By S. Terry Canale, MD
First Vice Presidential Speech
67th Annual Meeting
March 17, 2000
There is an old southern saying that when you see a turtle on top of a fence post Ė you know he had some help getting there. I would like to thank Dr. Jim Beaty and Dr. John Garland for pulling me on top of that "post". One pulled and the other pushed. Iíll leave which did each to your imagination.
My two children are here also. My daughter Haines as well as my son Robb. I would like to thank them both for putting up with this dysfunctional, egocentric self-centered orthopaedic surgeon posing as a father. Thanks.
Finally and most importantly, I am indebted to my first wife who has made thankless sacrifices in her career to foster mine. She has been my inspiration and we have trudged together for 33 years. Somewhere along the way, I have fallen in love again with her. In fact, she is the inspiration for my address to you today.
My message to you today is very simple. We need to fall in love again -- fall in love again with our patients and with our reasons for choosing to be physicians. Managed care is still in front of us and we have not yet overcome all of the hurdles. But, for the last several years, managed care has been our focus and our patients have taken a back seat. It is time we move from the plan to the patient.
When we graduated from medical school, we took the Hippocratic Oath and were willing and dedicated to take care of anyone. As we specialized in orthopaedics, we wanted to provide the best care for anyone with a musculoskeletal problem. Ability to pay never entered the equation. However, in the new order of business, a patient is first asked what kind of insurance, not what his medical condition is. We must turn this around and become aware of who we are.
It has been said that the definition of humility is knowing exactly, precisely who you are. We are orthopaedic surgeons - that is what we do -- nothing more, nothing less. We are not entrepreneurs, not insurance brokers, not managed care gurus, and not landlords of outpatient surgery centers. We are physicians treating the patient first. We must fall in love with the concept again of who we are and what we do best -- treat patients with musculoskeletal problems.
In my opinion three problems have eroded the relationship between the physician and the patient. First, personalized service has been lost and replaced by speed of service. We've become the drive-through fast care center. While the public demands speed and impersonalization in many aspects of life, they want personalized medical treatment and a personal relationship with their physicians. Second, because of the increased financial burden of managed care, we have been forced to sacrifice the quality of care for the quantity of care. And third, we have spent most of our recent educational experiences learning about managed care at the expense of our orthopaedic education and at the expense of our patients.
How do we solve these problems? How do we make a change in our relationship with our patients? As you know, awareness is the first step toward change. If we are aware that impersonalization and lack of quality care have crept into our system, then we can solve our problems through education and communication. If you are aware that you have been neglecting your continuing orthopaedic education and are not happy about the manner in which you relate to and communicate with your patient, it's not too late to get back that "old loving feeling".
We need to fall in love again with learning. We need to rededicate ourselves to continuing education so we can learn the very best treatment options. Over the last five years I have spent countless hours reading journals, articles, trade papers, and magazines and attending CME courses on managed care. I have become very familiar with the Journal of Medical Economics, more so than that of the JBJS or the Academy Journal. This is okay if you are a rapid reader and learner and you have time to keep up with both managed care and orthopaedic diseases. But if you are just average and busy like me, it is quite difficult to do both and my orthopaedic education has suffered.
It suddenly dawned on me that I havenít read a thing on the glenohumeral joint in the past five years. New innovative arthroscopic diagnoses and procedures, no doubt, have come along. The bottom line is, Iím five years behind all because of the focus on managed care and economic concerns.
As managed care has settled in, all the difficult jargon, definitions and business concepts have become "old hat". So, now we have the time to renew our orthopaedic educational experience, and stay on the cutting edge of orthopaedic advances and treatment. We can do this by educating and reeducating ourselves through Academy CME programs, both electronic and written, and being open to new ideas like, for example, alternative medicine. Alternative medicine may not be orthopaedics, but it often pertains to musculoskeletal disorders. Besides, we may not like it, but it just isnít going to go away.
This year our Academy will provide CME endeavors on alternative care and musculoskeletal diseases so we will be able to advise our patients on the scientific validity, benefits and hazards of various alternative modalities. What a loving feeling it is to know that the treatment you are rendering to the patient is the latest, most up-to-date orthopaedic care.
The second area in which we can fall in love again is the art of communication. We must reeducate ourselves by listening to and communicating with our patients. The Academy is putting forth a new public relations effort beginning this year in an effort to differentiate orthopaedists from other musculoskeletal providers and to send a message to providers and the public, about what musculoskeletal care we provide. This program is intertwined with physician-patient communication. In developing this public relations program, we learned much about ourselves. The Public Relations Task Force surveyed two groups: orthopaedic surgeons and members of the general public, some of whom were patients. We found that orthopaedic surgeons would like to be perceived as: Caring, compassionate, informative, supportive of the patient, accessible and the primary care physician for musculoskeletal diseases.
When we asked the public and the patients how they perceived an orthopaedic surgeon, they replied: Highly trained and educated, held in high esteem.
Neither comment elicits a warm fuzzy feeling! That is where the love story ended. Patients felt that orthopaedic surgeons were somewhat impersonal, and aloof, listened poorly and were costly caregivers who were difficult to see on short notice.
And even more importantly, they believed that we were not necessarily the only quality musculoskeletal care provider. The public did not care so much about how well we were trained and what degree we held, or whether we were orthopaedists, osteopaths or chiropractors. What mattered was whether the caregivers were caring, compassionate and accessible and whether we listened and communicated with the patient. There is a wide discrepancy in how we want to be perceived and what others think of us. The old adage that applies here is, "If I could buy myself for what I was worth and sell myself for what I thought I was worth, I would be wealthy."
One of the most important things we learned from the PR survey is that we need to change the image of the orthopaedist as perceived by patients and providers. But the real message is, first we need to change ourselves. The worst thing we can do is to try and sell something to the public that we are not. So, how do we turn this image around? Can we re-learn caring and compassion or has the world, and we as orthopaedists, become too impersonal? Is it too tough a sell? I think not. The public expects the medical profession, above all others, to be personal, caring and compassionate.
Can we be taught the importance of these qualities? The answer is yes. But we donít need to teach these qualities, we just have to remind ourselves of these qualities that we already possess or we wouldnít be in the patient care field to begin with. We need to emphasize to ourselves and our members that physician-patient communication is the mechanism by which the qualities of caring and compassion are perceived. But how do we make our fellows listen? It is not easy and there are many obstacles.
How do we convince ourselves that physician-patient satisfaction is present when "in the office" is now more of a chore than a challenge?
How do we convince our members that medical errors that are being popularized presently can be largely prevented by proper communication with patients and with medical personnel. How do we convince ourselves that we have communications problems.
How do we overcome the idea that, "There may be a problem but itís not mine - I am a great communicator." I admit that I suffer from this last egotistical phenomenon.
I have been seeing patients in the office for 25 years and not once have I stopped to ask whether the methodical approach I use daily is correct. I rationalize that it has to be correct or patients wouldnít keep coming back. Besides I know how to communicate. I, like all orthopaedists have a proven track record. We were captain of our football team, class representative, president of our fraternity and the life of every party, after a little ethanol imbibment. What do you mean I donít know how to communicate? Iím an expert.
The solution may be in creating the ideal office encounter. Dr. Wendy Levinson, who is a pioneer in the physician communication field and is working with the Academy, has started research in offices of orthopaedists. Physician and patient encounters are being taped and graded. Exciting work in this field is being done, such as removing the words and listening only to the tone. Just listening to the tone of the orthopaedistís voice can give one insight into the interaction of the office encounter and how the orthopaedist relates to the patient. Research also needs to be done on how we relate to the elderly, to people with disabilities, and to other diverse groups of patients at different socioeconomic levels.
While this research is being done, we can teach some simple practical communication concepts. Know your patient's name. Go into the examination room and sit down. Establish eye contact. Examine or at least touch the patient. Show the patient the X-rays. Involve your patient in the treatment plan and before leaving the room make sure your patient is reassured and understands the instructions.
Itís not the amount of time, but the quality of time you spend that counts.
Sounds easy, but built into these mechanical steps are the hard parts of communication: Listening, asking open-end questions, allowing the patient to discuss the treatment options, showing compassion for the patient.
I am as guilty as anyone in being deficient of the latter. I often ask "how are you feeling" or "are you feeling any better." Both questions are an effort at quantitative objectiveness; but I never say as a statement of compassion or concern unconditionally "I hope you are feeling better." What a difference in the meaning by just changing a few words.
Our Academy will also be working on office-patient communications. How do we make our office a friendly caring place for our patients? Betsy Springer will continue to work on patient satisfaction surveys and hopefully we can ask the BONES organization, which is a strong association of orthopaedic practice administrators, to join with us in making office communications friendly.
One of the charges of the new Council on Communication is to determine how to best communicate our educational message via the web. This year we will put considerable resources into its web site. Not only for member education, but also for patient and public education. Patient education on the web isnít going to go away so we need to be involved upfront. We must give our patients and the public correct orthopaedic information and make the Academyís web site the gold standard for patient satisfaction and information.
At this meeting, your orthopaedic practices can sign up to link with the AAOS web site and give your patients easy access to patient education on the web through your own orthopaedic officeís web site. As you can see, these are exciting times in communications.
Al Ingram once told me that in a leadership position, one should keep the ship straight with a steady rudder, but also at the beginning of oneís tenure to try to accomplish two or three significant projects.
My presidential year will be dedicated to communication with the patient. This year, we will institute CME courses in communications at the graduate level for our fellows and later at the resident level, and then ultimately in the medical school curriculum.
The American Academy of Orthopaedic Surgeons will be the leader in the medical field in patient communication; the resource from which other specialties can draw inspiration, similar to our role in preventing wrong site surgery.
Immediately after this ceremonial and business session, a symposium will be held on communication. In addition, the task force on patient-physician communication has many recommendations that are being put into place in the next three years.
If we are going to "fall in love again" with our patients and our profession, we must first rededicate our efforts to providing our patients the very best and up-to-date treatment by reeducating ourselves through CME efforts and second, to rededicate ourselves to the ideals that led us into medicine to start with: caring, compassion and communication.
Please join me in making this the year of the patient. Patients donít care how much you know until they know how much you care!