July 1995 Bulletin

Across the President's Desk
Uniting the 'House of Medicine'

United we stand, divided we fall. - G. P. Morris

A house divided against itself cannot stand. - Abraham Lincoln

At our May 1995 Workshop, the Academy's Board of Directors attempted to explore the changes in the delivery of musculoskeletal care which would substantially alter the practice of orthopaedic surgery in the next 5 to 20 years. We were impressed by the impact that an aging population may have on our specialty and by a prediction that we could be treating twice as many hip fractures by the year 2030. We also listened to experts who enlightened us on the rapid advances which are occurring in biologics, telemedicine, medical informatics, and, of course, the infrastructure and financing of future health care delivery systems. We then tried to determine the effect that these changes will have on the individual orthopaedist, the specialty of orthopaedic surgery, and the American Academy of Orthopaedic Surgeons.

These deliberations led to a substantial revision of the Academy's Strategic Plan in five different areas and the preliminary revised plan was reviewed and passed by the Board at its May meeting. The plan is now undergoing the scrutiny of the Board of Councilors, the Council of Musculoskeletal Specialty Societies, and the Academy staff before final debate and passage in December 1995.

Perhaps the most significant change in the Strategic Plan was the addition of a new category entitled "Patient Care." The value statement, goal, and objectives of the Patient Care category, which follow, clearly enunciate a more aggressive effort toward the development of collaborative relationships with other organizations representing providers of musculoskeletal services.

Patient Care

Value Statement

The ideal approach to the care of the musculoskeletal patient is a team comprised of orthopaedists and other providers of musculoskeletal care. Working together to coordinate patient care, each provider shall participate in a way which maximizes the quality and cost-effectiveness of the overall care.


Our goal is to develop programs and relationships that will improve the quality of musculoskeletal care by exploring a variety of health care systems.


  1. Identify and develop models of musculoskeletal health care delivery that maximize the quality and cost-effectiveness of care.
  2. As new delivery models are developed, provide programs to assist orthopaedic surgeons to redefine their roles, appropriate to local and regional needs.
  3. Work with other organizations representing providers of musculoskeletal services to develop systems of patient management that will be physician-controlled, cost-effective, and preserve timely access to specialty care. These cooperative efforts may include research, provider education, patient education, advocacy, and patient care models and tools.

I believe that, by these important additions to the Strategic Plan, the Board has taken a very important stance in support of the pursuit of unity between the various medical disciplines that contribute to the management of patients with musculoskeletal disorders. Clearly, the large, profit-oriented insurers who are directing the rapid shift towards managed care in this country would like nothing better than a continuation of the territorial competition between primary care physicians and specialists with little or no meaningful effort by those factions to cooperate in the development of delivery systems which smoothly cross interdisciplinary boundaries. Such disunity permits the insurers to establish protocols for patient care with a paucity of concern for the capabilities of providers; be they non-physicians, primary care physicians, or specialists. Cost savings alone become the driving force behind these insurer-controlled systems with quality of patient care relegated to secondary importance.

The Academy's Board of Directors believes that if all organizations representing providers of musculoskeletal services can work in unity to develop integrated systems for providing high quality, cost-effective patient care, we may well retain or, in some instances, regain physician control of the services we provide.

As we strive to establish integrated musculoskeletal care systems, we must insure that - at all levels - patients receive expert, high value service, delivered by well-trained, competent providers. To achieve this "team approach," the Academy will have to strengthen its relationships with other organizations including family practitioners, gerontologists, pediatricians, physiatrists, emergency physicians, therapists, and others.

To begin exploring the role of orthopaedic surgeons and other musculoskeletal providers in future delivery systems, the Board has just approved the Work Group on Future Delivery Systems for Musculoskeletal Care which will be chaired by Douglas Jackson, MD, the Academy's second vice president. The composition of the work group also includes: James S. Breivis, MD; D. Kay Clawson, MD; Paul C. Collins, MD; Walter B. Greene, MD; Jeffery B. Husband, MD; Richard F. Kyle, MD; and David R. Mauerhan, MD.

The charges to the work group are as follows:

  1. Critique existing models for delivering musculoskeletal care;
  2. Identify emerging delivery models and assess their impact on the current and future orthopaedic work force;
  3. Develop a plan for working with organizations representing providers of musculoskeletal services;
  4. Identify and evaluate new models of musculoskeletal health care delivery that maximize the quality and cost-effectiveness of care;
  5. Evaluate systems of musculoskeletal patient management that are physician controlled vs. "cost managed"; and
  6. Look into the feasibility of cooperative efforts in research, provider education, patient education, advocacy and patient care models and tools.

The Work Group on Future Delivery Systems for Musculoskeletal Care will report its findings and recommendations to the Board in December.

Armed with the findings of the work group, the Academy should be able to proceed with efforts to initiate harmonious and productive relationships with other organizations to develop systems of patient management that will be physician-controlled, high quality, and cost-effective. Needless to say, the dissolution of some interorganizational, interdisciplinary, protectionistic boundaries will be necessary before responsible dialogue can be established between organizations that have historically addressed only the perceived best interests of their constituency. These barriers can and must be broken down so that the "House of Medicine" can unite to ensure that it will still be standing and firmly in control after the new systems resulting from health care reform have completed their evolution.

James W. Strickland, MD


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