TO THE EDITOR:
I had an opportunity to meet Dr. Sarmiento during some of the SICOT meetings. I have read practically every article that he has written because I have always found wisdom in his statements, which is so important when one is managing a large number of patients in a developing country that has limited material resources and specialized centers. In general, Dr. Sarmiento's thoughts correspond with the philosophy that I have been preaching, practicing, and promoting to my students and to society at large. I have often wondered how the thoughts and philosophies of two orthopaedists working in totally different environments could be so similar. While reading "Commentary. Responding to Change" (80-A: 601-603, April 1998), by Sarmiento, I got the impression that, if the primary goal is to promote the welfare of the patient by employing the clinical art of orthopaedics, with minimum or only essential operative procedures being performed in the interest of cost-effectiveness, the basic treatment philosophies that emerge would be almost the same. Most of my students, if they were to read Dr. Sarmiento's Commentary, would be happy and satisfied to know that I am not alone in my philosophy of teaching and training in orthopaedics.
Orthopaedic surgeons are best trained to develop the philosophy of treatment of all ailments or injuries of the locomotor system. It should be the surgeon's decision or prerogative to seek the help of other specialists for conditions that may require microvascular techniques or the transfer of free vascularized tissues. Unfortunately, sometimes the patient or his or her guardians are taught to ask the attending orthopaedic surgeon who is treating a fracture of an extremity to call a plastic surgeon to stitch an uncomplicated facial wound or a neurosurgeon to repair a damaged peripheral nerve. Having treated all varieties of spinal diseases over the last forty years (until 1995, when I began private professional work), I am now aware that the attendant or the patient often suggests or demands that a neurosurgeon be involved during the operative treatment of paraplegia due to tuberculosis or during the operative treatment of a disc herniation. One wonders who educates such patients; is it weekend subspecialists or the orthopaedic surgeons themselves? I have seen orthopaedic surgeons refer patients who have a fracture of the spine to a neurosurgeon!
The current generation of orthopaedic surgeons frequently relies on instrumentation and technology for the treatment of even simple orthopaedic problems. One possible reason for this tendency is the societal recognition or financial rewards, or both, that are available when an orthopaedic surgeon chooses an operative technique. Nonoperative techniques that rely on biological processes for the healing of many simple orthopaedic problems, such as tendinitis, fibrositis, sprained joints, low-back pain, and closed fractures of the limbs, are often neglected because they are nonexhibitionistic and do not convey as much financial reward as interventional methods do. Many of the newer generation of orthopaedists consider treatment with plaster outmoded and beneath their dignity. I have seen nameplates at some clinics that say "Dr. XYZ, International Orthopaedic Surgeon, Fractures Here Are Treated without Plaster." Have the teachers, senior peers, or articles in orthopaedic journals failed? I have always wondered how a large number of rare procedures can be performed for the treatment of rare clinical entities and how sufficient data on such procedures can be collected, analyzed, and published in the international literature. I understand, from Dr. Sarmiento's Commentary, that a surgeon must perform a certain number of related procedures in order to be entitled to membership in a prestigious subspecialty society, such as those related to the hand or to orthopaedic oncology.
I am in no position to comment on the wisdom of the rules imposed by these prestigious societies; however, the emphasis on such rare procedures, which are of questionable benefit when compared with simpler, time-tested methods, conveys an imbalanced message to the younger generations. I believe that the best procedures are those that can be performed by an average orthopaedic surgeon in a modest setting in any part of the world, with consistent results.
Nonoperative or semi-invasive treatment of fractures is an art that has been practiced and improved on by generations of orthopaedists. Where newer technologies are available, we should improve on this art of closed treatment (because there is no upper limit on art) rather than discard it.
All universities, teaching departments, and educators should ensure balanced teaching, training, and practice in order to produce general orthopaedic surgeons who can diagnose, treat, and guide the treatment of all injuries, defects, and diseases of the musculoskeletal system. Only after five years of active professional work after postgraduate training in orthopaedics should the general orthopaedic surgeon be encouraged or induced to choose an area of subspecialization depending on his or her work environment. Such a practice would ensure the cohesive nature of orthopaedic disciplines. Present students do not learn from sermons, which are hollow and in abundance all over the world. Trainers and peers have to set practical personal examples to induce the current generation to offer the best to the patients in a particular setting.
S. M. Tuli, M.S., Ph.D.: Vidyasagar Institute of Neuroscience, Nehru Nagar, New Delhi 110 065, India