by Randall J. Lewis, MD
Randall J. Lewis, MD, is clinical professor of orthopaedic surgery at George Washington University, and associate clinical professor at Georgetown University Medical Center. He is a former member of the Board of Councilors from Washington, D.C. and former president of the District of Columbia Orthopaedic Society.
The success of the Academy in meeting the needs of a large, diverse and increasingly global specialty has varied markedly in the two broad areas of Academy activity: education and socio-economic and practice issues. Despite the relatively small size of orthopaedic surgery, the breadth and quality of the educational offeringscourses, books, monographs, the Journal of Bone and Joint Surgery, the Journal of the American Academy of Orthopaedic Surgeons: A Comprehensive Review, Orthopaedic Knowledge Update, educational materials for patients and allied health personnel, a growing library of electronic media, and an Annual Meeting of unparalleled variety, quality and diversityare unmatched by any other specialty.
The development of alternative pathways for recertification represents another achievement. The involvement and integration in Academy programs of fellows who are primarily clinical practitioners, along with professional educators, is a real accomplishment of the Academy, and of our specialty, in general. We should all be proud of these successes.
In the second area, our record is mixed. The attempts of the Academy to further the interests of orthopaedic surgeons (and our patients), and to balance the conflicting economic and political agendas within our specialty have been hampered by the government, by tradition, and by our organizational structure. Although Academy efforts in the noneducational area have intensified manyfold in the past five years, there is clearly a need for more investment and, hopefully, greater returns.
In an increasingly hostile, competitive, and cost-driven environment, there has been major incursion by nonphysicians and nonorthopaedic physicians into the provision of musculoskeletal care. Combined management with our professional peers, e.g., rheumatologists, generally maintains or enhances the standards of patient care. But major surgery by podiatrists, unsupervised treatment by physical therapists, extensive chiropractic manipulation, and nonorthopaedic "sports medicine" treatment often entail inappropriate and excessive expenditures with suboptimal outcomes.
Our Academy has not been a strong or effective voice in this arena, and has even invited nonphysicians to register for Academy skills courses, lending legitimacy to their claims of equal stature. Rather than taking a strong, aggressive, pro-orthopaedist stance, we have become enmeshed in turf squabbles and attempts by subspecialty groups to carve out exclusive areas of orthopaedics for themselves. Despite some positive efforts to resist fragmentation, such as the recent Academy decision to again oppose further CAQS, we have not exerted enough discipline over our own special interest groups. Nobody ever proposed special credentials or exclusive participation schemes with the expectation that he would not hold the credentials or would be barred from the exclusive participation. If we are to survive, we must all hang together. We need to preserve the prerogatives and independence of every orthopaedic surgeon. There are too many enemies attacking from outside for us to weaken ourselves from divisiveness within.
Academy efforts in the area of reimbursement and relative values have generally been stymied by the government. Until recently, the Federal Trade Commission even prohibited the Academy from releasing the independent Abt Associates study, documenting the inequities in the orthopaedic portion of the resource-based relative value scale, upon which most reimbursement today is based. Here the Academy took the right stance, expended appropriate resources, and finally seems to be making headway, if painfully slowly. While clearly necessary, protecting orthopaedics' interests will be an expensive, uphill battle.
A related area in which the Academy has failed to do enough is manpower. Unlike our colleagues in neurosurgery, who dealt with this question some years ago, the orthopaedic leadership (ostensibly for fear of triggering antitrust retribution) has consistently ignored pleas from the community that we are producing too many orthopaedic surgeons. Supply and demand factors obviously have economic implications, but the adequacy of the residency experience for so many trainees can and should be called into question. The effects on overall quality, surgical indications and resource utilization that result from too many underemployed orthopaedists are of real concern: "The devil makes work for idle hands."
There has, however, been considerable resistance in the academic community to a reduction in residency positions. Residents are part of the currency of academic medicine: cheap labor to generate clinical income, captive scholars to carry out studies and produce papers, and the tangible instruments of power and influence, both in the university hospitals and their affiliates. While the new realities of funding residency positions change the picture somewhat, few emperors, academic or otherwise, readily volunteer to reduce the size of their empire. Immediate past president Bernard Morrey, MD, is to be congratulated for his courageous, no-nonsense demand for a workable plan within 12 months to reduce orthopaedic residency positions, no matter what the antitrust consequences. Better late than never!
What then must the Academy do to better serve the needs of the fellowship? We must continue to maintain excellence in orthopaedic education and recognize those who provide it. But we must also take a more aggressive stance and become a stronger advocate for the orthopaedic surgeon. It can no longer be considered inappropriate or unseemly for the Academy to promote the socioeconomic interest of its members, or of the patients we serve. The practicing surgeon, the laboratory researcher, the educator, and the trainee will all benefit if we succeed, and suffer if we do not. We must continue to draw upon leaders who combine professional accomplishment with both a talent for and a strong commitment to public advocacy.
If the Academy is to remain relevant to the daily concerns and practical problems of orthopaedic surgeons, it seems elementary that we must change our organizational structure. We have always been leaders, and the need for leadership and cohesiveness in medicine has never been greater. We cannot increase our effectiveness with the limitations on public advocacy, lobbying and the promotion of our specialty's interests that a 501(c)(3) (nonprofit) structure imposes on the Academy. To adequately represent the fellowship, we need to become a "c6" organization and get down to business. Dues will remain a deductible business expense. A dues checkoff will give us a strong PAC. We still will be committed to education. Research can be funded and charitable contributions solicited through the Orthopaedic Research and Education Foundation. Those who oppose these essential changes have the burden of presenting cogent counterarguments for public debate.