April 1999 Bulletin

Education is key to nonoperative care

It will require major restructuring of residency education: Academy support is doubted

By Augusto Sarmiento, MD

It was reassuring to hear Dr. D'Ambrosia's First Vice Presidential address to the Academy (1999 Annual Meeting) emphasizing how important it is for the orthopaedist to seek involvement in the nonsurgical care of patients with musculoskeletal problems. He eloquently echoed statements made previously by his predecessor, James Heckman, MD. To see continuity of purpose in the hierarchy of the Academy is indeed a welcome development.

Placing emphasis on our broader involvement in nonoperative orthopaedics is music to my ears. For many years I tried to champion that concept, both as an academician as well as an officer of the Academy. During my eight years on its Board of Directors and as its President in 1991-1992, I strived to increase the awareness among my colleagues of the dangers of our exaggerated glorification and promotion of surgical subspecialization in our discipline. I also did my very best to warn all concerned parties of the erosion or our profession and the likely consequences of the steady loss of territory to others in medicine and surgery.

Earlier in my career, I suspected that those trends which began in the 1960 needed attention. As a newly-appointed chairman of the department of orthopaedics at the University of Miami, I persuaded the dean of the medical school to change the name of the department to "orthopaedics and rehabilitation." He acquiesced and ours became the first such department in the country. Several other departments of orthopaedics across the land followed suit and became departments of orthopaedics and rehabilitation.

Having a department with enlarged educational and patient care opportunities made it possible for us to maintain control of a large segment of musculoskeletal territory which was slowly being taken away by others. I think we succeeded in attaining our goals. Residents became exposed in a major way to musculoskeletal conditions where surgery is not a major component, but where the orthopaedist's understanding of their pathophysiology best qualifies us to be the primary providers of care. Victims of hemiplegia, amputees and spinal cord injured patients constituted a large segment of the teaching material. This happened without neglecting the traditional traumatic, congenital, developmental and degenerative diseases.

Unfortunately, the explosion of surgically related technology and the advent of total joint replacement and arthroscopic surgery in the early 1970s rapidly diminished the fledgling interest in rehabilitation while enhancing a parallel growth in the surgical management of orthopaedic conditions. Now, we are witnessing developments that concern all of us. For example, neurosurgeons, plastic surgeons, podiatrists, chiropractors, general practitioners, rheumatologists and others have become responsible for the care of an increasing larger number of patients with conditions of the musculoskeletal system which previously were managed entirely by the orthopaedist.

As a I reflect on the possible outcome of the Academy's efforts to stem the tide and encourage the orthopaedist to assume once again the care of those patients, I worry over the best way to accomplish that goal. It is not an easy task, but a tall order. Words and good intentions will not do any good. Action is essential. We must realize that effective change cannot take place unless a rather revolutionary joint effort of multiple segments within our profession can be orchestrated.

Without major restructuring of residency education nothing will ever be accomplished. If future generations of orthopaedists are not appropriately trained in the surgical and nonsurgical management of musculoskeletal conditions, nothing will change. Assuming that such a reorganization takes place, the question of who in academic medicine will do the teaching must be answered. For the most part, orthopaedists knowledgeable in the nonsurgical management of musculoskeletal conditions are not found in the full-time faculty of medical schools. Department chairmen and deans encourage the recruitment of orthopaedists whose private surgical practices are guaranteed to be financially successful. Those on the faculty who do not contribute generously to the department coffers and have to support themselves oftentimes find their positions discontinued. It is well known that deans involved with for-profit hospitals excuse the major revenue producing surgeons of any educational responsibilities with nonpaying indigent patients so their time in the operating room, taking care of the insured, is not infringed upon.

Will deans and department chairmen be willing to subsidize the salary of the faculty who devote a major portion of their time to the teaching students and residents the nonoperative aspects of patient care and who by the nature of their work are not major earners? I seriously doubt it. Even if that eventuality were to take place, where are the candidates for those positions unless the chairmen and deans are willing to accept orthopaedists who in earlier years learned the nonsurgical aspects of orthopaedics. This, because those who graduated in the recent past never learned that segment of the profession.

The next question that needs to be addressed is whether or not the Academy will provide major support to the effort and assist financially in its development and implementation. Based on my perception of the direction in which the organization has elected to move, I doubt it. In spite of the reassuring words we have heard in recent months that the establishment of the parallel (c)(6) organization will not diminish the Academy's major commitment to education, I suspect that the move toward a trade union organization is inevitable and education might take a back-seat to lobbying the political establishment. Not only could the money available to educational endeavors decrease, but the interest in education might diminish.

We have observed with some discomfort the Academy's recent exaggerated emphasis on business affairs and I suspect that the amassing of greater and greater profit has become a major obsession in the minds of the hierarchy of the organization. Its commercialization has become rampant. Its financial independency is virtually nonexistence as it depends more and more on industrial subsidies to support its many educational activities. The Annual Meeting is a show where the tail wags the dog and commercial exhibits are a major source of revenue for the Academy. The Academy's significant and successful involvement in publishing medical journals and textbooks, the filling of half the Journal of the American Academy of Orthopaedic Surgeons and the Bulletin pages with paid advertisement of commercial products, and more recently the use of the Annual Meeting's printed program for the marketing of drugs and orthopaedic gadgets are clear indicators of the direction in which the organization is moving. At the most recent Annual Meeting in Anaheim, we witnessed, for the first time, the sale of syllabuses, prepared by the various speakers participating in symposia.

Some probably believe sincerely that such moves are appropriate and they might be in concert with of the ethos of the times. However, I consider them ominous warnings that the Academy's major commitment to education may be dwindling in favor of one directed toward business. I wish President D'Ambrosia success in his position in the Academy's hierarchy and offer him my unconditional support. I know that many in the fellowship feel the same way.

Augusto Sarmiento, MD, is emeritus professor and chairman, department of orthopaedics and rehabilitation, University of Miami, and 1991 Past President of the Academy.

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