A Single Constant In a World Of Change

Address to 1998 Class of the American Academy of Orthopaedic Surgeons

By John B. McGinty, MD

President Jackson, members of the Board of Directors, Fellows of the Academy, distinguished guests and members of the Class of '98, it is indeed an honor to have been asked to address you this afternoon. It was eight years ago that I gave an address in this same auditorium in New Orleans entitled The Winds of Change. I don't believe that any of us, at that time, realized just how hard the winds were blowing and how profound the changes in the practice of medicine in this country, and therefore, the practice of orthopaedics, would be in the ensuing eight years.

We have seen the control of clinical practice arrested from the hands of the physician by managed care administrators and the entrepreneurs of for-profit health care. We have seen the length of hospital admissions and the parameters of hospital care pass from control by physicians to control by the giants of the insurance industry. As a result of these changes, we have seen the quality of care diminish, ostensibly in the interest of containing the accelerating costs of health care. But costs have only increased with profits going to the business interests in health care and gains going to stock holders instead of being passed back into the system to lessen the financial impact of health care on consumers. There has been a shift of income from quality high-technology medicine with its necessary research and education to the entrepreneurs and investors. And, probably most important of all, we are seeing increasing efforts to change the art and practice of medicine into a business, with its cold cost-cutting efficiencies and attendance to a profitable bottom line attaining a higher priority than the quality of care and the sensitivity of the care-giver. The magnitude of these changes has been enormous and frequently at the expense of the providers and institutions that give the best health care in the world. Health care has become, at $1 trillion, one of the largest industries in the United States.

The purpose of this presentation is not to belabor these changes, but rather to give you a single important message, a message that is essential if you are to enjoy a satisfying and productive career in orthopaedics such as I have been fortunate enough to enjoy in the past forty years. There is, and always has been, one constant in medicine and in orthopaedics and that constant is caring for your patients. No changes in the business of health care and its ensuing profits, no efforts in cost containment, no financial gain by providers can change that constant. The difficulties of providing care under managed care systems does not change the responsibilities of the care-giver to maintain a doctor-patient relationship that is based primarily on caring for the patient.

A very disturbing story was published in the Wall Street Journal last year of a nine-year old boy who had a stick driven through his cheek to the base of his brain in an accident. The parents called their health plan for permission to go to a hospital, where, 10 hours later, surgeons removed the stick and attended to the laceration. Days later the youngster was still feeling ill and inspite of the parents queries of any relationship between the illness and the previous trauma and their request for an MRI, the gatekeeper gave the patient Advil and advised waiting. Two days later when the child complained of a severe throbbing headache, the parents took him to the hospital and twice asked if he should have a brain scan. Twice they were told that he had a form of meningitis and were sent home. Weeks later, because his condition had worsened, he got the scan which revealed a brain abcess. He ultimately had stunted intellectual development, spasticity and blindness. This story graphically illustrates how physicians are losing control of their patients because of corporate bureaucracy resulting in the weakening of the doctor-patient relationship. An HMO executive was quoted as saying: "We see patients as numbers. It's easier to make a decision. Just like Ford we're a mass-production assembly line and there is no room for the human equation in the bottom line. Profits are king."

A strong doctor-patient relationship is essential to successful treatment. A recent survey showed that today doctors spend eight minutes talking to patients in each visit, less than half as much as a decade ago. Without a stake in their practice, under managed care, some show up, do their job and are less likely to take a personal interest in their patient. It has been stated in an article in the Journal of the American Medical Association that "medicine is a moral enterprise grounded in a covenant of trust. Today that covenant is severely threatened. From within there is a growing legitimization of the physicians material self-interest; from without, for-profit forces press the physician into the role of commercial agent to enhance the profitability of health care organizations. Such distortions of the physician's responsibility degrade the physician patient relationship that is the essential element and structure of clinical care."

There is a guest editorial in the January issue of The Journal of Bone and Joint Surgery written by a pediatric otolaryngologist who related a very negative experience with the orthopaedic surgeon who performed a total knee arthroplasty on her 80-year old mother. The author was extremely disappointed with the lack of communication with her mother's surgeon. The surgeon's side of the story was not told, but it doesn't matter. What matters is the perceptions of the patient and her family in the course of communication or lack thereof. The author brings out the valid point that there is a difference between fixing and healing, between being a technician and being a physician. We have moved away from being the physician who listens and who looks at his patient as a person not just an anatomical problem to be fixed, from being a physician who cares. I urge all of you to read that editorial and never forget the message as you go through your years of clinical practice. It was in the twelfth century when the philosopher-physician Maimonides prayed, "May I never forget that the patient is a fellow creature in pain. May I never consider him merely a vessel of disease."

Bernard Lown, in his book "The Lost Art of Healing," which incidentally is a book that should be read by every young clinician, quotes a Russian physician as saying, "Every time a doctor sees a patient, the patient should feel better as a result." It is often the case that the real problems of the patient are far beyond his or her presenting complaint and it is the responsibility of all physicians to recognize this, even if it takes more than time necessary. It is rare that patients search for alternative therapies when physicians focus on healing as well as fixing. If one just listens it often takes very little to make someone feel better.

Advances in technology, which have been the driving force in the practice of orthopaedics in the second half of the twentieth century, have also resulted in increasing subspecialization and emphasis on fixing the mechanical problem as an entity unto itself rather than a part of the whole. Diagnosis is now frequently made by exclusion using expensive tests and procedures, which, of course, maximize the incomes of those who do the procedures, and also take the attention away from the patient as a person with a problem; in other words, the problem becomes the focus rather than a human being with a problem. We, as physician providers, will never reform our health care delivery system until the patient again becomes the central figure in the doctor's agenda.

Healing requires a doctor-patient relationship of mutual respect, a respect that needs to be earned by both parties as with an other human relationship. It is only with respect that the doctor gains the patient's trust and without that trust the doctor can not heal, regardless how well he fixes. In "The Doctor's Dilemma," George Bernard Shaw noted that "all professions are conspiracies against the laity." The physician must give an accurate and truthful picture of the patient's condition and realistic expectations of the result of management. There is no place for unreal expectations or unnecessary black crepes. And there is nothing wrong with saying those three golden words: "I don't know."

The single constant of the welfare of the mental and physical health of your patients must remain the bottom line and keystone of all decisions that you make in your professional lives. You have become physicians and orthopaedic surgeons because you care about more than your own self-interest. By becoming members of this still distinguished profession you have incurred a life-long debt to society, a debt that can only be repaid by keeping the physical and mental welfare of your patients as the prime motivation for every clinical decision you make, every research project in which you become involved and every medical educational effort that you undertake. You must never let self-interest distract you from the considered care of your patients.

Orthopaedics is a wonderful specialty and has given me more than I dreamed when I decided to enter the specialty. The American Academy of Orthopaedic Surgeons has given me opportunities to meet and work with people who are extremely productive, opportunities to visit and experience many professional activities that otherwise would not have been available to me and opportunities to involve myself in discussion, debate and education in the broadest sense. You have seen this afternoon and must have been impressed by the current activities of this Academy. It is an association from which you will gain much over your career and which will ask little from you in exchange. I urge you to participate in its activities, and if not, at least partake of them. The practice of medicine and of orthopaedics is a continuum of education throughout your entire professional lives. The Academy provides the ideal milieu for you to fulfill this responsibility.

I would like to close with a poignant comment that was published in The New England Journal of Medicine in December of 1996, a comment that I think applies to our professional life regardless how far the winds of change take us: "I am still a doctor, destined for more uncertain times, unmanageable days, undeserved rewards and the inexhaustible opportunity to touch the lives of those I treat. And to change their lives as they have changed mine. Our work bears the stamp of a centuries old tradition and is carried forward by each new class of physicians. Yea, though we walk through the valley of managed care and our business (if not our soul) is traded on the floor of the New York Stock Exchange, we are lucky to be here, doing what we do, still students of medicine, tending to the afflictions and infirmities of those who call us doctor."

Welcome to the Academy; Good luck and Godspeed!

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Last modified 26/March/1998