Only a few of the fifty generations that span a millennium are lucky enough to witness the dawn of a new one. Millennium has two definitions: "a span of one thousand years" and "a hoped-for period of joy, serenity, prosperity and justice." A span of one thousand years is almost incomprehensible but may be put in perspective when we consider that Homo sapiens emerged as a discrete species just sixty millennia ago.
Looking to the roots of medicine, we must travel back three thousand years, arriving midway through the millennium, before the birth of Christianity, to locate Hippocrates (466-370 B.C.), recognized as the father of medicine. In past millennia, the world was largely an agrarian society. Before the twentieth century, the practice of medicine employed little science and was mostly an art, yet its practitioners were held in the highest esteem. One hundred years ago, a physician had few tools with which to work, except those of compassion and caring. However, during this century, a technological explosion has led to spectacular advances in medicine and, as a consequence, physicians are infinitely better equipped to bring good health to their patients.
Our orthopaedic roots date back to 1743, when Nicholas Andry unveiled his splinted, crooked tree; however, it was not until the use of plaster of Paris 100 years later that we moved out of the splint age. Modern fracture management rapidly accelerated during and after World War I, with Sir Robert Jones espousing the principles of Hugh Owen Thomas. This was followed by the impact of World War II and battlefield medicine on our specialty.
Operative practice, however, came into its own with the introduction of modern anesthesia by William Morton (a dentist) in 1846, sterility courtesy of Joseph Lister in 1876, and antibiotics from Alexander Fleming in 1945. These advances made outcomes more predictable, and the practice of orthopaedics, in particular, expanded exponentially, as operative risks decreased substantially. New methodologies involving joint replacement, arthroscopy, spinal instrumentation, and reconstruction following trauma were all developed in the latter part of this century. Although this period represents only a small segment of recorded history, the changes in technology seem to be happening overnight. It behooves us to pause and reflect on where we are and from where we have come as orthopaedists in the past 100 years and to define our vision for the next century.
Developments in physics and engineering have rewarded our specialty with spectacular advances, but the changes in biotechnology by means of the DNA molecule—genetic engineering and stem-cell transformation—will be even more profound. This new area of biology has the potential to conquer cancer, grow new blood vessels in cardiac patients, create new organs from stem cells, and possibly even reset the genetic code that causes our cartilage to age. Very soon we will be able to transplant virtually any tissue without fear of rejection. In the next century, when computer technology merges with biotechnology, we may be able to map the ten billion or so neurons in our brain and replicate our minds in a machine.
Changes
So, what changes can we as orthopaedists expect? Well, to start out, we can pose the following questions.
Will our field become more of a geriatric specialty? The life expectancy of a child born at the beginning of this century was forty-eight years. In the year 2000, it will be seventy-seven years. Who knows how high it will rise in the next century? Will this cause us to see considerably more patients who have fractures or need an arthroplasty? Will the treatment of these conditions be through operative intervention or through genetic manipulation?
Also, will the elderly population need us to increase the amount of attention that we pay to rehabilitation? Our specialty has traditionally ignored this aspect of musculoskeletal disease. But, should we continue to do so?
Predictions
We can also formulate some predictions.
1. Biotechnology in medicine, with genetic engineering, will place increased emphasis on nonoperative management of musculoskeletal problems. This is and will continue to be the fastest growing area in the management of these problems. Unfortunately, with the patenting of genes the cost of medicine will be even more prohibitive.
2. The number of hospital beds will continue to decline, with hospitals being gradually transformed into chronic-care facilities. Only major procedures, such as transplants, reconstructive operations, joint replacements, and complex spinal operations, will be performed in a hospital setting.
3. Almost all musculoskeletal procedures, such as arthroscopy, operations on the hand and foot, and even the less complicated operations on the spine, will be minimally invasive and will be performed outside the hospital setting.
4. There will be increased emphasis on prevention through new biotechnological diagnostic techniques. The investment of the health-care dollar into prevention at a younger age will push investment in the treatment of disease to an older age. This should lower the overall cost of health care.
5. Trauma and cancer will continue to be the biggest threats to health in the future, with trauma being the more difficult of the two to treat. The incidence of cancer as a life-threatening disease will diminish, whereas that of arthritis as a lifestyle disease will increase as our population ages. Once we find the way to preserve cartilage and bone stock, the major operative challenge will involve the treatment of trauma.
Challenges and Opportunities
My friends and colleagues, we have major challenges to confront and opportunities to consider if we are to remain the musculoskeletal standard-bearers for the new millennium. Some of our difficulties are, admittedly, of our own making, but most have been thrust upon us. First, we have to recognize that we have lost some of our patients' confidence in our ability, and we have lost their trust in our willingness to place their overall well-being above our own interests and desires. Second, the managed-care industry has us by the throat. Finally, our government is attempting to legislate our practices into obscurity. These realities cannot be denied. In our headlong embrace of technology, we have fallen short in several areas. We have failed to properly explain our technology to our patients, we have not adequately promoted prevention, and we have not managed financial resources in a cost-effective way.
We cannot ignore the managed costs that corporate America has forced on us. Patients want their own expenses contained, but they also want the quality care to which they are entitled. They have already paid their insurance premium. Insurance companies are not interested in the quality of care that their clients receive; their only concern is that the cost of that care is markedly less than the sum of the premiums that they receive. This reality will not change until physicians and patients form a partnership that the managed-care industry cannot withstand. Managed care is making decisions for our patients—decisions that the patient-physician partnership should be making. This is wrong. If we improve communication with our patients through better information, they can help fight the battle both for and with us.
There is no question that the management of the financial aspects of medical care will change in the coming years. The profit motive will be contained, and dollars will rightfully flow to pay for the delivery of health care. Exactly how this will happen is evolving right now, but the process should be complete within the next five years. If we mobilize our patients appropriately, the insurance industry will not be able to withstand the increasingly strident public outcry. We can do this by partnering with our patients.
Additionally, government interference continues to be a growing factor in the delivery of medical care. An example with which we are all familiar is the promulgation of the evaluation and management codes and the unprecedented mountains of documentation required by government agencies. We need to ask ourselves: "Exactly how much government involvement will we tolerate?" Should the government legislate the patient Bill of Rights or should the patients, with the physician, be the authority? Partnering with our patients will present a formidable union between consumer and provider.
Ladies and gentlemen, it is very clear that our patients have the power to reverse the trends that oversee and constrict our practices. Their insurance premiums fund the managed-care system, and their taxes fund the Medicare and Medicaid systems. We can overcome these trends only through bonding with our patients. That will be difficult. Patients have become alienated, and we need to win back their confidence and their trust. We can and we will turn these challenges into opportunities by confronting these issues. We can then direct our energies toward building this bridge to patients' confidence.
What Do Our Patients Want?
Basically, our patients want to feel cared for. As part of that experience, they expect several things.
1. They want to be listened to. We need to consciously make the effort to hear our patients' goals and desires and to answer their questions honestly.
2. They expect a responsible discussion of alternatives that gives validity to informed consent. We need to take time and to offer information upon which they can base an intelligent decision.
3. They also want nonoperative solutions first and, only when these are not feasible, an operative solution if it will give better results with acceptable risk.
4. In brief, they want high-quality, evidence-based medicine at a reasonable cost. This will lead to value medical care.
In order to improve our communication with our patients so that we can make them believe that we care, we must be more open and we must understand them better. Not only must we be more aware of how they comprehend our medical jargon but, more importantly, we must understand their needs, their fears, and their hopes. We must talk to our patients with a new voice, listen with a fresh ear, and hear with new understanding.
Patients want to be empowered; they want to share in decision-making. They want to be our partners. If we want to earn back their trust, we need to embrace their wishes and desires. With the information that is out there, patients want to control their own lives and their environment. This philosophy assumes that most patients are and should be responsible for making important and complex decisions about their health care. It also assumes that, because patients experience the consequences of diseases and injuries as well as those of treatment, they have the right to be the primary decision-maker regarding their health problems. We are their facilitators!
We have lost our patients' trust because we have treated them with benevolent paternalism. There is no question that we are better educated in the area of patient care and that we are better qualified than other providers to suggest and implement treatment plans. Our role, however, should be to share that education with patients, not to thrust it upon them. Because of this age of information, we can no longer assume that the patient will not or cannot understand.
If I may quote Archbishop Desmond M. Tutu, who pleaded for help "in realizing my dream, my dream of a world that is more caring, a world that is more compassionate, a world where people matter more than profits."
Nonoperative Care
What is conservative care? Some patients are questioning whether we, as orthopaedic surgeons, are able to provide the best possible outcome for their particular needs. Other providers have given them relief when we orthopaedists could not guarantee their comfort.
More patients are coming to regard orthopaedic surgeons as high-priced musculoskeletal-care providers who are interested only in operative fees. These patients believe that we are too quick to decide on a technological solution and that we have little regard for the human aspects of medicine. Many view us as technicians who cannot think or diagnose and who are unable to treat musculoskeletal illnesses nonoperatively. The growth in the number of chiropractic and non-science-based alternative-medicine providers attests to this fact. When we have seen operative intervention as the best solution, many of us have been presenting it to our patients as the only solution.
Patients today are sophisticated and demanding as never before. This is not the patient population that we managed ten years ago. Patients have access to reliable information beyond what we give them. Unfortunately, they also have access to less reliable or, even worse, misleading marketing information. Advertisements for nonoperative alternatives in print, television, radio, and even sites on the World Wide Web are designed to appeal to disillusioned patients by promising outcomes that we as physicians ethically cannot promise. Patients are told of inconsistencies in our treatment regimens, outcomes that do not live up to the claims that alternative medicine makes, and statistics that contradict our advice. Is it any wonder why disillusioned and wary patients end up in alternative-medicine offices for nonoperative adjustments? Once patients are in the hands of other providers, we lose the opportunity to manage their care.
Goals
How do we improve communication with and education of our patients during the decision-making process? It is as simple as putting the radiograph up and looking at it with the patient. Discuss it with him or her. It is only the occasional patient who does not want you to. Share the operative and nonoperative possibilities for remedying the situation. The more information that you share, the more comfortable that your patient becomes. The outcome will be something that you have shared with him or her. Patients then become more responsible for their own care.
The perception is that, as surgeons, we want to operate on everything. We must regain the perception of balance by working with our patients. We should always be conservative when managing patients. Operative intervention may well be the conservative form of treatment, but these options must be discussed with the patient, who is the decision-maker. The patient thus becomes his or her own advocate, with the physician as the facilitator. In this age of the information superhighway, we should be where the patient stops first. With the involvement of our patients in their own care will come a return of trust in us as physicians. We must remember to always hold a patient's hand but to use a scalpel only when needed. We need to insert the heart between the head and the hand.
I consider myself a fourth-generation orthopaedist, with the fifth now on the scene as my younger partners. The philosophy of my third-generation teachers was that only 10 percent of the patients whom we see in the office should go to the operating room. If an orthopaedist is operating on more than that, he or she is being too aggressive and is not managing patients appropriately. We, as orthopaedists, should modify the emphasis of our practice so that it is more evenly balanced between operative and nonoperative care. We need to be musculoskeletal physicians with the added ability to perform operative procedures!
We can no longer dismiss the alternatives as being substandard or even dangerous. Insurance payment for alternative treatment gives these providers a legitimacy that, until recently, was ours alone. We must therefore offer appropriate nonoperative alternatives to our patients. If we do not adjust to this reality, we will be relegated to secondary status and will be called upon only when operative intervention is a last resort. We are not just surgeons; we are physicians! This realignment needs to start at the medical-student level and continue through residency training as well as through our Board requirements. Our certifying and recertifying examinations must also test appropriate nonoperative-care case management.
If we are to reclaim the areas of musculoskeletal care that we have neglected, we need to expand our scope of practice to include all nonoperative musculoskeletal solutions. Only when we do this will we be able to break the stranglehold that the managed-care industry has put upon us. We are not just cutters; we are total musculoskeletal-care providers.
How do we reclaim these areas?
1. We must embrace a vision of where orthopaedics is and where it should be going in the next millennium.
2. We need to enhance the image of the orthopaedist in the realm of total musculoskeletal care.
3. We must reclaim the areas of musculoskeletal care that we gave up when we began our courtship and romance with technology.
4. We need to take a leadership role in providing current, credible, and accurate information to patients by using all possible means of communication.
5. We must be willing to expand the scope of our practice to reflect the changing nature of our increasing geriatric population and the expanding methodologies of treatment for musculoskeletal problems. This strategy must include recognition of the projected benefits of alternative treatments once they have been studied.
How Can These Goals be Implemented?
In order for this undertaking to be effective, I need each and every one of you to participate in the process of making it work.
In April, we will be convening an Orthopaedic Summit of representatives from all of the major orthopaedic organizations to adequately define and project where our specialty is and where it should be going. We need your input for this meeting. To this end, an online survey that is accessible through the information kiosks and the e-mail stations will be active for the duration of this meeting. Please spend a few moments there to answer this question: "What factors will create change in the practice of orthopaedics during the next ten years, and how can your Academy help you to address these changes?" After the conclusion of this meeting, the survey will remain on the Academy's web site (http://www.aaos.org) until the end of February, under both the "What's New" and the "Member Services" sections. I would like each of you to log on and contribute to this discussion. Our electronic media section will tabulate your input and will report it to the Orthopaedic Summit in April.
Your Academy is planning an extensive and focused public-relations program this year to inform the public of our mission and our goals in the delivery of excellent musculoskeletal care. The campaign will also advise our members of the expanded scope of orthopaedic care. Part of the initiative will be to evaluate alternative care as it relates to the musculoskeletal system. This program will continue well into the next millennium. We will make this information available to our members to aid in the thoughtful management of their patients. Whenever possible, all alternatives will be evaluated for scientific merit, and the Academy will be the repository for all pertinent musculoskeletal information.
In our efforts to provide the most current, credible, and accurate information to patients, we should harness information technology so that each and every one of us can have a personal physician web site. I proposed that the Academy sponsor and maintain a World Wide Web-based library. This will be filled with medical information that is written for both the physician and the patient. Selected topics can be linked to your individual web site, to which you can refer your patients, possibly before the office visit. This will give your patients an additional tool with which to work with you, their physician. Furthermore, it is between the individual physician and the patient. We can use technology in this way to enhance the traditional physician-patient relationship. Your Academy will be developing this application of technology starting this year.
To formulate these efforts, I am proposing the creation of a council to work in the 501C-6 Organization. This council will be the repository and the disseminator of all of our communication and information efforts. It will also be the council that oversees our public-relations efforts. We want all orthopaedic organizations (the Clinical Orthopaedic Society; the Eastern, Mid-America, and Western Orthopaedic Associations; the Academic Orthopaedic Association; the American Orthopaedic Society; and all state societies—everyone!) to have free access to this council. This will be our voice to the world.
Humanitarian Efforts
Before I close, there is one issue close to my heart, the issue of humanitarian efforts, to which I would like to direct your attention. Our partnership with our patients must extend to our orthopaedic colleagues and their patients around the world. We must include all patients in all countries.
We have a responsibility beyond the borders of our country because of what we have learned and developed and because of the unique educational opportunities that we have to offer. The Academy must share these educational efforts with orthopaedists who were not fortunate enough to have had these opportunities. The world has shrunk: a spacecraft now can travel around the earth in only ninety minutes, and a message can be transmitted instantaneously to the other side of the planet. Our economy is global. Orthopaedics, with a common scientific language, is global, and all information should be shared with orthopaedists in every country of the world.
Along with other advanced countries in the world, we have the means and the opportunity to help the less fortunate. The Academy should and will pledge its support to humanitarian programs such as Orthopaedics Overseas and ICOE (International Center for Orthopaedic Education). We as individuals should take time from our busy schedules to share our skills with those who could benefit from them. We should also place more emphasis on humanitarian efforts within the United States. I am proposing that your Academy each year honor several of our fellows for their contribution to our specialty as well as for their humanitarian efforts in communities both in the United States and around the world. A mechanism for nominating candidates will be developed this year.