not be the “best” option for every patient, and we certainly did not intend this PSA to suggest that. We believe, however, that Ms. Gambale’s case provides information to both patients and surgeons not only about what can be done but what challenges must be faced. For more about the development of this message, see “Story Behind PSA Shows Value of Military Orthopaedics” on page 46.

Access conundrum
AAOS President John R. Tongue, MD, raises
“The Access-To-Care Conundrum” (April). Perhaps it is time for us to think outside the ideological box and consider what works quite well with greater public satisfaction, overall superior health outcomes, and vastly reduced cost: a single-payer system.

Government has done quite well in a number of arenas. Consider the national park or the interstate highway system; reflect on the nearly 50-year effort of the U.S. Army Ordnance Department to standardize machine parts, which resulted in worldwide advances in toolmaking. A single-payer system—with care provided by private physicians using private nonprofit hospitals—is a proven model among developed countries for quality universal coverage at half the U.S. per-capita cost.

I am no great fan of the Patient Protection and Affordable Care Act (PPACA) reforms, which have no proven cost control mechanisms. The already unconscionable 31 percent overhead in our $2.6 trillion healthcare nonsystem must now approach 35 percent due to PPACA rules and waste.

Contrast that with the eight pages of legislation embodied in the first passage of the Canadian single-payer system. That system has its detractors, as do all systems, but it is embraced overwhelmingly by Canadians, and the politician who pushed it through, Tommy Douglas, is considered a great popular hero. With overhead costs in Canada a third of U.S. costs, and universal coverage with high satisfaction, we would do well to respect their success, rather than dismiss it as unworkable, or manufacture disinformation about long waiting times for care.

Consider what a single-payer system would do for our tort system: If every American had comprehensive healthcare from birth, the roughly 40 percent of malpractice award costs for economic damages due to future medical expenditures would disappear.

With healthcare costs projected to exceed the average citizen’s total annual income within 13 years, we need to think outside the box and make some real headway at controlling costs and expanding access. Thanks to our new AAOS President for raising this important issue. If we do not make positive efforts to change to a sustainable system, we will likely be spectators (victims?) in what devolves.
Ray Bellamy, MD

Tallahassee, Fla.

Setting Now Straight
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