ORTHOPAEDICS IN THE NEW MILLENNIUM
A New Patient-Physician Partnership*

By Robert D. DíAmbrosia, M.D.Ü, New Orleans, Louisiana

* First Vice-Presidentís Address. Read at the Annual Meeting of the American Academy of Orthopaedic Surgeons, Anaheim, California, February 6, 1999.

Ü Department of Orthopaedic Surgery, The Louisiana State University Medical Center 2025 Gravier Street, Suite 400, New Orleans, Louisiana 70112

Introduction

Dr. Heckman, thank you for your more than generous introduction. I would also like to thank the Fellows of the American Academy of Orthopaedic Surgeons for giving me the opportunity to serve you as your next president, a privilege which I humbly accept. These are busy and exciting times with many forces testing our resolve. So, know that I call upon each of you to assist me in the work necessary to maintain the goals and standards of our Academy. It is special for me that my family can be with me today: my wife and partner of thirty-five, Barbara, our four children Lisa, Chris, Matt and Peter and their spouses Greg, Yuko, Tara and Rene, and especially my three sisters, my Mom and Dad, and Barbaraís Mom who are able to join us.

I also stand on the shoulders of great educators, not the least of whom are my teachers and colleagues at the University of Pittsburgh, University of California at Davis with Paul Lipscomb and Louisiana State University, whose Chancellor, Merv Trail, is here with us. Thank you, Merv. I thank them for inspiring and challenging me. In addition to my family, they deserve credit for what I have accomplished professionally. There is one man I would like to single out: Albert Ferguson. Thank you, Ferg, for being there as a role model for me and my colleagues.

I would like you to sit back, relax, (let me be nervous) and think about the future with me for a few minutes.

I will not distract you with slides.

Past History

We must start this journey with the past:

Only a few of the fifty generations that span a millennium are lucky enough to witness the dawn of a new one. "Millenium" has two definitions: "A span of one thousand years," and "A hoped-for period of joy, serenity, prosperity and justice." A span of one thousand years is almost incomprehensible but may be placed in perspective when we consider that homo sapiens emerged as a discrete species just 60 millennia ago.

Looking to the roots of medicine, we must travel back three thousand years, arriving midway through the millennium prior to the birth of Christianity to locate Hippocrates (466-370 BC), recognized as the Father of Medicine. In past millennia, the world was largely an agrarian society. Prior to the 20th century, the practice of medicine employed little science and was mostly an art, yet its practitioners were held in the highest esteem. One hundred years ago, a physician had few tools with which to work, except those of compassion and caring. However, during this century, a technological explosion has led to spectacular advances in medicine and, as a consequence, physicians are infinitely better equipped to bring good health to their patients.

Our Orthopaedic roots date back to 1743 when Nicholas Andry unveiled his splinted, crooked tree, and not until the use of plaster of paris 100 years later, did we move out of the splint age. Modern fracture management rapidly accelerated during and after World War I with Sir Robert Jones espousing the principles of Hugh Owen Thomas. This was followed by the impact of World War II and battlefield medicine on our specialty.

Surgical practice, however, came into its own with the introduction of modern anesthesia by Morton (a dentist) in 1846, sterility courtesy of Lister (1876) and antibiotics by Fleming (1945). These advances made outcomes more predictable, and the practice of Orthopaedics, in particular, expanded exponentially, as surgical risks decreased substantially. New methodologies involving joint replacement, arthroscopy, spinal instrumentation and trauma reconstruction have all been developed in the latter part of this century. Although this period represents only a small segment of recorded history, the changes in technology seem to be happening overnight. It behooves us to pause and reflect where we are and where we have come from as orthopedists in the past 100 years. And to define our vision for the next century.

The Future

Developments in physics and engineering have rewarded our specialty with spectacular advances. But the changes happening in Biotechnology via the DNA moleculeógenetic engineering and stem cell transformationówill be even more profound. This new biology has the potential to conquer cancer, grow new blood vessels in cardiac patients, create new organs from stem cells and possibly even reset the genetic code that causes our cartilage to age. Very soon we will be able to transplant virtually anything without fear of rejection. In the next century, when computer technology merges with biotechnology, we may be able to map the 10 billion or so neurons in our brain and replicate our minds in a machine.

Changes

So, what changes can we as orthopaedists expect? Well, to start out, we can pose these questions:

First: Will we become more of a geriatric specialty? Life expectancy for a child born at the beginning of this century was 48 years. In 2000, it will be 77 years. Who knows how high it will rise in the next century? Will this cause us to see significantly more Arthroplasty cases and more fractures? Will the treatment of these conditions be operative or through genetic manipulation?

Secondly: Will the elderly population require our increased attention to rehabilitation? Our specialty has traditionally ignored this aspect of musculoskeletal disease. But, should we continue to do so?

We can also formulate some predictions:

1. Biotechnology in medicine, with genetic engineering, will place increased emphasis on non-operative management of musculoskeletal problems. This is, and will continue to be, the fastest growing area in the management of M-S problems. Unfortunately, with the patenting of genes it will make the cost of medicine even more prohibitive.

2. The number of hospital beds will continue to decline with hospitals being gradually transformed into chronic care facilities. Only major procedures, such as transplants, reconstructive surgery, joint replacements and complex spine surgery, will be performed in a hospital setting.

3. The vast majority of musculoskeletal surgery, such as arthroscopy, hand and foot surgery and even the less complicated spine surgery, will be minimally invasive and performed outside the hospital setting.

4. There will be increased emphasis on prevention through new biotechnological diagnostic techniques. The investment of the health care dollar into prevention at a younger age will push investment into disease treatment to an older age. This should lower the overall cost of health care.

5. Trauma and cancer will continue to be the biggest threat to health in the future, with trauma being the more difficult to treat. Cancer as a life-threatening disease will diminish, while arthritis as a lifestyle disease will increase as our population ages. Once we find the way to preserve cartilage and bone stock, the major surgical challenge will involve the treatment of trauma.

Challenges & Opportunities

My friends and colleagues, we have significant challenges to confront and opportunities to consider if we are to remain the musculoskeletal standard-bearers for the new millennium. Some of our difficulties are, admittedly, of our own making. But most have been thrust upon us. First, we have to recognize that we have lost some of our patientsí confidence in our ability, and we have lost their trust in our willingness to place their over-all well-being at a priority level above our own interests and desires. Second, managed care has us by the throat. Finally, our government is attempting to legislate our practices into obscurity. These realities cannot be denied. In our headlong embrace of technology, we have fallen short in several areas: We have failed to properly explain our technology to our patients; we have not adequately promoted prevention; and we have not managed financial resources in a cost-effective way.

We cannot ignore the "managed costs" that corporate America has forced on us. Patients want their own expenses contained, but they also want the quality care to which they are entitled. They have already paid their insurance premium. Insurance companies are not interested in the quality of care that their clients receive ... only that the cost of that care is significantly less than the sum of the premiums they receive. This reality wonít change until physicians and patients form a partnership that "managed care" cannot withstand. Managed care is making decisions for our patientsódecisions that the patient-physician partnership should be making. This is wrong. If we improve patient communication through better information, our patients can help fight the battle both for and with us.

There is no question that the management of the financial aspects of medical care will change in the coming years. The profit motive will be contained and dollars will rightfully flow to pay for the delivery of health care. Exactly how this will happen is evolving right now, but the process should be complete within the next five years. If we mobilize our patients appropriately, the insurance industry will not be able to withstand the increasingly strident public outcry. And, we do this by partnering with our patients.

Additionally, government interference continues to be a growing factor in medical care delivery. An example with which we are all familiar is the promulgation of the EM codes and the unprecedented mountains of documentation required by government agencies. We need to ask ourselves, "Exactly how much government involvement will we tolerate?" Should the government legislate the patient "Bill of Rights" or should the patients, with the physician, be the dictators? Partnering with our patients will present a formidable union between consumer and provider.

Ladies and gentlemen, it is very clear that our patients have the power to reverse the trends that oversee and constrict our practices. Their insurance premiums fund the managed care system and their taxes fund the Medicare/Medicaid system. We can overcome these trends only through bonding with our patients. That will be difficult. Patients have become alienated and we need to win back their confidence and their trust. We can and we will turn these challenges into opportunities by confronting these issues. We can then direct our energies toward building this bridge to patient confidence.

What Do Our Patients Want?

Basically, patients want to feel cared for. As part of that experience, they expect several things:

1. To be listened to. We need to consciously make the effort to hear our patientsí goals and desires and honestly answer their questions.

2. Responsible discussion of alternatives that gives validity to informed consent. We need to take time and offer information upon which they can base an intelligent decision.

3. Non-operative solutions first, and only when these are not feasible, surgery, and, then only if it will give better results with acceptable risk.

4. In brief, they want high quality, evidence-based medicine at a reasonable cost. This will lead to "value" medical care.

In order to improve our communications to make our patients feel that we care, we must be more open and understand them better. Not only must we better regard how they comprehend our medical jargon, but more importantly, we must understand their needs, their fears and their hopes. We must talk to our patients with a new voice, listen with a fresh ear and hear with new understanding.

Patients want to be empowered, they want to share in decision-making. They want to be our partners. If we want to earn back their trust, we need to embrace their wishes and desires. With the information that is out there, patients want to control their own lives and their environment. This philosophy assumes most patients are and should be responsible for making important and complex decisions about their health care. It also assumes that, because patients experience the consequences of having diseases and injuries and being treated for them, they have the right to be the primary decision-maker regarding their health problems. We are their facilitators!

We have lost our patientsí trust because we have treated them with "benevolent paternalism." There is no question that we are better educated in this area and that we are better qualified than other providers to suggest and implement treatment plans. Our role, however, should be to share that education with patients, not to thrust it upon them. Because of this age of information, we can no longer assume the patient wonít or canít understand.

If I may quote Archbishop Desmond M. Tutu, "In realizing my dream, my dream of a world that is more caring, a world that is more compassionate, a world where people matter more than profits".

Non-Operative Care

What is conservative care?

Some patients are questioning if we, as orthopaedic surgeons, are able to provide the best possible outcome for their particular needs. They have found temporary relief from other providers when we as orthopaedists could not guarantee their comfort.

More patients are coming to regard Orthopaedic surgeons as high-priced musculoskeletal care providers who are interested only in surgical fees. These patients believe that we are too quick to decide upon a technological solution and that we have little regard for the human aspects of Medicine. Many are viewing us as technicians who canít think or diagnose, and who are unable to treat musculoskeletal illnesses non-operatively. The growth in Podiatry, Chiropractic and non-science-based alternative medicine providers all attest to this fact. Where we may have seen surgery as the best solution, many of us have been presenting it as the only solution to our patients.

Patients today are sophisticated and demanding as never before. This is not the patient population we treated ten years ago. They have access to reliable information beyond what we give them. Unfortunately, they also have access to less reliable or, even worse, misleading marketing information. Advertisements for non-surgical alternatives in print, television, and radio, and even sites on the World Wide Web, are designed to appeal to disillusioned patients by promising outcomes that we as physicians, ethically, cannot promise. Patients are told of inconsistencies in our treatment regimens, outcomes that donít live up to the claims that alternative medicine makes, statistics that contradict our advice. Is it any wonder why disillusioned and wary patients end up in alternative medicine offices for non-surgical adjustments? Once patients are in the hands of alternative providers we lose the opportunity to manage their care.

How do we improve patient communication and education in the decision-making process? It is as simple as putting the x-ray up and looking at it with the patient. Discuss it with him or her. Itís only the occasional patient who doesnít want you to. Share the operative and non-operative possibilities of remedying the situation. The more information you share, the more comfortable your patient becomes. The outcome will be something you have shared with them. They become more responsible for their own care.

The perception is that, as surgeons, we want to operate on everything. We must regain the perception of balance by working with our patients. We should always be conservative when treating patients. Surgery may well be the conservative form of treatment, but these options must be discussed with the patient, the decision-maker. The patient thus becomes his own advocate in alliance with the physician as facilitator. In this age of the information superhighway, we should be where the patient stops first. With the involvement of our patients in their own care will come a return of trust in us as physicians. We must remember to always hold a patientís hand, but a scalpel only when needed. We need to insert the heart between the head and the hand.

I consider myself a fourth generation orthopedist with the fifth now on the scene in my younger partners. The philosophy of my third generation teachers was that only 10% of the patients one sees in the office should go to the operating room. If an orthopaedist was operating on more than that, he was being too aggressive and not treating his patients appropriately. We, as orthopedists, should modify the emphasis of our practice so that it is more evenly balanced between surgical and non-surgical care. We need to be musculoskeletal physicians with the added ability to do surgery!

We can no longer dismiss the alternatives as being substandard and even dangerous. Insurance payment for alternative treatment gives these providers a legitimacy that, until recently, was ours alone. We must, therefore, offer appropriate non-operative management alternatives to our patients. If we donít adjust to this reality, we will be relegated to secondary status, and will be called upon only when surgery is a last resort. We are not just surgeons! We are physicians! This realignment needs to start at the medical student level, and continue through residency training and in our Board requirements. Our certifying and re-certifying examinations must also include appropriate non-operative care case management.

If we are to reclaim those areas of musculoskeletal care we have neglected, we need to expand our scope of practice to include all non-operative musculoskeletal solutions. Only when we do this will we be able to break the strangle-hold that managed care has put upon us. We're not just cutters, we're total musculoskeletal care providers.

How do we do this?

1. We need to embrace a vision of where orthopedics is going and should go in the next millennium.

2. We need to enhance the image of the orthopedist in the realm of total musculoskeletal care.

3. We must reclaim those areas of musculoskeletal care we gave up when we began our courtship and romance with technology.

4. We need to take a leadership role in providing current, credible, and accurate information to patients by using all possible means of communication.

5. We must be willing to expand the scope of our practice to reflect the changing nature of our increased geriatric population and the expanding methodologies of treatment for musculoskeletal problems. This must include recognition of the projected benefits of alternative treatments once they have been studied.

How Can These Goals Be Implemented?

In order for this undertaking to be effective, I need each and every one of you to participate in the process of making it work.

In April, we will be convening an Orthopedic Summit of representatives from all the major orthopedic organizations to adequately define and project where our specialty is and should be going. We need your input for this meeting. To this purpose, an on-line survey accessible through the information kiosks and email stations will be active for the duration of this meeting. Please take a few moments there to answer this question: "What factors will create change in the practice of orthopaedics during the next ten years and how can your Academy help you address these changes?" After the conclusion of this meeting, the survey will remain on the Academy website ( until the end of February under both the "Whatís New" and "Member Services" sections. I would like each of you to log on and contribute to this discussion. Our electronic media section will tabulate your input and report it to the Orthopedic Summit in April.

Your academy is planning an extensive and focused public relations program this year to inform the public of our mission and our goals in the delivery of excellent musculoskeletal care. The campaign will also advise our membership of the expanded scope of orthopaedic care. Part of the initiative will be to evaluate alternative care as it relates to the musculoskeletal system. This program will carry well into the next millennium. We will make this information available to our membership for their thoughtful treatment of their patients. Wherever possible, all alternatives will be evaluated for their scientific merit and the Academy will be the repository for all pertinent musculoskeletal information.

In our efforts to provide the most current, credible, and accurate patient information, we should harness information technology so that each and every one of us can have a "Personal Physician WebSite". I propose that the Academy sponsor and maintain a World Wide Web-based library. This will be filled with medical information written for both the professional and for the patient. Selected topics can be linked to your individual website to which you can refer your patients, possibly before the office visit. This will give your patients an additional tool with which to work with you, their physician. And further, it is between the individual physician and the patient. We can use technology in this way to enhance the traditional physician-patient relationship. Your Academy will be developing this application of technology starting this year.

To formulate these efforts I am proposing the creation of a council to work in the 501C-6 Organization. This Council will be the repository and disseminator of all our communication and information efforts. It will also be the Council that oversees our public relations efforts. We want all orthopaedic organizations to have free access to this council (AOA, AOS, WOA, EOA, Clinical Orthopaedics, Mid-America, all state societies) Everyone! This will be our voice to the world.

Humanitarian Efforts

Before I close, there is one issue close to my heart, the issue of humanitarian efforts, to which I would like to direct your attention: Our Partnership with our patients must extend to our orthopaedic colleagues and their patients around the world... including all patients in all countries.

We have a responsibility beyond the borders of our country because of what we have learned and developed, and because of the unique educational opportunities we have to offer. The Academy must share these educational efforts with those not fortunate enough to have had these opportunities. The world has shrunk to the size of a spacecraft that can travel around the earth in only 90 minutes and a message that can be transmitted instantaneously to the other side of the planet. Our economy is Global. Orthopaedics, with a common scientific language, is global and all information should be shared with Orthopedists in every country of the world.

We have the means and opportunity, along with other advanced countries in the world, to help the less fortunate. The Academy should and will pledge its support to humanitarian programs such as "Orthopaedics Overseas" and ICOE. We as individuals should take time from our busy schedules and share our skills with those who could benefit from them. We should also place more emphasis on other humanitarian efforts within the U.S. I am proposing that your Academy each year honor several of our Fellows for their contribution to our specialty as well as for their humanitarian efforts in communities both in the U.S. and around the world. A mechanism for nominating candidates will be developed this year.

In Conclusion

Our 50th President, David Murray, in 1982, created an eloquent analogy with Nicolas Andryís illustration of the crooked tree representing this organization. Asking rhetorically why the tree was still bent, after all these years of splinting, he writes, "...the twisted trees are located at the uppermost reaches of the forest, buffeted by the elements, surviving at the edge where lessor foliage has been eliminated. The shape of the tree attests to the rigors of its existence and suggests strength, resilience, vitality, adaptability, and a faith in the future." I believe these words are as true today as they were then. As Dr. Murray indicated, the roots are strong, the trunk is sturdy and the limbs are still bountiful with fruit. But now the tree takes root in a world-wide base and the branches are spread over many countries and cultures.

We must expand upon our Orthopaedic Hippocratic Oath by not only teaching ourselves and our children the benefits of good health and the ways of good health care, but by teaching and partnering with our patients throughout the world. Yes, the tree has grown strong. Let us work together to keep it that way. We are poised to move on to a new relationship with our colleagues around the world and their patient partners. Let this be how Orthopaedics is remembered for in the next millennium.

Thank you.

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Last modified 18/March/1999