October 1995 Bulletin

Are we professional societies or unions?

by Stanley J. Bigos, MD

Stanley J. Bigos, MD, is professor of orthopedics, University of Washington; chairman of the Agency for Health Care Policy and Research's Guideline Panel on Acute Low Back Problems.

How we are perceived as a professional group by our patients and agencies has served us well and will definitely impact our future. I remember my view of professional medical societies as a resident. I fully realize that those were easier times. There didn't seem to be enough orthopaedists, Medicare reimbursement was still like a bonus, and at Academy meetings you could easily differentiate the technical exhibits from the scientific exhibits.

The professional societies seemed to be groups of professionals seeking science to find the best way of caring for their patients. Even those who looked askew at the American Medical Association after its war on Medicare, saw groups like the Academy as a source of non-self-serving guidance about musculoskeletal care. The focus was more upon trying to find science than what was most politically correct. I was impressed that putting the needs of the patient first was the motto. Marketing seemed beyond reproach. I am sure that politics were played at that time, but the perceived attitude seemed noble enough to bring orthopaedics to its zenith. Those did seem to be simpler days. Perhaps then it was also easier for professional groups to make logical decisions.

Professional medical societies seem to be viewed as more self-serving today. A question can be raised as to whether health care reform could even have become an issue if patients really thought we always had their best interest in mind. Much of the public resentment and questions target hospitals, large medical groups, and professional societies. We may well be at a crossroads that could mold our future depending upon what decisions we make as "professional organizations." Every day we see emotional reactions to fear foster self-defeating decisions, that result eventually into a self-fulfilling prophesy. It is my sincere hope that our organizational fears and anxieties about the present health care issues do not set in motion a self-fulfilling prophecy dangerous for specialists.

Plan pseudoscience

Are professional societies changing for the better? I see arguments in some of our periodicals about whether the Board of Councilors or the subspecialty groups are really representing (the rank and file) orthopaedists. I hear "professional societies" planning pseudoscience for the good of their constituencies. I hear members of professional societies and even elected officials promoting and participating in non-peer reviewed attempts to sway politicians to discredit published peer reviewed efforts. Others fund pseudoscience to prove their care is more "cost-effective" than other providers without attempting to first find out if it is really the case.

Paranoia seems to grow about any scientific effort not controlled by certain elected officials. I find it a bit disconcerting that elected officials would seek to portray themselves as scientific experts through the press before really doing their homework. An official of one subspecialty group actually boasted about having scientists investigated to publicly discredit them as "selling out to the government."

I have struggled with a government agency attempting to gloss over distention between science (evidence about safe and predictable) and but one example of how to bring the science to life. I challenged repeatedly to clearly differentiate between facts and hypotheses, but they have now jeopardized their future by avoiding a clear distinction for whatever the reason. Most medical science can only be brought to life with logical additions where data is scarce. A logical approach uses the safest, cheapest means available for this filler purpose? Should not safe and inexpensive act as a benchmark for future research on more expensive or more dangerous methods when no data is available?

I have had some unique experiences with elected leaders of "professional organizations" since being chosen as chair of Agency for Health Care Policy and Research's Low Back Guideline panel. I've heard of meta-analysis efforts on data that is impossible for meta-analysis. The goal seems to be an attempt to reverse prior scientific efforts by aiming at helping clinicians justify their actions rather than seeking what patients need to know to make informed decisions. Groups have become upset because their favorite article, though published as an "outcome study" in the title, was not put on evidence tables. Could the reason for exclusion be that the article lacked a control group? The best is the suggestion that orthopaedic surgeons, doing a scientific clinical effort that considers the patients' needs to make a decision, are "not the orthopaedist's friend."

Appease groups

I can see seeking knowledge, but I question just trying to get a wanted result. It disheartens me to see professional societies actively avoid making scientific efforts available to members to appease splinter sub-specialty groups who don't like the results of a scientific effort.

If we are truly professionals, we might seek science and its dissemination to make care safer and easier for our membership to provide. Would not members rather have their professional society credible to avoid being at the mercy of attorneys quoting inappropriate "should," "must," and "never" statements from non-peer reviewed texts when something goes wrong? Many textbooks and even some periodicals make little distinction between what medical science supports as being predictable and what can't yet be supported as predictable. "Shoulds" and "must" are rarely justified by our scientific data and commonly are only the strong opinion by an author.

Thus, true professional societies can be very valuable to the practitioner if credibility is maintained. They can serve as a beacon for the best interpretation of medical science. It can best distinguish the basis for emergency actions required of a clinician from the stricter rigors needed for providing recommendations to patients trying to decide upon their own elective care.

A professional society should demand the least biased process to seek knowledge rather than a specific results to protect the financial and ego base of some of its constituents. Scientific guidance is hard to come by when done to justify rather than to understand. Only "res ipsa loquator" (allow the thing [result] to speak for itself) can guide our future. If a method is safe and effective, it will be easier to prove than if it is risky and of, at best, marginal effectiveness. We rarely get in trouble trying to do the best we can for our patients based upon the best data available. Unfortunately, it seems rare for us to avoid past mistakes without scientific guidance.

I have no intentions of dismissing significant, well-intentioned survival efforts by specialists. I only ask that we maintain some balance to avoid painting all of us with a brush that could make our worst fears become self-fulfilling prophesies. I hope that from a national standpoint there can be some moderation. Nationally serve real science, rather than pseudoscience. Leave the needed union activity to other groups so that our professional national societies can provide some protection and credibility for members out there doing their best to take care for patients needing services.

Academy or union?

Perhaps it is time for someone to call for a vote so we can honestly declare our intentions. Then all of us will know for sure whether we are a professional society or not. Is it American Academy or College or should the name be American Union or Brotherhood? It is our choice. How would the general public react if they knew for sure we don't necessarily have their best interests in mind? What activities might well assure the general public that we are doing otherwise?

Elected specialty and subspecialty officials, who will hopefully not be influenced only by the uninformed, the politically motivated, and the scientifically challenged, can then declare our societies intentions. Are we a union or professional society? Make it clear to basic scientists as well, whether they should continue to use scientists to obtain credible data or must they also succumb to the pressures applied to clinical scientists to bring elected union officials into their labs so the results are politically correct.

What professional oaths would we have to publicly disavow if we vote to be unions? We could no longer hide behind Hippocrates or be allowed to call our union activities real science. Elected officials can then run studies for the sake of the membership and quit trying to fool the general public and our patients about our intentions. Are we Academies and Colleges or are we Unions? Before answering, consider trying to sell a 15-story building or large bridge planned by the elected officials in the construction trades rather than engineers and architects? Furthermore, tell me which unions look so appealing that we are ready to give up our professional standing to emulate them? Until informed otherwise, I will assume that science is the goal and continue to work with scientists, not union officials, while doing science aimed at the needs of the patient.

"Knowledge will forever govern ignorance and a people who mean to be their own governors, must arm themselves with the power which knowledge gives. "

- James Madison

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