A Time For Renewal

by Douglas W. Jackson, MD

Renewal entails monitoring and evaluating what is working, reaffirming what is essential, and making the adaptations to the changing environment. Renewal is a process every established organization and profession must go through in changing times if they are to remain vibrant and relevant. The American Academy of Orthopaedic Surgeons has a renewal process, a dynamic strategic plan, in place for our organization. This was developed with broad based input from members. This living document is constantly renewed by the Board of Directors. This renewal process for our organization is working. The challenge before us is the renewal for our profession and the role the orthopaedic surgeon will play in the health care delivery systems of the 21st century.

Because the changes we are experiencing in our professional lives as orthopaedic surgeons today are so profound, I want to reassure you that I am focused on the present. While renewal for our future members is a commitment I feel strongly we need to address, I want you to know I am here to serve the current members of the American Academy of Orthopaedic Surgeons and the patients we serve.

You will be hearing the details of the multiple array of current and ongoing projects and programs that the Academy is engaged in from our President, Dr. Ken DeHaven, at this meeting. You will be hearing the progress of these ongoing projects in the coming year and through the methods of communication we have with you. In addition, two areas of special renewal will occur this year. This March, your Board of Directors and Council on Education will hold a workshop which will culminate one year of preparation looking at the education of orthopaedic surgeons in the year 2001. The changes impacting adult continuing education will require the renewal of our strong tradition and commitment to innovative and quality education. You will be reading and experiencing the outcome of this work.

The other area of renewal this year will evolve as the Medicare reform debate proceeds. Our organization will need to step up and be part of responsible debate representing the patients we serve and the professional concerns of our members. Personally, I have come to the point in my practice that the continued one-sided cost reductions as a solution to financing health care have gone too far. We need to continue to be part of a solution that empowers patients, thus rewards patients that are responsible for their own health and lifestyles, that offers portable coverage, choice and access. We need to continue to work towards a system that returns the real savings from health care cost reduction to the patient and the providers and not to an investor. Simply reducing reimbursement to providers does not address these real basic issues. You will be hearing further details of the Academy's Medicare reimbursement coalition-building activities and individual efforts in the April edition of the Bulletin.

What I want to focus on today is the renewal of our profession and the role of the orthopaedic surgeon. Take your thoughts away from our situation today and think about the new members sitting in your seats as well as those of you who will be attending our Annual Meeting in 10 to 20 years. Our profession will continue to be impacted by changes that the AAOS cannot respond to alone. The entire House of Orthopaedics, including the Academic Orthopaedic Society, American Board of Orthopaedic Surgery, Resident Review Committee, American Orthopaedic Association, Specialty Societies and the American Academy of Orthopaedic Surgeons will need to re-evaluate, reassess, and possibly restructure the selection and education process of the orthopaedic surgeon of the 21st century. Some of you have said to me, "We have been on the right track for our patients and our members, there is no reason to consider changes if that is what renewal might bring."

Will Rogers said it succinctly, "Even if you are on the right track sometimes you can get run over if you are not going fast enough." We have been on the right track but there is another train on our track and it is gaining momentum. That train is called the "Market Place Express." It is a big, fast train with some large forces on board. These include some new parameters in the supply and demand of orthopaedic surgeons, managed care's impact on the role of the orthopaedist, the funding of orthopaedic residency and fellowship training, and the funding of musculoskeletal research. If we do not choose to speed up the pace of our professional renewal, then our other choice is to let the market place do it for us. Market forces may induce many changes whether we are involved or not. But if we do not come together and address these forces impacting our profession, we will not have an affect on our outcome.

The choices our profession is facing are analogous to finding ourselves in the middle of a river that has entered a narrow canyon and we are suddenly in the strongest currents we have ever known. There are some decisions to be made, however, we can not stay where we are. One decision is to let the current determine our outcome. We can choose to lie back, put our toes up, protect our head as best we can, and ride it out until we can regain some control again. When we do reach calmer water, we can assess what is left of the things we started with and go on. The other option is to work in and with the current. We will end up to the right or left from where we started and will end up a bit downstream. The current does not have to have total impact on our outcome. I am proposing we consider in our collective and collaborative wisdom the role and profession of "the orthopaedic surgeons" of the 21st century.

As I look out at you today, I take great pride in being one of you. We have been educated and trained in different parts of the country and at different times; we practice in different settings from private offices and clinics to universities, to managed care organizations, to the military, to missionary and volunteer work, to the veterans hospitals and other government agencies. We have one thing in common, we are orthopaedic surgeons. While under the umbrella of being orthopaedic surgeons, we function differently as surgeons. Some do many different operations, some perform a large volume of surgery, some perform a few different operations, some do no surgery, some perform evaluations, some do research, some teach, most of us volunteer in various capacities, some work full-time and some work part-time, but we are all focused on patient care involving injuries and problems related to the musculoskeletal system. Regardless of where we are in our careers, we have another thing in common and that is as society struggles with its financial support for medical care, we have all adjusted our behavior to cost-containment programs. Some of these changes have been positive and some have been objectionable. These forces will increase as we enter the 21st century. They have the potential to significantly change the role of orthopaedic surgeons in future health care delivery systems.

We have the opportunity and the obligation to those that follow us in orthopaedic surgery to see that they will feel just as privileged as we feel to be in this profession. Let me give you some specific examples where we might decide we want to renew for the future rather than totally accept the decisions of the market place.

Patient care is an area in which we have expanded our role. We have excelled in individual patient care in the examining room, the emergency room, or the patient's bedside. In privacy, you and the patient have made the best decisions for that patient. This will still remain fundamental, but in the 21st century we will need to define and consider our role and our responsibilities to the musculoskeletal needs of "populations of patients." This attention will be directed to "community outcomes" as well as individual outcomes. At the same time we consider expanding our role, society is putting limits on the resources to provide communities of patients with their musculoskeletal care.

Our focus should broaden to the collective needs of all musculoskeletal patients. In addition to treatment of the musculoskeletal system, research and education is needed to assist patients in areas of risk reduction and health incentives. Our involvement in "wellness" education should lead the way in preventing injuries, reducing the effects of degeneration, minimizing repeat musculoskeletal injuries, reducing workplace disability, and promoting the well being of the musculoskeletal system. We need to be part of the data gatherers and researchers that will further define the beneficial basis of exercise and conditioning, we need to take on the deleterious effects of obesity, poor conditioning, and nutrition on the musculoskeletal system. Much like those medical professionals who addressed the role of cigarettes through documented research and education in addition to treating its effects. As with the example of cigarettes, not everyone will choose to strive for improved health of their musculoskeletal system. Educating those patients more at risk for their musculoskeletal problems is a real challenge. Patients need education to assess, monitor, and to know when they need to seek appropriate care. The algorithms of the future will start with an educated patient entering the system. This is an area where there is a real potential for other health care providers to address and take the lead. There is, also, an increased potential for to have other providers interposed between the patient and the orthopeadic surgeon for nonoperative conditions of the musculoskeletal system.

We must be involved in the establishment of the future "seamless musculoskeletal care." The goal of the 21st century should be for patients to receive quality and cost-effective care without encumbrance. The marketplace will determine who takes care of which musculoskeletal patients unless the physician providers of this care bring forward a workable model. The issue should be, is appropriate care being given and is it value-added care? The care that is provided is more important than the title of who gives the care. This is a concept we do not agree upon in medicine at this time, but the 21st century will demand a solution. We can not do this in isolation as we are not the only physicians and providers meeting the musculoskeletal needs of patients. We as orthopaedic surgeons do not even provide care for the majority of musculoskeletal complaints in the general population. If one corrects for the severity of the musculoskeletal problem, we care for a much higher percentage of musculoskeletal conditions.

Overall, musculoskeletal conditions are the second largest disease category second only to respiratory disorders. In 1994, there were 38.1 million new problem visits involving musculoskeletal patients, representing 15 percent of all new problems. We are treating less then one-third of these patients now. Where will the orthopaedic surgeon of the 21st century fit into the spectrum of musculoskeletal care? That is an issue we must address, evaluate, build consensus upon, and make necessary adjustments. The American Academy of Orthopaedic Surgeons cannot do this alone. It will take all of the House of Orthopaedics involved in internal collaboration as well as external collaboration. The bridge building initiated two years ago by then President Jim Strickland will need to be expanded.

Winston Churchill said that Americans always get it right, after they have tried everything wrong. Hopefully, we as musculoskeletal physicians and providers of care will not have to try too many wrong tracks in the health care revolution. We and our profession are in a revolution. A simplified definition of a revolution is, a redistribution of the wealth. We are living through a major reallocation and redistribution of the health care dollar.

As part of this reallocation, we are being told by health policy analysts, managed care organizations, and governmental agencies that there currently are, and we are training, too many orthopaedic surgeons. We have an obligation to our future members. After years of hard work and sacrifice we need to be certain they have professional opportunities commensurate with their training. In addition, we have a responsibility to see that they receive the type of education and training that is appropriate for the musculoskeletal needs of the population of patients and individual patients they will be serving. We need to develop some consensus and then reshape our education process if we agree it is necessary.

As part of our renewal as orthopaedic surgeons, it would behoove us to work on our image as cognitive physicians that have a high proficiency in certain motor skills. We should help society define how proficiencies in motor skills are taught and documented. We have the most sophisticated motor skills facility in the world in our Academy building, developed in partnership with the Arthroscopy Association of North America. This offers us the opportunity to study and develop objective measurements of surgical motor skills. This has never been done. The old methodology of "see one, do one, teach one" may be the best method, but we need to re-evaluate that concept. This would be a major contribution by our profession to all of surgery.

An objective way to measure motor skills is one way we have to respond to the challenge of volume. "Volume" is being proposed as the measure to decide which surgeon does which procedures. We must address this and not let the market place decide it on cost alone. This should not be a threat, as real professionals enjoy demonstrating their motor skills if the evaluation is objective and fair. We need to give our future surgeons the support they need to be proficient, and if there are those that for some reason cannot achieve the motor skills, we must be able to recognize the deficiency. What is best for the patient will continue to set the standard.

We also need to re-address residency and fellowship training. What should the scope of an orthopaedic surgeon's practice be after five years of residency? Why do we need additional years of training for some? Why can't those needs be met in a five year curriculum? The 21st century will ask us to justify why our training programs need five years of funding. Another question we will have to respond to, is it cost effective to have interventionists giving first contact musculoskeletal care? We must be part of this debate with convincing data in hand. This will require us to further define our role as nonoperative musculoskeletal physician care givers. If we focus on being technocrats and interventionists only, we need far fewer orthopaedic surgeons. Technocrats will be quite vulnerable to changes in technology that reduce the motor skills necessary for the treatment of a given condition. For example, new drug therapy, gene manipulation, local applications of cells, biologically-active molecules and factors may reduce the need for surgery in certain conditions.

Who will give the "nonoperative orthopaedic care" of the future? Will it be a primary care physician, a rheumatologist, an ER physician, or a physiatrist? What role will the chiropractor, therapist, or podiatrist play? We have an obligation in our renewal to help define what an orthopaedic surgeon of the future will be and do. We cannot assume our present role will be maintained. We must participate in responsible dialogue and planning on what the standard of care will be for the musculoskeletal system. The House of Medicine in the future cannot remain so territorial. "Defending turf" is not the debate our society and patients need from us in the 21st century. How do we best educate those providing value-added care for the spectrum of musculoskeletal problems? We need to train the appropriate number of qualified providers of the spectrum of musculoskeletal care. It serves no one to train too many orthopaedic surgeons.

As we enter the 21st century, in addition to the number of orthopaedic surgeons, our specialty needs to assess the diversity of our members. Meeting individual and population patient needs with more sensitivity can be enhanced by having those populations represented in our membership. More diversity within our midst contributes to cultural richness in our organization and enables us to better meet the needs of underserved populations. Unintended barriers to more diversification must be eliminated. We need to continue to attract the best possible minds and caring physicians into our profession.

Women are not proportionately represented in orthopaedic surgery considering 40 percent of medical school student entrants are women. Two percent of our members are women and 6.3 percent of orthopaedic residents. Of our 158 orthopaedic residency programs, 110 have graduated a women. Only cardiovascular surgery has a lower percentage of women in their surgical specialty. We must in our renewal make sure there are no intentional or unintentional barriers to women becoming orthopaedic surgeons. If they choose not to be in our specialty that is a different matter. I personally doubt that accounts for all the current discrepancy from the medical school pool of potential candidates.

There are similar issues related to our ethnic diversity. Part of increasing diversity is encouraging qualified individuals in medical school to consider becoming orthopaedists (AAOS members). We need to evaluate our input and image among medical students as well as among our physician colleagues, and non-MD musculoskeletal providers. Trying to understand our image among medical students and colleagues in other specialties, I have been asking many of them their impression of the typical orthopaedist. It is very common for someone to express an image of an orthopaedic surgeon as being very physically strong and not as intellectually gifted as others in many fields of medicine. There is an image expressed of an athletic, affluent caucasian male who is not always a team player; like fighter pilots who may not like to fly in formation. These perceptions were elicited repeatedly and randomly but not as part of a scientific survey. My sampling found these perceptions widespread among physicians and medical students. These perceptions impact who chooses our profession. The "isolation" of being different is something that often slows change. We all have a comfort level in selecting those like ourselves.

Our internal image of ourselves is somewhat different. We all take pride in the high quality of our residents and young members. We describe them as the "cream of the crop." Many chairmen of residency programs have said they take primarily AOA medical students, only those in the top 10 percent of their medical school class. We need to reconcile our internal and our external image. Those that are coming after us are going to practice with less autonomy and they will be compensated more similarly to their colleagues in other fields. More of them will have to be members of teams of physicians and providers that give musculoskeletal care to populations of patients. More of the orthopedists of the future will do ambulatory care and mostly outpatient surgery.

We have one other very important challenge in our renewal process. We need to replenish our orthopaedic academicians and researchers. They are an endangered species and represent our lifeline to staying in the forefront of musculoskeletal care. In addition, we need to nurture a new breed of "orthopaedic surgeons" that are administrators of the musculoskeletal care for populations of patients. While many of these issues are generic to the rest of medicine and society, we must be the ones that focus on our profession and its renewal for the future-The Orthopaedic Surgeons of the 21st Century.

All this renewal will take effort, commitment and vision. As I have traveled getting to know you better these past two years, I have come to appreciate even more the unbelievable talent and resources the member volunteers have in this organization. We, also, have one of the finest professional staffs in organized medicine. We are up to the challenge. Remember, someone did it for us and our patients. Let us speed up and stay on the right track, make those changes we agree upon within the current of market forces, and let us get it right sooner, rather than later. I have confidence that we will.

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Last modified 20/March/1997