January 1996 Bulletin

Challenges fellows to face change

The tide won't recede, says Dr. Mauerhan

When it comes to considering the future role of orthopaedic surgeons in musculoskeletal care, there are lots of questions and no easy answers.

Just ask David Mauerhan, MD, who addressed the subject in a thought-provoking speech to the Board of Councilors last October. Admittedly anxious about the issue that he dealt with in tell-it-like-it-is terms, the president-elect of the Board of Councilors asked that his remarks "stimulate discussion, fuel debate, and lead to solutions that will help position orthopaedic surgeons as respected colleagues and team participants in musculoskeletal care."

The field of orthopaedic surgery has experienced great scientific and technical advances in the last 50 years and, said Dr. Mauerhan, "the Academy has become one of the best organized and most respected of all specialty societies. We have the very best educational resources. We continue to attract the best and the brightest medical students into our training programs. We continue to keep society mobile, working, and playing."

So, what's the problem?

"To put it simply," he said, "we have become some of the most expensive physicians in America. The care we provide is expensive. Expensive tests, expensive devices, and expensive therapy. Our personal incomes are among the highest in medicine. Now society is asking, 'what's the value of our service?'

"Our successes are evident, but we have yet to document which methods are the most cost-effective and which may be ineffective or even unnecessary. Our cost-plus, fee-for-service, do more, work more, make more system has brought us to this point. Society is asking, 'we are paying more, but are we getting more?'

"It is no wonder then, that our specialty is under siege from government agencies and third-party payers."

Furthermore, he said, orthopaedic surgeons are not perceived by managed care entities as being team players. "Government agencies see us as self-serving," Dr. Mauerhan said. "We have been criticized as wanting to play on
the team as long as we get to be captain of the team. How can we change this perception?"

Change must come

And change must come because of changes in the health care delivery system.

"As medical care organizations evolve, the cottage-trade, specialty-dominated systems are giving way to primary care-driven organizations," Dr. Mauerhan said. "Orthopaedic surgeons are seeing other providers involved in the care of the spine, foot, and sports medicine. The nonsurgical musculoskeletal care required in these areas contributes to the bulk of patient visits."

Some advanced medical care organizations are referring patients to comprehensive back care teams that may include family practitioners, osteopaths, chiropractors, physiatrists, physical therapists, orthopaedic surgeons, neurologists, and neurosurgeons.

"It is interesting that many orthopaedists in medical care organizations do not want to see more back patients," he observed.

"Future health care systems may develop around the concept of disease management. Disease states such as cardiovascular disease, osteoarthritis, and polytrauma will have clinical care continuums and clinical pathways that will focus on the complete care of these disease states. Care teams will evolve that will provide both disease management and wellness education."

Orthopaedic surgeons will obviously play a role in these new delivery systems, he said, "but will we be ready as team players?

"Currently, our specialty is heavily procedurally-based. Many orthopaedists are not interested in meeting the need for nonsurgical musculoskeletal care. They feel they should interface with the patient when surgical intervention becomes necessary.

"In the conservative care of the back and foot, for example, we have abrogated our responsibility to the point that many medical care organizations now prefer nonorthopaedic providers. This erosion of our patient care base will continue unless we are willing to consider the care team models."

Dr. Mauerhan warned that as other providers embrace nonsurgical musculoskeletal care with eagerness, there may be a decreased demand for orthopaedic surgeons, especially if fewer surgeons can manage larger surgical caseloads. The result, he said, would be an increasing oversupply, increased competition, and possibly fragmentation and loss of collegiality within the profession.

Embrace challenge

"What if, on the other hand, we embrace the challenge and develop ways for orthopaedic surgeons to provide general ambulatory musculoskeletal care?" he asked.

"Directors of medical care organizations believe there is a need for more physicians doing nonsurgical musculoskeletal care. At Kaiser Permanente, for example, 40 percent of patient visits to primary care physicians are for musculoskeletal conditions. The overall national shortage of primary care physicians may provide opportunities for orthopaedists to practice nonsurgical orthopaedics.

"Do we want to evolve into musculoskeletal technocrats, that is, proceduralists who intervene only after heavily screened patients require surgery. If we do, certainly fewer of us will have job security.

"Or, on the other hand, will we embrace the concept of the orthopaedic generalists who can provide good, cost-effective musculoskeletal conservative care? If we begin now, we can successfully blend the best elements of surgical and nonsurgical care to fill the needs of future medical care organizations.

"Finally, and perhaps most importantly, what steps should we take to insure that the practice of orthopaedic surgery remains fun and satisfying?" he asked.

Interviews with orthopaedists in various managed care organizations disclosed factors that contribute to satisfaction, including:

Several factors that were listed as being dissatisfying are:

"Can we broaden our horizons so that some can choose to practice office-based orthopaedics while others may elect more procedurally based practices?" he asked. "Will we ensure that both can maintain positions of honor and respect in our professional societies? Can we change the emphasis of our training programs so that we are able to respond to the evolving needs of musculoskeletal care teams of the future?

"Whether we like it or not, change is upon us and although many would like, the tide will not recede."

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