August 1999 Bulletin


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


I wish to respond to the editorial commentary of Michael A. Simon, MD, and G. Paul DeRosa, MD, in a recent issue of The Journal of Bone and Joint Surgery (which was reprinted in the June 1999 issue of the Bulletin.) Their arguments in support of American Board of Orthopaedic Surgery (Board) recertification are certainly persuasive. But contrary to their belief, the Board is not an organization of our peers. Most, if not all members of the Board represent the academic and subspecialty orthopaedic communities, which are still a minority of orthopaedic surgeons in the United States. After I completed recertification in 1994 (with a fairly high score), I offered my volunteer services to the Board. I was politely thanked, and informed that "occasionally" general orthopaedic surgeons are asked to participate in Board functions. I never received any further personal communication. Are there any community-based general orthopaedic surgeons serving on the Board? How are Board members selected? Many of us "generalists" perceive our leaders as an elitist group that has lost touch with the rank and file.

The authors cite the high rate of compliance by diplomats in pursuing recertification. But, most surgeons resent the "success" of this exam and comply with recertification only to maintain credentials at our hospitals and with managed care organizations. If one does not maintain Board certification, one does not practice orthopaedic surgery in today's practice environment. The high pass rate of the exam reflects that most of us maintain our skills. The vast statistical numbers cited in the article are impressive. But we do not need a proctored exam to coerce us into providing quality care to our patients.

I resent the "Big Brother" enforcer tone the Board appears to have adopted. It is great that they have managed to cull from our ranks between 17 and 21 candidates through their in-depth investigations. But, at the same time, they acknowledge that all of these suspect surgeons could have passed a knowledge-based examination. Then why persist in a proctored examination?

If the Board wishes to continue credentialing us in this fashion, that is their prerogative because they are in control. And if their purpose is to protect the public from suspect surgeons, then maybe they were successful with these few. But why must you inconvenience the overwhelming vast majority of us that you acknowledge are competent?

I remain against any type of proctored written or oral examination for the purpose of recertification. The exam is costly, time consuming and not particularly relevant to most practices. State licensure requirements and Board CME requirements are more than enough to demonstrate that one is up-to-date in current patient management techniques. And none of these options truly demonstrate technical competence.

If further testing is felt necessary, why not mandate more continuing education hours on a yearly basis (to include bioskills courses), and recertify more often with a home-based exam? To qualify for the exam, the Board can continue to do their investigations to satisfy the elitists in our profession and the demands of the American Board of Medical Specialties and various federal government agencies.

I am not proud that I passed the Board recertification exam in 1994. I am proud that I was one of those who stood at the AAOS meeting in 1989 in favor of the Academy splitting away from the Board. I ask again, is it still too late?

Joel E. Cleary, MD

Helena, Mont.

Cumulative trauma

The points of view expressed in the June 1999 Bulletin (Point of View column) on cumulative trauma are well presented; each has at least some points with which I can agree and disagree.

I am concerned that we are still struggling with the issue of cause for certain conditions; carpal tunnel syndrome is a good case in point. We can not decide among ourselves whether it is or is not caused significantly by work. It actually seems to be multifactorial, caused by work, nonoccupational activities and associated medical conditions. My state, like others, likes for the physicians to decide "51 percent probability," which is very unscientific, but fits the courts' agenda. It seems to me that the determination of cause for carpal tunnel syndrome depends more on which physician a patient sees, and which company the patient works for, than on any real scientific quantification.

Therefore, I think we need to move toward a "no fault" system of compensation for medical treatment and disability, without having to prove cause. Then fairness might prevail, and one's employer and choice of physician would exert less influence on compensation.

William H. Milnor, MD

Owensboro, Ky.

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