To The Editor:
In his uplifting address, "The Academy on the Edge:
Taking Charge of Our Future" (83-A: 946-50, June 2001),
Dr. Richard Gelberman, as incoming President of the American Academy
of Orthopaedic Surgeons, reported at the March 2001 annual meeting
that the Academy’s special task force will include among
its goals for the coming years an investigation of the inequities
in the availability of medical care. Dr. Gelberman cited studies
showing that black men with osteoarthritis of the hip are less likely
to have joint replacement surgery than are white men and women despite
the greater incidence in black men. He intends to improve this situation
by presenting the results of investigations of this type to various
governmental organizations responsible for health policy.
The task force, called The AAOS in 2005, should be applauded
for its decision to undertake this cause. Although only
racial discrimination is cited in Dr. Gelberman’s address,
the failure of our country’s patchwork system of health
insurance to ensure even marginal care for a large percentage of
our people is a national scandal that deserves our attention. More
than forty million Americans are without health insurance of any
kind, and many millions more have seriously limited coverage
and lack the means to obtain essential medication1.
During the recent sustained economic boom, the number of Americans
with health insurance progressively declined as fewer employers
found ways to provide these benefits to their employees2.
Many physicians are fearful that any change in the present system
of medical care could affect our autonomy and our income, two issues
that are already a cause of contention with administrators of managed-care
programs. However, one of the most rewarding aspects of practicing
medicine is the gratification of enhancing the lives of others.
It would be consistent with the most admirable traditions of our
profession to support a policy aimed at achieving universal medical
care in the United States.
The Academy leadership has steadily strived to improve the quality
of patient care. We have an equal obligation to see to it that all
people get equal access to the remarkable achievements of American
medicine.
R.H. Gelberman replies:
In his thoughtful letter, Dr. Schneider has focused on one of
the critical shortcomings of our country’s social contract—the
failure to provide a uniformly effective system of health
care for its citizens. This year, health-care premiums will increase
by 11%, the largest increase since 1992, which will further
compromise an already strained health-care system. As a result,
millions of Americans will continue to lack health insurance and
countless others will have only marginal coverage.
In response, this year the Academy has developed a multidisciplinary approach
to influence the ways in which musculoskeletal care is provided
in America. While our approach will not fully rectify the substantial
inadequacies that exist, I believe that we can improve both the
access to and quality of care available to our patients. Once this progress
is achieved, we will be able to focus more of our energies on our
three fundamental missions: educating the next generation of orthopaedic
surgeons, advancing our specialty through musculoskeletal research,
and, most importantly, providing compassionate state-of-the-art
patient care.
We have gone further this year by initiating, with members around
the country, programs designed to gain a better understanding of
the most difficult musculoskeletal health-care issues facing our
nation. Working with the Centers for Disease Control and Prevention
and other federal as well as private agencies, our research
council has become increasingly proficient at collecting data on
the incidence, prevalence, impact, and causes of musculoskeletal
disease and the outcomes of musculoskeletal care. In addition, we
have teamed with the Center for the Evaluative Clinical Sciences
at Dartmouth, a leader in the study of the distribution
of health care, to provide an in-depth look at national delivery
of musculoskeletal health care. This has resulted in the publication
of The Dartmouth Atlas of Musculoskeletal Health Care3, an eye-opening and in-depth look at
how orthopaedic care is delivered throughout the United States. We
learned, for instance, that the practice of orthopaedics encompasses
just under 50% of all musculoskeletal health care in the
United States, with only 2% of practicing physicians providing
that care. We learned also that there are enormous variations in
the provision of care across the country associated with geographic
region, sex, or race. To move forward, the Academy is partnering
with two of its members, Dr. Jim Weinstein of Dartmouth-Hitchcock
Medical Center and Dr. Jim Wright of the Hospital for Sick Children
in Toronto, to submit a National Institutes of Health grant designed
to document variations in the utilization of joint arthroplasty
according to geographic region, a phenomenon called "geographic
area variation." Previous research conducted in Canada
demonstrated a substantial unmet need for hip and knee arthroplasty,
particularly in women. Whether or not these findings can be generalized
to the United States, where the rates of joint arthroplasty are
much higher, is unknown. Determining geographic area variation and
unmet need will be a research priority for the Academy over the next
several years.
Consistent with our focus on arthritis, we have created a project
team to explore the development of a national registry of total
hip and knee arthroplasties. Under Dr. William Maloney,
a project team consisting of national leaders in joint replacement
is meeting with representatives of federal agencies to develop mechanisms
for establishing such a registry with a well-organized database
that can be used to improve patient outcomes, reduce costs for revision
surgery, and provide a more comprehensive effort in post-market
surveillance.
At the same time, we have developed a plan of action to reach
a better understanding of what our patients want and need to make well-informed
choices as our partners in the health-care decision-making process.
Through a unique project called Shared Decision-Making, we will
be able to supply the type of evidence-based information that our
patients need both to understand what orthopaedic surgery can offer
and to make better decisions regarding their own care.
The Academy is committed to improving the practice of orthopaedic
surgery while continuously exercising rigorous peer review. We believe
strongly in improving the health-care coverage and access of all
Americans. With the help of concerned, energetic members, I am confident
that we will be able to achieve measurable progress this year and
in the future.