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Sunday, February 07, 1999

Partnership with patients can wrest control from MCOs: Dr. D'Ambrosia

If orthopaedic surgeons are to remain "the musculoskeletal standard-bearers for the new millennium," they must forge a new partnership with their patients, Robert D. D'Ambrosia, MD, said Saturday in a first vice presidential address that pulled no punches about the state of orthopaedics.

The specialty has lost the confidence and trust of many patients, "managed care has us by the throat and government is attempting to legislate our practices into obscurity," he said.

But Dr. D'Ambrosia believes a strong partnership of patients and physicians can wrest control of medical decision-making away from managed care organizations and stem growing government interference in medical care delivery.

"Only our patients have the power to reverse the trends that oversee and constrict our practice," Dr. D'Ambrosia said. "Their insurance premiums fund managed care system and their taxes fund the Medicare-Medicaid system. We can overcome these trends only through partnership with our patients."

It was a thought-provoking address, that looked back at the history of orthopaedics and offered a glimpse into a future of bright promise in medical care and major changes in health care delivery. Looking ahead, Dr. D'Ambrosia sees biotechnology holding the prom-ise of profound medical advances such as conquering cancer, creating new organs from stem cells and possibly resetting the genetic code that causes cartilage to age.

He sees biotechnology in medicine, with genetic engineering, placing emphasis on nonoperative management of musculoskeletal problems. It is a future when only major procedures such as transplants, reconstructive trauma and joint replacements will be done in hospitals. He expects increased emphasis on prevention through new bio-tech-nological diagnostic techniques.

Cancer, as a life-threatening disease, will diminish. Arthritis, as a lifestyle disease, will increase as the population ages, but once ways are found to preserve cartilage and bone stock, the major surgical challenge in the future will involve the treatment of trauma.

But in getting to the future, Dr. D'Ambrosia stressed orthopaedists must win back the confidence and trust of patients and must expand the scope of practice.

"Patients want to feel cared for," Dr. D'Ambrosia said. "They want to be listened to. We need to consciously make the effort to hear our patients' goals and desires and honestly answer their questions. This will leade to value medical care"

Patients want nonoperative solutions first, he said, "and only when these are not feasible, surgery, and then only if it will give better results with acceptable risk." They also want high quality, evidence-based medicine at a reasonable cost, he added.

Dr. D'Ambrosia called on Academy members to empower their patients by allowing them to share in the decision-making process which guides their health care and to improve patient communications. "They want to be our partners," he said. "This philosophy assumes most patients are and should be responsible for making important and complex decisions about their health. 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 have lost our patients' trust because we have treated them with 'benevolent paternalism.'"

Dr. D'Ambrosia warned that "some patients are questioning if orthopaedic surgeons are able to provide the best possible outcome for their particular need. 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 only interested in surgical fees."

Dr. D'Ambrosia pointed out that the public has access to reliable information from many sources other than physicians. And, they have less reliable and even misleading marketing information that promises outcomes which physicians cannot ethically promise. "Is it any wonder why disillusioned and wary patients end up in alternative medicine offices for nonsurgical adjustments?" he asked. "Once patients are in the hands of alternative providers we lose the opportunity to manage their care." If orthopaedic surgeons share information with their patients, the patients will be more responsible for their care, Dr. D'Ambrosia said.

He urged orthopaedists to be conservative when treating patients and to expand the scope of practice to include all nonoperative musculoskeletal solutions. "We need to be musculoskeletal physicians with the added ability to do surgery," he stressed. "If we don't adjust to this reality, we will be relegated to secondary status, and will be called upon only when surgery is a last resort."

Dr. D'Ambrosia stressed, "I always hold the patient's hand, but hold a scalpel only when needed."

To prepare for the future, Dr. D'Ambrosia said members need to "embrace a vision of where orthopaedics is and where it should go in the next millennium. In April, the Academy will convene an Orthopaedic Summit of representatives from all major orthopaedic organizations to define and project where the specialty is and should be going.

He asked Academy members to give their views for the Orthopaedic Summit. Members are asked to respond to the question, "What factors will create change in the practice of orthopaedics during the next 10 years and how can your Academy help you address these changes?" Members can respond to the survey at the information kiosks in the convention center during the Annual Meeting and by accessing the Academy home page through Feb. 28.

The Academy also is planning an extensive and focused public relations program "to inform the public of our mission and our goals in the delivery of excellent musculoskeletal care," he said. "The campaign also will 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" and to make it available to the membership for thought-ful treatment of patients.

To provide the most current, credible and accurate patient information, Dr. D'Ambrosia urged harnessing information technology so that every member can have a "personal physician web site." He proposed that the Academy sponsor and maintain a web site-based library with medical information written for the professional and for patients. Selected topics could be linked to the individual web sites of orthopaedic surgeons. Orthopaedists could refer their patients to the information, providing an additional tool with which to work with the physician.

Dr. D'Ambrosia closed his address by observing that "our partnership with our patients must extend to our physician partners and their patients around the world. We have a responsibility beyond the borders of our country because of how much we have learned and developed and because of the unique educational opportunities we have to offer."

He said the Academy should pledge its support to humanitarian programs such as Orthopaedics Overseas and the International Center for Orthopaedic Education. Also, there should be more emphasis on other humanitarian efforts within the U.S. And the Academy should recognize individual orthopaedists for their efforts in different regions of the U.S. and around the world.


James D. Heckman, MD, 1998 Academy president, left, gives medal signifying the office of the president to Robert D'Ambrosia, MD.

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Last modified 16/February/1999