A Little History
Within the past few years, our academy celebrated its 75th anniversary with many events, including the publication of a fascinating timeline of the history of orthopedics. This timeline highlights many of the seminal figures in the development of our specialty--men and women who were true visionaries and who built the foundation for every aspect of our current professional lives. At this time of intense financial challenges and debate concerning our response to these challenges, it is quite illuminating to remember our medical heroes and the circumstances under which they practiced and loved orthopedics.
As we look back over the past 75 years of achievement, we also look forward toward a time of great financial uncertainty. We must realize that our current American medical system is unsustainable, and we are quite likely to feel downward pressure on our incomes for years to come. As other articles and links on this site more fully demonstrate, both our federal and state governments simply cannot continue to support the medical establishment as richly as they have in the past. For example, without changes to the system of reimbursement, Medicare alone is projected to cost more than half of all federal tax revenue within the next 30 years or so, and this does not include the federal government’s share of Medicaid expenses.
Fortunately, during this time of daunting financial uncertainty, we can all look to the example of our orthopedic heroes for inspiration. Their achievements, outstanding patient care, and love of orthopedics all occurred, by and large, in environments where they made considerably less money than the typical contemporary orthopedist. We enjoy a mean salary of $394,000 based on the most recent academy survey; this is approximately 10 times the salary of the average American worker. Let us look first to the year 1931; it was in this year that 7 visionary orthopedists founded the American Academy of Orthopedic Surgeons and first enunciated the ideals that we still strive to emulate today. They agreed that we must first be champions of our patients and strive for excellence in patient care. What is easily forgotten over the years is that these gentlemen worked in an environment where the average orthopedic salary was just under 3 times the pay of the average American worker or less than $120,000 in today’s money. Despite this, their legacy reveals that these eminent gentlemen enjoyed their orthopedic practices and the wonderful results that they achieved for their patients just as much as we enjoy them today.
Next, imagine the Annual Meeting of the American Academy or Orthopaedic Surgeons in 1958; Paul Harrington stood up to fierce criticism of his idea for using instrumentation to correct spinal deformity. Before his revolution, orthopedists were fighting a losing battle against scoliosis with their patients undergoing years of external fixation accompanied by occasional spine fusion procedures. Time Magazine said of the treatment: “Some ailments seem almost preferable to their cures. A case in point is scoliosis.” Dr. Harrington’s perseverance, determination and dedication to helping improve the lives of his patients at Jefferson Davis County Hospital in Houston completely revolutionized spine deformity care and allowed us the wonderful opportunity to cure spinal deformity patients in a way not even imagined before him. At the time of Dr. Harrington’s efforts, orthopedic salaries were approximately 5 times those of the average American worker or significantly less than $200,000 in today’s dollars. Do any of us question that Dr. Harrington enjoyed his work any less that today’s spine surgeons who are paid many multiples of Dr. Harrington’s income for comparable work using procedures that are entirely dependent on Dr. Harrington’s original ideas?
We can look back almost to the beginning of orthopedics to find further examples of individuals whose love of learning and caring for their patients can still inspire us today. An excellent example is Abraham Colles. He was born of humble origin in Ireland in 1773. He developed an early interest in anatomy and care of the sick. After much study and apprenticeship, he began his career in 1797 as a teacher of anatomy and surgery, and he opened a practice of his own to care for “the sick poor”. His first year of his medical practice, he earned 8 pounds. This is equivalent to $460-$560 today. In his best year, he earned 421 pounds in 1800 or $32, 564 in today’s dollars (conversion made using CPI data). He continued to teach anatomy, physiology and surgery at the Royal College of Surgeons and was elected its president in 1802. His 1814 paper, “On The Fracture of the Carpal Extremity of the Radius” was far ahead of its time in describing the fracture we now name in his honor, the colles fracture, and discussing principles of its treatment. Furthermore, he accomplished all of this decades before the advent of x-rays. In retrospect, his work and insights are quite amazing, and we have no reason to think that his humble to middle class earnings tarnished his love of medicine in any way.
Our history, indeed, is rich with stories of innovation, intellectual exploration, teaching, and compassionate care for the sick or injured. Throughout nearly our entire history, our predecessors, those giants of orthopedics, worked diligently and with astonishing achievement for much lower incomes than we expect today. In point of fact, it was not until the 1970s, after the advent of Medicare and Medicaid, that physician’s salaries began to grow exponentially compared to median household income, and this growth has been largely confined to physicians practicing in the United States. Very high incomes have never been the norm for physicians and are not the norm in other parts of the world. We should be thankful that we have had the opportunity to enjoy such a large income from the practice of orthopedics but also understand that it has always been unsustainable. As discussed above, maintaining the economic status quo in medicine would eventually bankrupt the country; there simply is not enough available money. While I acknowledge that this is discouraging, we can all draw strength and inspiration from our orthopedic heroes. They loved their work, their patients, and their profession, and made astounding innovations while working for far less money than almost any of us enjoy today. They clearly found fulfillment in their work from non-monetary sources, and we must do the same. We can start by remembering every day the joy that comes from realizing the improvements that we are making in the lives of others. Few workers in history have been able to help their fellows as much, and that is a blessing to all of us.
In the coming years and budget battles, we can choose to squabble and scratch for every dime of reimbursement, or we can turn our collective attention to protecting our patients in the approaching years. It will be quite tempting to rationalize our goal of protecting our income as a patient centered goal--such as preserving their access to us—however, this will lead us down the road of work stoppages or the refusal to treat certain classes of patients. We must never harm our patients in the name of fighting for them, and, in reality, we can accommodate large reductions in our reimbursement and still earn the historical average for orthopedists while continuing to provide the same excellent care that our predecessors provided to their patients. There is no reason for our patients to suffer our loss. Our academy’s mission statement includes this phrase: “AAOS will serve the profession, champion the interests of patients”; we can choose to view these goals in harmony with each other, or we can see our interests as sometimes diverging from those of the patients we serve. If we recognize that patient interests must come first and foremost, even when this will cause us disappointment or loss, then our academy can continue its high mission. If we place our own interests equal to or above those of our patients when they inevitably clash in the coming years, then our Academy will become just another interest group. The choice is ours, and just as we rely on the inherited knowledge and the pioneering techniques of orthopedists who have gone before us, let us also reconnect with their motivation and love for the practice of orthopedics as we wade into an uncertain economic future.
U.S. Bureau of Labor Statistics
AAOS member survey
Sources for Abraham Colles from the Royal College of Surgeons (Ireland)
Source for converting pounds circa 1800 to modern dollars:
The Economic History Services query services (http://www.eh.net)
The Anatomy Lesson of Dr. Nicolaes Tulp is a 1632 work by Rembrandt and is housed in the Mauritshuis Museum in the Hague.