April 1999 Bulletin


Write to The Editor, AAOS Bulletin, 6300 North River Road, Rosemont, Ill. 60018-4262

Nonoperative care

In his February message (Across the President's Desk, February 1999 Bulletin) Dr. Heckman asks the Academy members to do "critical self-analysis and identify who we want to be before we project that image to the public." Prerequisite to this process we must focus on two issues: who are we now and what is actually best for the people in our communities.

As Dr. Heckman suggests, what many of us have become are "surgically oriented technologists" who do all we can to avoid treating nonoperative conditions. After all, consider what has evolved as the epitome of a successful orthopaedic practice: an abundance of surgical cases and only a minimal number of chronic pain patients. Discussion between orthopaedic colleagues often develops into a virtual contest of who is doing the most cases. Consider how rare it is to hear a colleague boast about how they infrequently need to perform a subacromial decompression or any elective surgical procedure for that matter. How often do you hear a colleague boast about all the nonoperative back pain patients they are treating?

Anyone who attends the Academy meeting can clearly see that our focus as orthopaedic surgeons is surgery. We are bombarded with new instruments, techniques, and technologies, many of which will fall out of favor by next Academy meeting. Look at our Academy leaders and instructors. By and large they are subspecialists whose practices are principally surgical. Moreover, our leaders and instructors train an army of residents and fellows who are eager to employ the techniques they learned from the "experts."

Unfortunately, as you suggest, the "musculoskeletal needs" of our individual communities extend far beyond our surgical skills and technical expertise. Many of us leave most of the less glamorous work to physiatrists, podiatrists, chiropractors and primary care physicians, who are often under-trained in treating musculoskeletal conditions. What our communities need are orthopaedists who are willing to use their expertise and training to treat nonoperative conditions. Our leaders and teachers must spend more time addressing management of nonoperative conditions and "lead by example" in their own practices. We must all strive to be outstanding nonoperative clinicians as well as technicians.

Dr. Heckman has asked us to decide on our public image. I believe we must instead consider who we actually are and how we can change that reality. After all, if we focus on what is best for all the people with musculoskeletal problems in our communities, our positive image will be restored.

Donald C. Pompan, MD

Salinas, Calif.

I strongly disagree with Dr. Heckman's report in the latest Academy News (the 1999 Annual Meeting newspaper edition of the Bulletin). I understand that one pathway for dealing with the physician oversupply issue is to increase the scope of practice of orthopaedic surgeons. I agree that there is nonoperative medicine that orthopaedic surgeons can perform in ltheir offices. We obviously need to be training physicians in the nonoperative care of many musculoskeletal conditions. I foresee, however, that expanding our scope of practice to include osteoporosis care, for example, will lead orthopaedists to using gimmicky imaging technologies and effectively churning charges for these services to justify the need for more income. This will only raise medical costs and further alienate physicians and insurers.

Maintaining an orthopaedic surgery practice is expensive. Our overhead costs are much greater than those of our primary care colleagues. Malpractice rates are higher, and we have much more difficult billing and scheduling needs. In my opinion, the Academy should be placing more emphasis on maintaining adequate reimbursement for the work that we do rather than to promote the creation of income from ancillary medical practices.

My personal experience of developing a practice in a crowded, competitive area lead me to spend much of my early years doing nonoperative orthopaedic medicine. I feel this was extremely unfortunate in that I struggled to maintain my surgical skills and felt very frustrated. I believe that orthopaedic surgery training is long and challenging for a very good reason. It takes time to develop the surgical skills to be a good practitioner. I do not believe that orthopaedic surgeons should dilute this experience by developing ancillary nonoperative skills. I believe that it would be better for some orthopaedists to train in nonoperative care, and create a division of labor so to speak. Another alternative would be for some orthopaedic surgeons who no longer wish to practice surgery continue with office based medicine. I believe the Academy should work hard to lower the malpractice rates for retiring surgeons as mentioned in the current (February 1999) Bulletin so that this type of medicine can be done by competent specialists at the lower reimbursement levels seen with office medicine.

Alan Greenwald, MD

San Francisco, Calif.

Volunteers in Medicine

I applaud your article in the February 1999 Bulletin about "Removing the Barriers to Volunteerism in the U.S." I am one of two board certified orthopaedic surgeons in a volunteer group of physicians, dentists and nurses who work to serve indigent on and around Hilton Head Island, S.C. Luther Strayer, MD, is my orthopaedic associate at the clinic.

This volunteer group is "Volunteers in Medicine." It has been in existence for six years. We serve with special volunteer licenses from the state of South Carolina and with appropriate malpractice protection. We are dealing in medical orthopaedics for the most part, with some minor trauma.

While we do no surgery, the total clinic personnel see more than 15,000 patient visits per year. The entire clinic has hours five days a week. Our oldest physician is 88 years of age and brings a tremendous amount of knowledge to the clinic. The physicians' ages span three decades.

The community has been very supportive. They built a new clinic building for "Volunteers in Medicine." They sponsor each day of operations in many ways and are now providing funds for ongoing operations.

The clinic provides all of the retired people who provide care with a feeling of usefulness and returning to our community the benefits of our education and experience. The community hospital has benefited by the care we provide to the indigent and is supportive of our work.

Please encourage anyone who is with the Academy to stop in and visit us when on Hilton Head Island. We are proud of our clinic, "Volunteers in Medicine," and the people who provide care, free to the indigent.

Edward D. Sugarman MD

Hilton Head, S.C.

Orthopaedic oncology

Mike Simon's article (Point of View, February 1999 Bulletin) regretting the declining influence of orthopaedic oncologists should be mitigated by the information that John L. Eady, MD, orthopaedic oncologist of eminence in South Carolina, recently (December 1,1998) became professor and chair, department of orthopaedic surgery, University of South Carolina School of Medicine. I hope this cheers Mike up.

Edward E. Kimbrough,III MD

Columbia, S.C.

"Without major restructuring of residency education, nothing will ever be accomplished," says Augusto Sarmiento, MD, 1991 Past President of the Academy in the Point of View column.

Would you like to comment on something you read in the Bulletin? Let's hear from you. Send your letter to the Editor, Bulletin, AAOS, 6300 N. River Rd., Rosemont, Ill. 60018. Fax (847) 823-8026.

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