February 1999 Bulletin

Task force urges balance in specialty

Scope of practice should include nonoperative treatments

Many solutions have been advanced to solve the work force issue-reducing the number of residents training in orthopaedics, reducing the number of hours worked by orthopaedic surgeons and early retirement. Each has a flaw.

Reductions of residency programs must avoid federal antitrust laws and overcome the lack of support by some program chairmen. The RAND report on work force issues, developed for the Acadmey, shows it would take drastic cuts to make a dent in the surplus and that wouldn't happen for years.

Reducing the hours worked by orthopaedic surgeons may not spread the total patient volume among more orthopaedic surgeons because physicians in other specialties may see those patients.

Early retirement is not appealing to orthopaedic surgeons who like to do what they do-treat patients.

The solution offered by 1998 Academy President James D. Heckman, MD, is to expand the scope of practice-increase the volume of nonoperative care. An Academy task force looked at the issue and came to the conclusion that "our technical skills have never been better," Michael H. Graham, MD, task force chairman, told the Academy Board of Directors at the December meeting. "We're highly skilled and the best at what we do. We should strive to remain the best." But he observed that "the new cadre of orthopaedic surgeons are more specialized and are poorly skilled in nonsurgical care and have no interest in it."

If this trend continues, eventually orthopaedics will be a "surgical technocracy and we'll lose chunks (of orthopaedic care) to others," Dr. Graham said. "The physician surgeon will be reduced to a mere technician.

"The task force is not recommending a polar axis shift in the educational program," but a "move back to more balance in orthopaedic care, including nonsurgical treatments."

The task force recommendations and board actions are:

Encourage the Academic Orthopaedic Society (AOS) and the Residency Review Committee (RRC) to increase the emphasis on nonoperative care in orthopaedic residency programs. (Referred to AOS and RRC after the board develops implementation methodology at the spring 1999 workshop.)

Encourage the American Board of Orthopaedic Surgery (ABOS) to increase its emphasis on nonoperative orthopaedic care in the primary certification examination and the recertification process. The ABOS should reconsider its position and allow examiners who have stopped doing surgery to continue to be eligible as examiners. (Recommend that ABOS to do both.)

The Council on Education should increase its emphasis on nonoperative care in its educational programs, exams and materials. (Referred to the Council on Education.)

The Journal of the American Academy of Orthopaedic Surgeons, The Journal of Bone and Joint Surgery (JBJS) and the Bulletin should increase emphasis on nonoperative care by providing information on "alternative" and "integrative" treatments. (Referred to the Council on Education, Council on Research and Scientific Affairs, to staff and JBJS.}

The Academy should consider changing its name to reflect a broader definition of the specialty. (The board accepted the recommendation as information and took no further action.)

Assure that the efficacy of nonoperative care is examined through MODEMS and other evidenced-based analysis. (Referred to the Council on Research and Scientific Affairs and to the Musculoskeletal Education and Research Institute.)

Encourage the Orthopaedic Research and Education Foundation (OREF) to fund studies on the merits and cost-effectiveness of nonoperative orthopaedic care. (Dr. Heckman will contact OREF to discuss funding such studies.)

Through the Bulletin and other means, the Academy should educate its members that patient satisfaction is vital to growing and sustaining an orthopaedic practice, and should make available training in patient satisfaction measures. (Referred to the communications department for the Bulletin and to the Councils on Education and Health Policy and Practice, the BONES Society and AOS.)

Increase members' awareness of important areas of practice expansion in which the orthopaedic surgeon has expertise such as foot and ankle care, disability and medico-legal evaluations, osteoporosis, geriatrics, rehabilitation, rheumatologic disorders and manipulative care. (The board added "spine" and "osteoporosis" and referred the recommendation to the Council on Education, Public Relations Task Force and the American Orthopaedic Foot and Ankle Society.}

Work with industry, through the Corporate Advisory Council, to facilitate clinical trials of new musculoskeletal technology. Assemble a sizable cadre of orthopaedists to participate with industry in these trials. (Referred to the Council on Research and Scientific Affairs.)

Provide educational opportunities and publications for orthopaedists to maintain awareness of basic research in the biological and genetic approaches to musculoskeletal care. (Referred to the Council on Education.)

Establish a Committee on Shared Interest Groups (SIG) to guide and oversee the activities of various groups organized to meet the individual needs of orthopaedic surgeons planning for and reaching retirement, surgeons with interests in osteoporosis and other possible disease entities, among others. (Referred to Committee on Committees to establish an oversight panel to develop guidelines and a mechanism for Academy SIGs and establish a pilot SIG on retirement and alternative careers.)

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