October 1999 Bulletin


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

Scope of practice

The view of John Wickenden MD, on the emergency "on-call" aspects of orthopaedic surgery (Point of View column, August 1999 Bulletin) are shared by many of our members and reflect the reasons emergency rooms are having more difficulty obtaining voluntary coverage. In addition to individual preferences, the new managed care market place and government reimbursement schedules are redefining "first contact" and "emergent and scheduled triage" of patients with musculoskeletal problems.

During this time of significant changes, our profession is experiencing growth in the number of board certified orthopaedic surgeons and a decreased utilization of our specialty by managed care. The leadership of AAOS has suggested that one solution to this supply and demand issue is to expand the scope of practice of orthopaedic surgeons. In my interactions with other physician specialties and non-physician providers of musculoskeletal care, they also are all seeking to expand their scope of practices.

"Availability" of quality value-added care will be the key factor that eventually will satisfy our patients, our physician colleagues and the marketplace. It will take time to define all the caregivers and their expanded roles to providing the different aspects of musculoskeletal care.

Are we going to expand our roles as orthopaedic physicians and surgeons or limit ourselves to being highly trained technocrats? If we want to abdicate any aspects of our profession scope and involvement in musculoskeletal care, we need to cut back on the numbers being trained. That is not possible for us to do as a professional organization. The U.S. Department of Justice has clearly stated that the number of physicians being trained will be determined by two forces: 1. the market place and 2. government funding.

Individually, we can make decisions about our own scope of practice as Dr. Wickenden proposes (and which I have done personally), but as a profession we must consider what is best overall for our patients and all of our members. There is no easy answer that fits all situations. We are in an evolving health care environment that will never be like the one those of us in our third decades of practice prefer. The quality value-added providers of the entire scope of musculoskeletal care at each level is being challenged and redefined. The training of the new physicians and non-physician providers needs to be responsive to patient needs.

It is necessary for us all to be involved in this debate dealing with our scope of practice at the local and national level. We, as individuals, each will make decisions and our profession needs to make decisions. Fortunately these decisions are usually in unison, but we can all be grateful for the opportunities present for individual expression of our talents and contributions to patient care.

Douglas W. Jackson, MD
Long Beach, Calif.
1997 AAOS President


These are comments regarding the letter written by Joel E. Cleary, MD, in the August Bulletin. I have to agree with much of what he has written about the American Board of Orthopaedic Surgery.

I was a community surgeon without academic connections, and I had just completed my term as chairman of the Board of Councilors. I was nominated to be a member of the Board by a previous Academy president and endorsed by a second. Despite these factors, the Board chose to have an academician. This is the Board's prerogative, but it points out the concern expressed by Dr. Cleary: The Board is not an organization of our "peers."

His last statement regarding "the Academy splitting away from the Board" is not really valid as these are two very separate legal entities.

Robert C. Shoemaker, MD
Claremont, N.H.

HCFA guidelines

I have just read the article in the August Bulletin that listed the HCFA guidelines for examinations. This quickly reminded me of an experience I had years ago when my mother taught me how to use a cookbook. In the how to cook a "roast" section, she noted 18 ingredients that were needed to make the product tasty. In the "cake" section, there were 12 items, while there were only six required for cookies. We both realized that all the ingredients were needed to satisfy her guests.

Perhaps the people at HCFA utilized the same "cookbook" style of including "ingredients" when they devised their 18, 12 and six items for examinations.

Need all of us practitioners remind them that regardless of their ingredients, in no way will their end products ever satisfy their "guests."

Charles B. Gillespie, MD
Albany, Ga.

Hits HHS strategy

The letter by William W. Tipton Jr., MD, (AAOS executive vice president) to Donna Shalala, Secretary, Health and Human Services, was beautifully written. However, as cynical as this may sound, I am convinced that the thesis of his letter that the bounty program
". . . will drive a wedge between physician and patients the likes of which have not been seen before" is actually part of an overall strategy that HHS and HCFA are employing across the spectrum of healthcare to impede its delivery initially and destroy the current system ultimately-ostensibly to replace it with a socialized system.

This began in earnest with severe reimbursement cuts for total joint replacement surgery, extremely punitive reimbursements for total joint revisional surgery and for cardiac bypass surgery. As we all know, these surgical procedures entail a substantial cost to the government, a small fraction of which includes the physician reimbursement. Nevertheless, the physician is the de facto gatekeeper for determining which patients will get these operations. Therefore, to punish the gate keeper (i.e., the surgeon) and make it economically undesirable for him or her to perform the procedure, ultimately improves the overall economics in terms of total cost to the government. Introducing the 50 percent reduction of payment for bilateral procedures was one of the initial strategic moves in this direction.

Recently, the extraordinary amount of documentation that the government is mandating for the use of synovial fluid enhancers (i.e., Synvisc® or Hyalgan®) to the point of subjecting the practitioner to penalties if all these criteria are not documented, clearly shows HHS's intent to restrict care by punishing the practitioner and making it appear to the patient that it is the physicians and practitioners that are restricting care, thereby absolving the government of its true role in the restriction of these services. What is more galling is that HHS pursues this strategy even in light of the humongous budget surpluses we keep hearing about.

I personally would like to see the Academy call HHS on this strategy and take aggressive action to expose this behavior and force them to try to publicly defend it.

Bliss W. Clark, MD
Harlingen, Texas

Selling products

I am a retired orthopaedic surgeon and have been out of practice for one year. The main reason that I retired at age 64 was the fact that I could not work hard enough to pay the ever-increasing expenses and make a decent living doing spine surgery, which was my primary specialty. The reimbursements had been lowered so many times and there were so few in the specialty that the HMOs and insurance companies would not listen to the facts. My overhead increased steadily even though we had and followed the management consultant's recommendations.

Now I see that the AMA says that a doctor can't make a profit on products sold in the medical office. It's no wonder that many doctors think little of organized medicine. I've been a member since 1966 when I was an officer in the Student AMA. I must say I'm ashamed that our leaders are still in the dark ages and are not supporting the membership. There is nothing wrong with providing medical products as long as the prices charged are consistent with other sources in the community.

P. William Haake MD
Scottsville, N.Y.

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