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The Orthopaedist and Fracture Care

1997; Lippincott Williams & Wilkins; Volume: 11; Issue: 6 Linguagem: Inglês

10.1097/00005131-199708000-00001

1531-2291

Augusto Sarmiento,

Musculoskeletal Disorders and Rehabilitation

Today ARTOF, the Association for the Rational Treatment of Fractures, holds its first educational venture. I hope it will be a worthwhile experience for all of you. On behalf of ARTOF, I welcome you. ARTOF was founded a very short time ago. It was born out of growing concern held by a group of orthopaedists over disquieting trends in the overall spectrum of medicine. We pondered upon the likely effect that the worldwide revolution in health-care delivery will have on our ability to maintain and enhance the standards of care of patients suffering from fractures. We saw the unfolding events as dark clouds on the horizon and decided to do something about them. Five years ago, shortly after completing my tenure as President of the American Academy of Orthopaedic Surgeons, I published an editorial in the Journal of Bone and Joint Surgery which I titled "Orthopaedics at a Cross Roads." In that editorial, I extrapolated on the state of our profession from the vantage point of a surgeon, educator, researcher, and administrator. I stated that despite the technological advances and benefits reaped by millions of patients, orthopaedics was rapidly drifting in a direction where technical skills were replacing biological considerations so rapidly that it was reaching an undesirable degree. This trend has resulted in the growing perception that orthopaedics is no longer a clearly defined body of scientific knowledge but a series of surgical procedures. The excessive proliferation of subspecialties within our profession has trivialized orthopaedics and has weakened the glue that had made our discipline one of the most solid and prestigious in medicine. Its resulting fragmentation, usually along surgical techniques, has been partially responsible for the growth of the perception I have alluded to, that if the practice of orthopaedics is nothing more than the performance of several surgical operations, any other surgeon can master those techniques and then be just as qualified as the orthopaedist to perform them. Once others began to reason in that manner, the erosion of our territory became inevitable. It is no secret that others in medicine are, with increasingly frequency, involved in the care of patients afflicted with disorders of the musculoskeletal system, which for many a year had been considered exclusive and essential components of orthopaedics. Plastic surgeons, neurosurgeons, and podiatrists are vivid examples. Trauma, in essence, is the backbone of our profession, and fractures constitute a large percentage of the afflictions of the musculoskeletal system treated by the orthopaedist. Others outside of orthopaedics are now expressing interest in being involved in their care. They are taking advantage of the current political move to find means to reduce the cost of health care. Profit-motivated people, who now control a large segment of the health field, seem to believe that with a modicum of training, other physicians and paraprofessionals can appropriately treat fractures by nonsurgical means. It is disturbing and ironic that there are orthopaedists who share that philosophy and suggest that the orthopaedist should handle only those fractures that require surgical intervention and leave their closed management to others. They have not considered the consequences of such a change. They have not realized that once it happens, the nonorthopaedists responsible for the nonsurgical treatment of fractures will dictate that many fractures which we know are best treated surgically will be managed by them by nonsurgical means. Third-party payers will welcome their decision. That scenario will not unfold tomorrow, but it could easily become a reality within the next decade. Academicians, comfortable in their ivory tower positions should, individually and collectively, stand tall and assist their colleagues who practice in nonacademic centers, in protecting the territory that is rightly theirs and provides for their financial well being. I believe that the trend is unwise. If left unbridled, it will inevitably lower the standards of fracture care and seriously compromise the viability of orthopaedics. These concerns do not negate the possibility that when emerging molecular biology and genetic engineering technologies crystallize, the care of many musculoskeletal conditions will be provided by anyone who wishes to be involved. This is not going to happen overnight, but chances are it will become a reality in the not too distant future. As a concerned student of historical moves in our profession, I have concluded that the unfolding of those events has been greatly influenced by the subservient role that orthopaedics chose to play to industry. At this time, the education of the orthopaedist is structured primarily to satisfy the marketing needs of industry. This is true in the Americas and it is true in Europe and probably in the rest of the world. It is obvious to all that the effective marketing of a plethora of industrial products has not only created and exploited an over-whelmingly surgical-technical mentality in the orthopaedic community, but in doing so it has contributed to the escalating cost of medical care. Much of that increased cost is due to the conscious or unconscious abuse of technology. Bombarded by industry, the orthopaedist seeking to upgrade his education is being led to believe that the surgical treatment of fractures is the one and only appropriate choice. Successful nonsurgical methods of treatment, tested by time and experience, are summarily dismissed or discredited by those interested in either the greater financial rewards that surgically driven therapeutic modalities offer or by the desire to perpetuate the false impression that surgery is more prestigious and occupies a higher level in the hierarchy of the medical profession. This statement is not belittling or diminishing of the enormous contributions that surgical techniques, supported by advanced imaging technology, have made. At this time the surgical treatment of many fractures is the standard against which other methodologies must be measured. What is highly questionable is the furious attempt to seek clinical indications to fit newly developed techniques, even in the absence of medical, practical, or economic need. One cannot help but surmise that current orthopaedic graduate and postgraduate education is undertaken primarily to obtain "training" on how to perform surgery. During one of our basic sciences meetings dealing with fracture healing, a resident of ours demonstrated no interest in the topic. When I tried to bring to his attention the importance of understanding the biology of tissue repair he responded with great candor. "Doctor Sarmiento, I do not really care to know how fractures heal. I simply want to know how to fix them." The resident's statement should not be taken lightly for it is symptomatic of a rapidly developing ethos. Orthopaedics is losing its basic biological foundations as an epidemic of surgery sweeps the world. At the sight of skeletal pathology depicted by an x-ray, the orthopaedist of today, with increasing frequency, instinctively reacts by asking the question, "What operation does this problem need?" rather than "What is best for this particular patient?" This abuse of surgery represents a major additional cost in patient care, a cost that no nation in the world can afford to ignore. We have already begun to see the response given to the growing problems of a financially strapped health-care system by those who, in a very rapid and effective way, have succeeded in controlling an expanding sector of the health economy. Individuals who took advantage of the opportunity presented by the "crisis" have effected a questionable "managed care system." Their response has been increased limitation to our autonomy in determining what treatments we should provide to our patients; by telling us in increasingly stronger terms who we can or cannot admit into the hospital; how long to hospitalize our patients; what diagnostic tools to use and what surgical procedures to perform. What will come from this disturbing trend is difficult to predict. I suspect that a newly enlightened citizenry will eventually make its displeasure known and will force reasonable changes that will ensure them good and affordable medical care. The obscene profits that are being made by professional business entrepreneurs will then end. We must not forget, however, that our insensitivity toward the warnings of financial ills in our society concerning health care and our abuse of the privileges granted to us by society encouraged others to step into the arena and eventually control the destiny of health-care reform. ARTOF, the acronym for The Association for the Rational Treatment of Fractures, simply wishes to help the orthopaedic community recognize that there is not only one, but several viable therapeutic approaches available in fracture care, and that a sound and reasonable balance between all of them is desirable and that decisions in this regard are best made by the medical profession. We maintain that there is no single method of treatment that is superior to all others under all circumstances, and that the application of certain technological advances, developed and practiced in wealthy and economically advanced countries and communities, are not likely to succeed in other nations or communities lacking the necessary infrastructure. It is imperative that we pay attention to the financial implications of the treatments we perform and that economic considerations can no longer be ignored; good care should not be sacrificed for the sake of frugality. ARTOF insists that a clear definition of what constitutes a complication must be articulated. To state that any deviation from the normal, detectable only through radiographs, is a complication, is wrong. It simply moves us closer to becoming skeletal cosmetologists. This pattern of behavior inevitably leads to abuse, abuse that should be rejected not only on moral and ethical grounds, but by the fact that it increases the cost of medical care, an increase that prompts third-party payers to restrict our autonomy, professional rights, and income even further. This, our first educational venture and the many others we will hold in the future, will attempt, through dialogue, to generate a logical and rational consensus among the orthopaedic community as to the most appropriate means to approach fracture care. In that manner we will not only preserve the distinction of being truly professional physicians and surgeons, but will be better qualified to participate in the serious debate on health care reform. Augusto Sarmiento, M.D. President, ARTOF