The Lull Before Reform: Taking Advantage of an Opportunity
Article detailing the medical device industry's influence over orthopedics and urging orthopedists to begin reform efforts.
Article detailing the medical device industry's influence over orthopedics and urging orthopedists to begin reform efforts.
http://jbjs.org/article.aspx?volume=93&page=222 Extract only w/o subscription
Essay discussing how the medical device manufacturing industry exerts influence on orthopedic education.
Essay discussing how the medical device manufacturing industry exerts influence on orthopedic education.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888758/?tool=pubmed
Article discusses ethical problems between academic medicine and the medical device industry.
Article discusses ethical problems between academic medicine and the medical device industry.
On Rise and Decline was published in The Journal of Bone and Joint Surgery (American). 2009;91:2740-2742. (unavailable without subscription)
doi:10.2106/JBJS.I.00830
© 2009 The Journal of Bone and Joint Surgery, Inc.
On Rise and Decline Augusto Sarmiento, MD
1 10333 S.W. 72nd Avenue, Miami, FL 33156. E-mail address: asarm@bellsouth.net
Disclosure: The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
In 1776, the year when America declared its independence, Edward Gibbon released his book The Decline and Fall of the Roman Empire.He concluded, rightly or wrongly, that the fall of the empire was mainly due to barbarian invasions and the spread of Christianity.Since Gibbon's day, many others have observed that great nations and institutions, after reaching the pinnacle of power and success,gradually decline because of internal degradation. Arnold Toynbee,another British historian, is reported to have said, "An autopsy of history would show that all great nations commit suicide."I am using these pronouncements to create an analogy with the condition of the orthopaedic discipline. The metaphor is based on observations on the manner in which our profession appears to be showing symptoms suggestive of decline.
The technological explosion that began in earnest in the 1960shas changed the face of orthopaedic surgery. As a result, its representative organizations, such as the American Academy of Orthopaedic Surgeons, the American Orthopaedic Association,the American Board of Orthopaedic Surgery, and state and regional orthopaedic societies, expanded their territory and became large,comprehensive business-like organizations.
Simultaneously, the unrestrained growth of subspecialization began, leading to the creation of twenty-six subspecialty societies to date. The overemphasis on the fragmentation of orthopaedics into subspecialties incited other surgical and medical disciplines to erode the orthopaedic territory as they perceived that orthopaedics was no longer an eclectic body of knowledge but rather splintered groups with a territory consisting of one or several operations.Within a very short time, areas traditionally the purview o f the orthopaedist became either partially or completely the possession of other disciplines: neurosurgery, in a number of institutions,is now in virtual control of all conditions of the spine. Plastic surgery includes in its territory the treatment of fractures from the phalanges to the wrist. Podiatry covers acute trauma and degenerative conditions of the foot, ankle, and leg. In some areas of the country, podiatrists perform open reduction of tibial fractures, and efforts are being made to eventually include the knee. General surgery and physiatry have, for all practical purposes, taken over amputation surgery and the rehabilitation of the amputee.
The subspecialization trend has had a major effect on the education of orthopaedic residents. Because of the growth in the number of subspecialties, residency programs modified their structure to accommodate the new superspecialized faculty members. Defined blocks of time were allocated to several subspecialties. This move was helpful in some areas. However, it led to a situation in which some rotations became too short to satisfy the residents' needs.
Some twenty-five years ago, by adding one year of fellowship,most residents, at their own initiative, chose to increase the length of their training from five to six years. I was thereat the creation. At first, I thought it was a good idea, simply because I surmised that, for residents who believed their program had left them weak on a given subject, a fellowship would take care of that deficiency. However, it did not always work out that way. Many residents elect to take the fellowship year not in an identified area of weakness but in the subspecialty perceived at the time to lead to a more successful and lucrative practice.The latter argument was sound some time ago, but now we are beginning to realize it was partially a mirage. Time has shown that many fellowship-trained orthopaedists have found it impossible to limit their practice to the area covered in their fellowship or even to invest most of their time in that particular area. Many cities are already becoming saturated with fellowship-trained surgeons in some areas, leaving no room for new arrivals. The income of these surgeons, wishing to deal exclusively or primarily on the subject of their fellowships, may find their income substantially lower than expected since there are not enough patients for each of them to satisfy their economic needs. A careful study of this issue should be undertaken, realizing that, despite the fact that previous answers to the subspecialization trend are not possible, we can gain a rough weighting of the evidence behind the shrinking territory of orthopaedics.
Another important development in the evolution of orthopaedics,leading to my perception of the decline of our profession, is the growing loss of professionalism in our ranks and the excessive role industry plays in the education of the orthopaedist. I lump the two together because I am convinced that the growing loss of professionalism is, to a great extent, the result of a misguided and inappropriately conducted relationship between orthopaedics and industry; a relationship that, nonetheless,is necessary and essential to both parties.
When I first heard about the U.S. Department of Justice investigation into the relationship between orthopaedists and industry, I wrote to the President of the Academy. I urged him to take advantage of the embarrassing situation and convert it into an opportunity by letting the government know that we have been aware of the ongoing problem but wished to become part of the solution, rather than continue to be part of the problem.
No matter how complicated the issue of health-care reform maybe, no party or segment of our society, other than the medical profession, is in a better position to be effective in addressing the serious consequences of the current unresolved health-care crisis. It is disingenuous to argue that unnecessary surgery and abuse of nonessential expensive tests are not widespread and becoming more frequent. Such a trend has not only aggravated the economic crisis, but has lowered our professional standards by accepting the values of the business community and the adoption of their hidden motto that says, "Everything is OK, and therefore nothing is morally wrong."
At a time when our discipline desperately needs a coherent response to the host of challenges it faces, some of our representative organizations seem to be mired in irrelevant parochialism dealing almost exclusively with growth and self-serving pocketbook issues.Growth is not an end in itself and is not synonymous with prosperity.Well-intentioned efforts to lobby legislators, hoping they would resolve the crisis in a manner satisfactory to us, have not yielded the anticipated results. The condition continues to get worse, and it has been festering for too long for us to think that at this late hour the continued effort will suddenly pay off. We have misdiagnosed the real problems, and consequently the medicines being applied will not work.
It is appropriate for us to recognize that if drastic measures in the health-care arena are not undertaken, we will have to accept the fact that the government may be forced to consider nationalizing the medical and medical-allied professions, as well as the pharmaceutical and surgical implant industry, when the crisis reaches the projected severity.
I am not in favor of socialization of our profession. I am simply trying to look objectively at the big picture in a manner that permits a clear perspective. No socially conscious citizens of advanced countries that have various degrees of socialized medicine would exchange their system for the American one.
The cause of the serious national economic crisis of 2008 to2009 has been identified as an exaggerated relaxed attitude and lack of regulation essential to the financial stability of the nation. An analogy can easily be made with the crisis facing medicine because the same thing is taking place in our profession. We ignored the warnings and kept telling ourselves that we were impervious to failure, and we remained unwilling to recognize the crisis that was engulfing us. We knew that medicine practiced entirely as a business enterprise could not long endure, but we insisted on making it medicine's raisond'être. We will be judged not only by what we do but also for what we do not do.
Even under the best of circumstances, we must become active partners in the ongoing debate and accept that a carefully and realistically structured rationing of the use of technology is unavoidable and necessary because, without surveillance and oversight, the costs of nonessential expensive tests and the performance of unnecessary surgical procedures make patient care unaffordable and unsustainable.
The Obama administration is rapidly moving a well-intentioned but misguided health-care reform to the front burner and building what appears to be an unstoppable juggernaut that without brakes is speeding downhill. Opposition to major changes will grow in anticipation of successfully derailing the process. It would be a mistake to take for granted the success of that effort for, in doing so, the lessons of history are ignored—lessons that have proved that events thought to be "impossible to occur"actually occurred, simply because ideas "whose time has come"usually win the day. Let us keep in mind that, as we become brittle and unable to cope with the ongoing challenges, our profession might break apart.
Some of the crises we are confronting are paradoxically intimately entwined with technological progress. We should remove our blinders and recognize that the rapid, unharnessed technological explosion in orthopaedics is partially responsible for the serious challenges we now face; that many technological developments, which we call expressions of progress, may not be progress at all but "madness on the loose," as philosopher Michael Novak recently said in referring to society in general1.
Reinhold Niebuhr, the famous and influential German-American philosopher, while discussing what he perceived as a rapid collapsing of the American culture, said, "In every civilization its most impressive period seems to precede death by only a moment. Like the woods of autumn, life defies death in a glorious pageantry of color."2 His words should be a wake-up call, a mandate to us to summon the courage to forcefully confront unfolding events with serenity and objectivity.
References
Top
References
1. Novak M. Response to an atheist friend. A reply to Heather Mac Donald. The American Spectator; 2006 Dec 1. http://www.aei.org/article/25208.
Rasmussen L, editor. Reinhold Niebuhr: theologian of public life. Minneapolis: Fortress Press; 1991. p 86.
doi:10.2106/JBJS.I.00830
© 2009 The Journal of Bone and Joint Surgery, Inc.
On Rise and Decline Augusto Sarmiento, MD
1 10333 S.W. 72nd Avenue, Miami, FL 33156. E-mail address: asarm@bellsouth.net
Disclosure: The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
In 1776, the year when America declared its independence, Edward Gibbon released his book The Decline and Fall of the Roman Empire.He concluded, rightly or wrongly, that the fall of the empire was mainly due to barbarian invasions and the spread of Christianity.Since Gibbon's day, many others have observed that great nations and institutions, after reaching the pinnacle of power and success,gradually decline because of internal degradation. Arnold Toynbee,another British historian, is reported to have said, "An autopsy of history would show that all great nations commit suicide."I am using these pronouncements to create an analogy with the condition of the orthopaedic discipline. The metaphor is based on observations on the manner in which our profession appears to be showing symptoms suggestive of decline.
The technological explosion that began in earnest in the 1960shas changed the face of orthopaedic surgery. As a result, its representative organizations, such as the American Academy of Orthopaedic Surgeons, the American Orthopaedic Association,the American Board of Orthopaedic Surgery, and state and regional orthopaedic societies, expanded their territory and became large,comprehensive business-like organizations.
Simultaneously, the unrestrained growth of subspecialization began, leading to the creation of twenty-six subspecialty societies to date. The overemphasis on the fragmentation of orthopaedics into subspecialties incited other surgical and medical disciplines to erode the orthopaedic territory as they perceived that orthopaedics was no longer an eclectic body of knowledge but rather splintered groups with a territory consisting of one or several operations.Within a very short time, areas traditionally the purview o f the orthopaedist became either partially or completely the possession of other disciplines: neurosurgery, in a number of institutions,is now in virtual control of all conditions of the spine. Plastic surgery includes in its territory the treatment of fractures from the phalanges to the wrist. Podiatry covers acute trauma and degenerative conditions of the foot, ankle, and leg. In some areas of the country, podiatrists perform open reduction of tibial fractures, and efforts are being made to eventually include the knee. General surgery and physiatry have, for all practical purposes, taken over amputation surgery and the rehabilitation of the amputee.
The subspecialization trend has had a major effect on the education of orthopaedic residents. Because of the growth in the number of subspecialties, residency programs modified their structure to accommodate the new superspecialized faculty members. Defined blocks of time were allocated to several subspecialties. This move was helpful in some areas. However, it led to a situation in which some rotations became too short to satisfy the residents' needs.
Some twenty-five years ago, by adding one year of fellowship,most residents, at their own initiative, chose to increase the length of their training from five to six years. I was thereat the creation. At first, I thought it was a good idea, simply because I surmised that, for residents who believed their program had left them weak on a given subject, a fellowship would take care of that deficiency. However, it did not always work out that way. Many residents elect to take the fellowship year not in an identified area of weakness but in the subspecialty perceived at the time to lead to a more successful and lucrative practice.The latter argument was sound some time ago, but now we are beginning to realize it was partially a mirage. Time has shown that many fellowship-trained orthopaedists have found it impossible to limit their practice to the area covered in their fellowship or even to invest most of their time in that particular area. Many cities are already becoming saturated with fellowship-trained surgeons in some areas, leaving no room for new arrivals. The income of these surgeons, wishing to deal exclusively or primarily on the subject of their fellowships, may find their income substantially lower than expected since there are not enough patients for each of them to satisfy their economic needs. A careful study of this issue should be undertaken, realizing that, despite the fact that previous answers to the subspecialization trend are not possible, we can gain a rough weighting of the evidence behind the shrinking territory of orthopaedics.
Another important development in the evolution of orthopaedics,leading to my perception of the decline of our profession, is the growing loss of professionalism in our ranks and the excessive role industry plays in the education of the orthopaedist. I lump the two together because I am convinced that the growing loss of professionalism is, to a great extent, the result of a misguided and inappropriately conducted relationship between orthopaedics and industry; a relationship that, nonetheless,is necessary and essential to both parties.
When I first heard about the U.S. Department of Justice investigation into the relationship between orthopaedists and industry, I wrote to the President of the Academy. I urged him to take advantage of the embarrassing situation and convert it into an opportunity by letting the government know that we have been aware of the ongoing problem but wished to become part of the solution, rather than continue to be part of the problem.
No matter how complicated the issue of health-care reform maybe, no party or segment of our society, other than the medical profession, is in a better position to be effective in addressing the serious consequences of the current unresolved health-care crisis. It is disingenuous to argue that unnecessary surgery and abuse of nonessential expensive tests are not widespread and becoming more frequent. Such a trend has not only aggravated the economic crisis, but has lowered our professional standards by accepting the values of the business community and the adoption of their hidden motto that says, "Everything is OK, and therefore nothing is morally wrong."
At a time when our discipline desperately needs a coherent response to the host of challenges it faces, some of our representative organizations seem to be mired in irrelevant parochialism dealing almost exclusively with growth and self-serving pocketbook issues.Growth is not an end in itself and is not synonymous with prosperity.Well-intentioned efforts to lobby legislators, hoping they would resolve the crisis in a manner satisfactory to us, have not yielded the anticipated results. The condition continues to get worse, and it has been festering for too long for us to think that at this late hour the continued effort will suddenly pay off. We have misdiagnosed the real problems, and consequently the medicines being applied will not work.
It is appropriate for us to recognize that if drastic measures in the health-care arena are not undertaken, we will have to accept the fact that the government may be forced to consider nationalizing the medical and medical-allied professions, as well as the pharmaceutical and surgical implant industry, when the crisis reaches the projected severity.
I am not in favor of socialization of our profession. I am simply trying to look objectively at the big picture in a manner that permits a clear perspective. No socially conscious citizens of advanced countries that have various degrees of socialized medicine would exchange their system for the American one.
The cause of the serious national economic crisis of 2008 to2009 has been identified as an exaggerated relaxed attitude and lack of regulation essential to the financial stability of the nation. An analogy can easily be made with the crisis facing medicine because the same thing is taking place in our profession. We ignored the warnings and kept telling ourselves that we were impervious to failure, and we remained unwilling to recognize the crisis that was engulfing us. We knew that medicine practiced entirely as a business enterprise could not long endure, but we insisted on making it medicine's raisond'être. We will be judged not only by what we do but also for what we do not do.
Even under the best of circumstances, we must become active partners in the ongoing debate and accept that a carefully and realistically structured rationing of the use of technology is unavoidable and necessary because, without surveillance and oversight, the costs of nonessential expensive tests and the performance of unnecessary surgical procedures make patient care unaffordable and unsustainable.
The Obama administration is rapidly moving a well-intentioned but misguided health-care reform to the front burner and building what appears to be an unstoppable juggernaut that without brakes is speeding downhill. Opposition to major changes will grow in anticipation of successfully derailing the process. It would be a mistake to take for granted the success of that effort for, in doing so, the lessons of history are ignored—lessons that have proved that events thought to be "impossible to occur"actually occurred, simply because ideas "whose time has come"usually win the day. Let us keep in mind that, as we become brittle and unable to cope with the ongoing challenges, our profession might break apart.
Some of the crises we are confronting are paradoxically intimately entwined with technological progress. We should remove our blinders and recognize that the rapid, unharnessed technological explosion in orthopaedics is partially responsible for the serious challenges we now face; that many technological developments, which we call expressions of progress, may not be progress at all but "madness on the loose," as philosopher Michael Novak recently said in referring to society in general1.
Reinhold Niebuhr, the famous and influential German-American philosopher, while discussing what he perceived as a rapid collapsing of the American culture, said, "In every civilization its most impressive period seems to precede death by only a moment. Like the woods of autumn, life defies death in a glorious pageantry of color."2 His words should be a wake-up call, a mandate to us to summon the courage to forcefully confront unfolding events with serenity and objectivity.
References
Top
References
1. Novak M. Response to an atheist friend. A reply to Heather Mac Donald. The American Spectator; 2006 Dec 1. http://www.aei.org/article/25208.
Rasmussen L, editor. Reinhold Niebuhr: theologian of public life. Minneapolis: Fortress Press; 1991. p 86.