February 2004 Bulletin

Across the President's Desk

Alternate approaches to medical liability reform

In this, my last editorial as Academy President, I would like to review a few of the accomplishments achieved by the Board of Directors, volunteers and staff during the past year and raise some of the challenges facing us in the future.

Patient safety
The Board of Directors held a workshop in April 2003 to better understand the issues of patient safety and the importance of changing our current practice culture to reduce medical errors. The Board also formed the Patient Safety Committee headed by David A. Wong, MD, and staffed by Kristin Glavin, JD, to accomplish our goals. The committee reports directly to the Board at each of its meetings.

The committee implemented 11 Board-approved projects, including forming a Patient Safety Coalition, developing an education program for our members and patients, creating a curriculum for residency programs, establishing a Patient Safety Member Alert system, and publishing an online Patient Safety E-News. Additional research initiatives include potential collaborative projects with GE Medical using Six Sigma methodology.

The Board approved a contract with Sun Clinical to begin a National Joint Registry pilot project. Heading this project team is David G. Lewallen, MD, William J. Maloney, MD, and Richard D. Coutts, MD. The AAOS was represented at two meetings of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) on signing the surgical site and recently endorsed, with 40 other professional organizations, the Joint Commission’s Universal Protocol. This Protocol requires proper patient identification, signing of the surgical site and a pre-operative huddle or “time out” for everyone involved in the surgical case, including the patient, to review the operation and ensure the proper surgical site.

Another Board workshop in December 2002 reviewed volunteer participation in the AAOS and, most importantly, how to increase participation. A telephone conversation at that meeting with several members of the Academy revealed that many members believe the Board is composed of only academics, who are not fully aware of issues confronting the average practicing orthopaedist and essentially distanced from the fellowship. In response, the Board implemented an active member feedback program to demonstrate otherwise.

Members of the Board, and especially the Presidential Line, are visiting more state and regional society meetings. This year we also have been asked to speak at each of the specialty societies’ meetings on Specialty Day of the Annual Meeting. In addition, the Presidential Line includes five or six members picked at random on its weekly conference calls. (See my editorial in the December 2003 issue of the Bulletin for details.) The response and open dialog has been tremendous; I think everyone is benefiting from these exchanges.

In addition, the Board has sought members’ opinions on strategic issues through polls and surveys more than ever this past year. Although there is no way we can include everyone who desires to serve on committees, we are trying to be inclusive by reaching out to younger members and those who have not served before. However, everyone can speak out via these polls and surveys. The Board wants and needs your input.

Medical liability reform
The crisis in medical liability remains a major issue; reform is essential to the future of medicine. Stuart L. Weinstein, MD, AAOS second vice president, and his team have done an outstanding job in carrying this issue forward. We have joined a coalition—Doctors for Medical Liability Reform—that begins a national public awareness campaign this month. This coalition includes several high-risk specialty professional organizations. Its focus is on federal legislative relief. The AAOS also is focusing on state reforms. Grants have been given to several states, including Texas, which recently passed a state constitutional amendment allowing caps on non-economic damages.

These activities require tremendous time, money and effort from all volunteers and staff. I personally want to thank all who have given of their time as well as money. Tort reform will probably be an issue in the 2004 presidential campaign, so please continue to be active and to support this effort financially until we achieve success.

Professional organization collaboration
With the merger of the Academic Orthopaedic Society and the American Orthopaedic Association, there has been increased enthusiasm in support of orthopaedic education. Our own Council of Academic Affairs, led by Chair Joseph P. Iannotti, MD, PhD, has met with the AOA’s newly formed Academic Issues Committee to develop mechanisms to work together on areas of mutual interest.

Recently the AAOS Board reorganized its Committee on Maintenance of Certification and developed new charges. Dr. Lewallen chairs this committee, which will continue to work with the American Board of Orthopaedic Surgery (ABOS) on issues of lifelong learning and maintenance of certification.

AAOS organization
The Board welcomed our new CEO—Karen L. Hackett, FACHE, CAE—who assumed office on August 1, 2003. Ms. Hackett comes with a superb financial and administrative background, having served most recently as Executive Vice President and Chief Operating Officer of the American College of Healthcare Executives. In just a short time she has already demonstrated her skills, met with numerous leaders in orthopaedics, learned a great deal about AAOS history and policies and displayed a tireless and committed work ethic.

A new organizational structure approved by the Board and modified by Ms. Hackett is being implemented. She will work directly with a staff leadership group consisting of a chief operating officer—Lawrence Rosenthal, PhD; a chief financial officer (search underway); a chief medical officer—currently William W. Tipton, MD, who will retire on March 31 (replacement search underway); and a chief education officer—Mark Wieting. This leadership group, together with our new CEO, incorporates the major directives of the AAOS—medical education and advocacy—with renewed attention to our fiduciary responsibility and important operational issues.

I would like to recognize the Board’s wisdom in including a lay member for the first time in the Academy’s history. Leslie Altick, executive vice president at Wells Fargo Bank, is an outstanding individual and addition to our Board. She frequently makes insightful and important contributions to our Board’s discussions. It is a pleasure to have her serve with us and assist the Board in its many difficult decisions.

Looking to the future, AAOS and the practitioners of orthopaedic surgery face some significant challenges.

Robert Bucholz, MD, first vice president, organized and chaired the Board’s December 2003 workshop on competition. The Board recognizes the increasing competition from industry, other specialty societies, hospitals and medical schools, with our CME programs and products. Dr. Bucholz co-chairs a project team with Joseph D. Zuckerman, MD, chair of the Education Council, focusing on these challenges.

Another area of concern is maintenance of certification. We know the ABOS will administer an examination, but what about CME programs, self-assessment exams, practice reviews and other educational activities to support our members facing this challenge? The AAOS must work closely with our specialty society colleagues to maintain a valid, irrefutable and credible initiative that keeps our orthopaedic profession whole and together.
Another concern is the threat to the development of specialty hospitals and ambulatory surgical centers. Congress recently passed a moratorium on physician-built specialty hospitals. The pressure to keep physicians from seeking practice alternatives is only going to intensify as the margins on health care services continue to diminish.

To counteract continued control and limitations, physicians must develop strategies, including attempts to partner with hospitals and others if opportunities arise. As a profession, we must be able to articulate the opportunity that many of these practice alternatives offer for delivering improved quality of care for patients and increased satisfaction for physicians.

Future roles for professional organizations
In their conversations with the Presidential Line, some members raised issues of misleading advertising, questionable ethics, and inaccurate or false testimony as expert witnesses. These concerns present a difficult challenge to a professional organization like the AAOS. We have begun to address these issues by developing an expert witness educational program and considering the pros and cons of a disciplinary program. Additionally, a project team headed by Jeanne L. DelSignore, MD, Chair of our Ethics Committee, is developing guidelines for ethical practices and conflict of interest for our Board of Directors, as well as Council and Committee Chairs.

New membership categories
The Board has approved the Membership Committee’s recommendations that the AAOS accept into membership foreign physicians living in the United States who have passed the equivalent of the ABOS exam in their home countries, as well as doctors of osteopathy who have passed their osteopathic orthopaedic board examination. The fellowship will be asked to vote approval on these new categories after the Annual Meeting. An area for future consideration is whether we should expand into other categories of membership such as orthopaedic physician assistants and orthopaedic clinical nurse specialists.

Advocacy issues
We remain in the fight for medical liability reform for the long haul. I hope everyone will continue to commit their time and dollars to this important issue. The time is right and momentum is in our favor.

Of course, Medicare reform also continues to be at the top of the list with potentially adverse effects on physicians and ultimately patients. A small increase in reimbursement this year and next has been approved, but thereafter cuts are again planned. This cycle of continuous reductions with only small, periodic gains in reimbursement will continue until the flawed formula for physician payment is corrected.

We should continue to work for nothing less than full reform. Without reform, more physicians will leave Medicare, to the detriment of our patients and the effectiveness of our health care system. Government may react as Massachusetts did and make participation in Medicare mandatory to obtain a license to practice medicine! I would not like to see this requirement adopted across the United States.

The Centers for Medicare and Medicaid Services recently challenged the orthopaedic community over payment for arthroscopy for osteoarthritis of the knee, based on a research study challenging the effectiveness of this procedure. This is a sign of future confrontations. The recent National Institutes of Health consensus panel on total knee replacement, chaired by E. Anthony Rankin, MD, is another example of increasing scrutiny on the worthiness of our treatments for patients.

As surgeons, we have not emphasized accepting more evidence-based practices in our decision-making as much as other professional groups. This has not gone unnoticed by payers or the government. We will continue to be challenged by such groups as well as the public. The Academy will be asked about the evidence for our physicians’ performance, and many of our actions. We must be prepared.

Unified research agenda
The Council on Research and Scientific Affairs, under the leadership of Joshua J. Jacobs, MD, recently developed a unified advocacy strategy so we can speak with one voice about needed musculoskeletal research. This strategy is detailed in the document “Research Priorities for the Unified Research Agenda,” which was developed with cooperation of the Council of Musculoskeletal Specialty Societies (COMSS), the Orthopaedic Research Society (ORS) and the Orthopaedic Research and Education Foundation (OREF).

Another important tool we have in our research advocacy effort is “Future Directions in Musculoskeletal Research: A Summary Report of the AAOS Research Committee Panel Studies.” This report of the AAOS Research Committee, currently chaired by Marc F. Swiontkowski, MD, serves as a guide for the future direction of musculoskeletal research.

Both reports are part of the Bone and Joint Decade 2002-2011 initiative. We must continue to support this “global initiative aimed at raising awareness, and reducing the burden of musculoskeletal disease on society, and advancing research in prevention, diagnosis, and treatment of musculoskeletal disorders.”

Keep orthopaedics unified
There are constant reminders of potentially divisive actions that threaten our unity—subspecialty exams, direct marketing to patients, continued subspecialty development and independence in CME activities. I do not see any change on the horizon.

AAOS membership, particularly those members who also belong to intersecting organizations, must remain aware of the potential for erosion and emphasize the importance and value in staying united. It makes sense economically and politically—we can do more together than separately. We must recognize the advantages of subspecialization as well as the advantages for our chosen profession to remain whole.

The Board is well aware of these issues. The Board and its Annual Meeting Committee chaired, by Richard F. Kyle, MD, wants to keep the Annual Meeting our flagship educational program. With the continued increase in subspecialists, a project team headed by Richard H. Gelberman, MD, is thoroughly reviewing the important role of specialty day and how to make the Annual Meeting a focus of interest for both sub-specialists and general orthopaedic surgeons. Dr. Kyle also chaired a two-day meeting on new strategies for the Annual Meeting that the Board will review next month.

Our Academy must continue to provide value to all members; it is essential for the Academy’s future growth and success. The Board cannot do this alone. All members must participate in the Academy’s decision-making and direction by taking part in polls and surveys.

In closing, I ask that everyone continue to ensure our patients’ safety, reduce medical errors and be aware of near-misses. Our continued partnership with our patients is essential for every advocacy issue. They will remain our partners if we become leaders for their safety as they move through the health care system.

It has been a privilege for me to serve as your President and a wonderful opportunity to work with a terrific Board and a dedicated staff. I look forward to continue working with Dr. Bucholz, Dr. Weinstein, Ms. Hackett and our Board and staff over the next two years.

Thank you.
James H. Herndon, MD, MBA

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