February 1996
Augusto Sarmiento, MD

Who has not heard words to the effect that we, as physicians, are going through one of the most serious crises in our history. That because of changes we are witnessing today, the practice of medicine, as we have known it, is experiencing the pangs of a slow death.

Almost daily we hear older physicians remark that "I would not recommend a medical career to my children because medicine has become a constant hassle; that we have lost our autonomy and cannot make any money practicing medicine. That we work harder than ever, but our earnings shrink."

Some of these complaints are justified. However, I disagree with the conclusions and do not share the Cassandric predictions about the future of the practice of medicine.

In the great scheme of things, the so-called crisis of today will be nothing more than a footnote in the annals of history and medicine will continue to be one of the most gratifying and exciting professions.

I am not overly concerned, and you should not be either, about the rapidly unfolding events or the magnitude of the dilemma we are confronting in regards to health care reform. We need to put the entire matter in proper perspective. We are not witnessing a crisis in medicine, but simply, a socio-political upheaval. Not a crisis in medicine, because medicine is vibrant and in excellent shape, particularly in our country where we have a level of medical sophistication which is probably second to none. Progress will continue to be made. New frontiers will be conquered. Quantum leaps forward will take place at an unprecedented pace and the human condition will further improve. After all, that is medicine's raison d'etre.

The erosion of our control over the care of patients has reached disturbing degrees as a result of government decrees or the actions of the newly empowered private sector and business entrepreneurs. It makes one wonder whether the quality of care will be seriously compromised.

I suspect that no matter how bad things have gotten or how much worse they might get in the future, eventually the problem will be resolved. The American people will not tolerate second class medical care and will demand the quality of care to which they have grown accustomed and are entitled to receive. I think that such an outcome is inevitable and suspect that a reasonable compromise where quality care is provided and cost is contained will be reached in the foreseeable future.

It is necessary, however, that we, as members of the medical profession, recognize the role we played in the genesis of the problem that the government and others have found necessary or convenient to address. That is, the unsustainable, escalating cost of the delivery of health care.

We need to admit that organized medicine failed to respond unselfishly and objectively when the problem first loomed on the horizon. It elected to ignore the gathering clouds and posited that the thundering was inconsequential.

It is not wrong for us to acknowledge our mistakes. Quite to the contrary it enhances our credibility and puts us in a better position to negotiate. To err and, sometimes, to fail are part of the human condition

My generation took many things for granted as we witnessed the ease and speed with which our medical and economic power grew. Now you have to pay the price of our hubris and our lack of humility and vision.

There are those who believe that with financial restructuring, the Academy will be capable of doing much to solve the problems facing medicine today. I submit to you that the power of the Academy is limited. No matter how much money we allocate toward that end, the affect that the Academy has in the final socio-political decisions will be very small.

The Academy's ability to provide advice to those who are in control of the situation would be preserved. However, this should not be done at the risk of losing the strength of our commitment to education, for it is in education where the Academy should continue to excel. Because it is in the area of education where our greatest needs lie.

When all is said and done; when this so-called health care crisis is over, we need the Academy, the premier orthopaedic continuing education body in the world, to remain the pillar upon which the cohesiveness and strength of our profession rest.

Any action that might move the Academy in the direction of a trade union would be a gross mistake. Such an outcome would have extreme and undesirable consequences. The Academy would then suffer the same fate that the AMA and other medical groups suffered and which made their educational roles almost irrelevant.

We should avoid greater politicization of the Academy. I urge you to get involved in its' affairs and to discourage such a trend for it is not in your best interest. I give you this advice based on my long association with the organization and, particularly, from my experience as a member of its Board of Directors for eight consecutive years. Over several generations, the Board has done an exemplary job. Look at where we stand today. Look at the excellence of the Annual Meeting which is the envy of organized medicine throughout the world; the CME courses and publications; the innovative educational methodologies and its activities in the health care delivery arena.

The greater participation recently given to the Fellowship in the election of the Nominating Committee increased the opportunity for a more careful and representative selection of the Academy officers. I am confident that the committee will, sometime in the future, be charged with the duty of selecting all members of the Board. Not some, but all.

If the proposed resolution to make resolutions of other groups binding on the Academy's Board is passed during this meeting, the effectiveness of our Board will be severely eroded. It would be a regrettable mistake that would, in effect, cripple the organization. The Academy will be converted into a political playground where special interest groups will have the final say.

I am candidly discussing with you issues germane to the Academy. However, these issues and their implications are also important to our profession as a whole and to its long term viability.

You have come to the Academy at a time when Orthopaedics is fragmented, but not critically so. Extreme fragmentation would be dangerous and should be prevented at all costs. It would dissolve the glue that holds our profession together. Excessive subspecialization trivializes orthopaedics and generates unhealthy divisive forces.

The current fragmentation of Orthopaedics was, to a great extent, the result of the rapid expansion of technology and the logical desire of people to assemble with others holding similar interests. However, some superfluous societies came into existence to the point where today there is virtually a society for every bone, joint, anatomical area of the bone, disease and surgical technique in existence.

The growth of subspecialization has increased the cost of training its practitioners and has resulted in the appropriate as well as the inappropriate utilization of expensive technology and the performance of unnecessary surgery.

Those in control of financing health care are stating in unequivocal terms that they are not going to cater to subspecialists as they perceive them to be the real culprits in the escalating cost of health care. The valuable contribution that specialty medicine makes is seriously threatened. We must continue our efforts to develop viable and logical approaches to this dilemma. As orthopaedists, we must present a united, not a divided front.

We have turned technology into a religion to fulfill all of our expectations. This is a very naive and simplistic response for it is known that in the process of solving problems, technology often creates new ones.

The abuse of technology has become Orthopaedic's Achilles heel and has contributed greatly to the position that we find ourselves in today. It has made it difficult for us to expose and criticize those who control an ever larger segment of the health care delivery system.

A number of musculoskeletal conditions which can be successfully and inexpensively diagnosed and treated by non-surgical means are frequently subjected to a variety of tests and surgical procedures of questionable value. Many gadgets and surgical implants proven to be marginally or outright ineffective are successfully marketed, often with the help of orthopaedists who function as agents of Industry. These so-called new, improved and always more expensive products replace recently introduced ones without sufficient documentation of their value.

In no area has the Orthopaedic-Industrial Complex been able to extend its powerful tentacles into the practice of medicine more than in the education of the orthopaedist. I have been a committed student of this phenomenon for the past two decades and there is no doubt in my mind that today the continuing education of the orthopaedist is structured, consciously or unconsciously, to satisfy the marketing needs of Industry. This is happening in our residency programs where the sources of funding for research and education have dwindled; in the activities of a myriad of orthopaedic societies and even in our own Academy where its economic dependency on Industry continues to grow at a rapid pace. You must remain vigilant and weigh the consequences of such an increased dependency.

It is no secret that with increasing frequency others in medicine are rendering care to patients with disorders of the musculoskeletal system which until recently had been treated exclusively by us. The erosion of orthopaedics has not yet ended. Make no mistake, third party payers are watching these developments with pleasure as they assume that in this manner the cost of care will be reduced.

We must be keenly aware of these phenomena and do whatever is necessary to demonstrate that orthopaedic surgeons are the ones best trained and qualified to provide surgical as well as non-surgical treatment for conditions of the musculoskeletal system. Our actions to date suggest that we are more interested in treating conditions by surgical means than otherwise. If that perception continues to spread, the scope and strength of our profession will be seriously compromised.

Several of the developments and problems that I have addressed today are largely the result of a decay in our professional and societal values. The real crises in medicine are the declining professionalism of its practitioners; the lowering and aesthetizing of ethical standards and the belief that everything is okay which eliminates the possibility of being morally wrong.

Success in Western Societies, particularly in the last decades, has been defined in terms of financial profit and virtually without consideration for the substance of one's achievements. We judge success in life primarily on the degree of material wealth, demeaning and undermining the spirit and foundation of our advanced civilization, Profit, the God that modern society has enshrined, dictates the ethos of our time.

You live in a time when a small, but vocal and influential segment of our society claims that the values of yesteryear are irrelevant today. I hope that you appreciate how wrong and damaging such a message has been. Look at the unraveling of our society. No one has been able to articulate this crisis better than Havel, the president of the Czech Republic, who said that 'we seem incapable of appreciating the ever increasing degree of spiritual, political and moral degradation that has permeated throughout the West' and that, 'if the current philosophy prevails, the Western culture will eventually collapse.'

You, the fledgling generation of American orthopaedists, come onto the scene, not in bad times, but in challenging times. You arrive at a time when we are losing our inheritance. Nonetheless, you can regain it. It requires only your Will to Action. It is your mandate to be active and committed participants in the renaissance of high values and professionalism in our ranks. It is also a great challenge and opportunity.

In order to be effective contributors to the solution of the current dilemma, you must be prepared to articulate a coherent set of values and transfer it from your generation to the next because the values that made our society so worthy have become dim. I trust that you will conclude that without moral, political and religious convictions, your message will be an empty one. Since it is very difficult to modify human behavior, you will not see the results of your commitment overnight. However, in times of crisis it is easier to rally support for worthy causes. Do not be discouraged by the magnitude of the task and the fact that the history of mankind is heavy with unrealized possibilities. With Promethean tenacity, other generations succeeded in changing trends and philosophies that appeared unchangeable at the time. You need not follow the path, blaze a trail.

I would suggest that you, the future leaders of orthopaedics, adopt the following lines from Hensley's poem as your motto.

On behalf of the Academy Fellowship, I wish you well and welcome your Will to Action as you venture into the uncharted waters of the next millennium.

Previous Page

Last modified 27/September/1996