October 2003 Bulletin

From our readers

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

Sports Medicine CAQ

The article in the June 2003 issue of the Bulletin described the qualities of a sports medicine specialist but also provided an outline of all the wisdom and knowledge that a Fellow of the AAOS has. The performance of all (except the nursing of an injured player on the field) that was outlined, is carried out on a daily basis by the qualified orthopedic surgeons throughout the country. The attempt by the American Orthopaedic Society for Sports Medicine (AOSSM) and Peter J. Fowler, MD, to establish a quasi-orthopaedic board or specialty is totally unjustified, unless it is a self-serving device by the AOSSM and by Dr. Fowler.

Within the article, Dr. Fowler states that the “AAOSM strongly supports the right and ability of all orthopaedists, regardless of post-graduate training and education, to provide sports medicine services in the team, clinical and surgical setting.” All orthopaedic surgeons that I know are very competent and able to perform that which the AOSSM strongly supports. Why then the AOSSM duplication of the AAOS?

Jack Kriegsman, MD
Los Angeles, Calif.

Using arguments aimed at assuaging concerns previously voiced by the Fellowship regarding the unsavory consequences that certificates of added qualification (CAQs) might generate, Peter J. Fowler, MD, president of the American Orthopaedic Society for Sports Medicine (AOSSM), provides flawed arguments, which he, however, calls “unambiguous” to justify the decision made by AOSSM to issue subspecialty certification in sports medicine.

Dr. Fowler states that subspecialty certification “does not preclude others from caring for athletes.” Later he adds, “AOSSM strongly supports the right and ability of all orthopaedists, regardless of post-graduate training and education, to provide sports medicine in the team, clinical and surgical setting.” So far he seems to be arguing against CAQs in sports medicine, reinforced by his comment that all orthopaedists are “qualified to deliver care to all patients suffering from athletic injuries.” In addition, he reinforces the position of the AAOS by saying that AOSSM has “specifically excluded using certificates as a criterion for membership [in AAOSM]” and that the issue of granting CAQs was not taken lightly, as depicted by the fact that it took more than a decade of serious deliberations before deciding to do so.

Dr. Fowler, in my opinion, has failed to present a logical argument to justify the actions of his organization. What is it that AOSSM really wishes to achieve by putting its members through the inconvenience and expenses necessary to obtain a CAQ? A cost that increases the already huge bills from one year of Fellowship, dues from other medical organization such as the AAOS ($750.00 annual dues), AOSSM ($400.00 annual dues), the Arthroscopy Society ($550.00 annual dues), the AOA, the AMA, the local, state and regional orthopaedic societies, etc. Keep on adding figures and soon we will have built a strong argument to further justify our concerns over reductions in the reimbursement for services we render!

Will those who take the examination to earn the CAQ (for which there will be a charge) be listed differently in the directory of the organization? Will those who believe that advertising of medical practices through newspaper and television ads are ethical and appropriate, display the certificate through their marketing gimmicks? Will they propose to claim a superior status when testifying in court, either on their own defense or in behalf or against colleagues?

I am disappointed to witness AOSSM make the same mistake the Hand Society made when it began to issue CAQs. I strongly opposed such a move and anticipated that other societies would seek similar status symbols, and that time would prove the futility of the certificates.1 We may ask today, 10 years later, what concrete benefits did hand CAQs wrought to the profession and patients alike? Did they improve the quality of care of the hand? Did they keep the “bad apples” out of the mainstream of surgery, reducing therefore the number of complications and bad results? Were they used unfairly to discriminate against orthopaedists who did not possess them?

The Fellowship of the AAOS, as stated in the short paragraphs published in the same issue of the Bulletin, has unanimously expressed its opposition to CAQs. I have also been told that in numerous occasions the fellowship of AOSSM has opposed the issuing of CAQs. That being the case, what prompted the hierarchy of AOSSM to act against the wishes of its fellowship and embark on a project that not only may harm the unity of the orthopaedic profession but also create unnecessary discord? In essence, what is it to be gained from this unwise move? Why legitimize controversial CAQs, which have no record of being of any benefit and possess no known redeeming features?


1. Sarmiento, A: Certificates of Added Qualifications in Orthopaedics: A
position against certification. JBJS, 1994:76(A): 1603-04

Augusto Sarmiento, MD
AAOS Past-President
Coral Gables, Fla.

Affirmative Action?

When reading the comments concerning the recent rulings on diversity that have been written and published in Bulletin over the last several issues, there are some very troubling points that need to be addressed. Firstly, let me say that I am neither for nor against affirmative action but I think that some of us have lost focus on what affirmative action was supposed to rectify. To help clear this up, allow me to ask a couple of questions.
Firstly, we are the most affluent members of this society and many of us were born into this affluence. It is quite difficult for me to understand how using this affluence to get loved ones into sought-after positions, schools, jobs, etc., differs from affirmative action. I went to Yale University long after our President Bush was admitted after a poor high school performance because of his family. This practice seems to be an acceptable form of affirmative action. Despite it being race-based and not socially or financially based, why is affirmative action not an acceptable form of nepotism?

Secondly, some of the readers have offered studies quoting vague statistics of drop-out rates for students that have been admitted under the guise of affirmative action. Any well-read person of our own literature realizes quickly that for every study, there is a counter study. Furthermore, it is interesting to note that rarely do people mention the drop out rate among the children of the affluent. How many of us have children, contemporaries, or know children of contemporaries that have attended more than one undergraduate institution for academic reasons or failed a course of study or two?

Lastly, there has been a growing trend in this country to recognize the effects of abuse on children. Many of the country’s most noted pediatric scholars agree that the mental and social damage may be irreparable and may be the onset of a vicious cycle that may even directly involve future generations. The legal and publicly supported abuse that the minorities that currently benefit from affirmative action endured was only a generation ago. An African-American of my father’s age had been enjoying the ability to drink from any water fountain of his choosing for only a year when he was my present age. In the same vein, those that committed these abuses are the contemporaries of today’s senior partners, CEOs, and Deans of America’s most prestigious academic, legal and financial institutions. I find it hard to believe that in the 40 years since the passing of civil rights legislation, all of the “abusers” in this country have become multi-cultural advocates. Therefore, are African-Americans not entitled to the same refuge, recognition and retribution that many of our abused youth demand?

Although many of the readers have found the stance taken by the AAOS disappointing, I would more strongly state my disappointment in the stance taken by the most educated and affluent among us. Although affirmative action is severely flawed in its current state, it is attempting to address a significant hiccough in our American history. The majority of us has benefited and continues to benefit from some form of affirmative action so we should not be so quick to cast our negative votes without offering a single, fair solution. Perhaps if orthopaedics were more diverse, an answer could be found.

Scott E. Porter, MD
Resident Physician
Charlotte, NC


I first became aware of the American Orthopaedic Association (AOA) and the AAOS efforts to teach orthopaedics communication at the AOA meeting three years ago. These efforts are politically correct, but the idea that the AAOS should be devoting time and money to teach adult surgeons how to communicate seems strange to me (June 2003). Talking about professional attire, eye contact, empowering words, explanation of thoughts, and use of analogies is a noble effort, but if you are dealing with orthopaedic surgeons at the age of 30, 35, 40 and 45 who have not learned these skills, you are really wasting your time. Perhaps I can communicate this to you by using the adage that “you cannot teach old dogs new trick.”

Communication skills are to some extent inherited and learned in childhood. Hopefully your mother told you to look grandfather in the eye when you shook his hand. If you learned that at the age of 3, chances are you will make eye contact with your patients at age 40. Teaching eye contact at the age of 40 is probably a waste of time.

If communication is a priority of the AOA and the AAOS, then I think we should make a serious effort to select residents who have demonstrated those skills by the time they apply for training in our specialty. I am sure you are aware as am I, that there are applicants who score in the 99 percentile in biochemistry, pathology and other important sciences but who are inept with other human beings. They learn empowering words the way they learn biochemical formulas and prefer to communicate via e-mails, interactive DVDs etc. More and more of our academic colleagues can be reached by e-mail only. Their human skills, if they ever had any, are well on the way to atrophy.

Let’s select orthopaedic residents with communication skills and whatever else it takes to be an orthopaedic surgeon and we will not have to waste our time and money on teaching them how to make “eye contact.”

The other concern I have is that the well meaning efforts of the AOA and AAOS will lead to a governmental agency that will require us to document the time we have spent shaking hands, listening, etc. The State Health Department will, of course, have the appropriate clerks to police this by requiring explanatory letters, withholding reimbursements, threatening licenses revocation, etc.

Kristaps J. Keggi, MD
Waterbury, Conn.

Patient Safety

I couldn’t agree more with John W. Thompson, MD (Letters to the Editor, August 2003) regarding the orthopaedist’s obligation to carefully prepare for a patient’s surgery, including reviewing the patient’s chart and X-rays, and talking with the patient in the surgery holding area. Unfortunately, sometimes even that is not enough to prevent wrong-site surgery. I vividly recall an incident 10 years ago when the hurried anesthesiologist wheeled the wrong gurney into the OR, and we almost did a hip nailing on a frail, elderly female wearing a blue surgical cap (don’t many in this age group look similar?) who was scheduled for thyroid surgery. Fortunately, the mix-up was recognized just before induction and the error rectified. However, had I “signed the site,” this potential disaster would not have occurred. So, even though the surgeon is very familiar with the case, I feel that the AAOS position of signing the site is appropriate and is a small inconvenience for the surgeon.

Emmerich von Haam, MD
Greensboro, Ga.

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