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The Orthopaedic Forum   |    
Are We Losing Objectivity?
Augusto Sarmiento, MD
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Augusto Sarmiento, MD
The Arthritis and Joint Replacement Institute, 1150 Campo Sano Avenue, Suite 301, Coral Gables, FL 33146. E-mail address: asarm@bellsouth.net

The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

J Bone Joint Surg Am, 2002 Jul 01;84(7):1254-1258
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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Carl B. Weiss
    Posted on January 08, 2003
    Searching for "Objectivity"
    Nassau Orthopaedic Surgeons

    I thought that the ideas expressed in Dr. Sarmiento's Orthopedic Forum "Are We Losing Objectivity?", and in those letters to the editor that followed, were very pertinent. I see everywhere signs that "objectivity", is falling by the wayside both in private practice as well as "academic" training centers. This is leading to the training of residents and fellows whose mentors practice economically based, rather than patient-based medicine. What are they going to do when they get out into the world?

    The reason that our residents are being so severely affected is simple: Many of the physicians who run our training programs are now essentially operating in a private practice setting, where the emphasis on production is high, and an "eat what you kill" philosophy pervades.

    I have seen three instances of loss of objectivity recently that have disturbed me. In one, a non- displaced open distal phalanx fracture was being fixed because "We are here anyway" and the patient was ostensibly brought to the operating room for routine soft tissue care because it was "easier to do it there" than in the emergency room.

    In the second instance, a discussion was underway about what to do with a slightly displaced tibial spine fracture in a skeletally immature individual. An attending who had just finished his sports medicine fellowship stated that he would undoubtedly perform arthroscopic surgery on this individual, even if full extension and an acceptable reduction could be attained closed. When asked why, he said that this is what he was taught in his fellowship, and "it makes me feel better to see myself actually push that fragment back into place". Note the inclusion of "me" and the exclusion of "the patient".

    Finally, I recently attended a lecture from an orthopedist with a very busy practice - he operates on an amazing number of distal radius fractures. On questioning from the audience, he admitted that he recommends surgery to all of his patients with "potentially unstable" distal radius fractures (isn't every displaced fracture potentially unstable?), regardless of the patient's age(yes, this includes the entire Medicare crowd!). He also performs carpal tunnel release and wrist arthroscopy on every patient he operates on. This doctor obviously feels that this is a high standard of care, but can't be bad for his bottom line or the numbers of patients in his studies, either. He is espousing his philosophy to residents, fellows, and anyone else who will listen to him. Is he sending the right message?

    In order to effect change and raise the level of consciousness of the orthopedic community, I suggest that JBJS and Dr. Sarmiento collaborate to publish a revised version of this Orthopaedic Forum annually. An Instructional Course Lecture at the annual meeting could also be considered to discuss these issues.

    John W. Thompson, M.D.
    Posted on July 18, 2002
    Congratulations, Dr. Sarmiento
    Emeritus fellow AAOS

    Over the years I have read with great interest the articles authored by Dr. Sarmiento, both those on technical subjects as well as those dealing with more philosophical subjects, such as "Are We Losing Our Objectivity." It is unfortunate that other well known and well respected orthopedists aren't speaking out on the same subjects as Dr. Sarmiento. Sometimes I think that he is like John the Baptist, "A voice crying in the wilderness."

    With each of the examples that are given in the article, I thought that he was right on the mark. I agree that the "modern" orthopedist is more concerned about how the radiographs look than what is best for the patient.

    When I was a resident in the 1960's, one of my attendings, Dr. E.G. Chuinard, once told the residents, that we don't operate on xrays, we operated on patients. The "orthopedist technician" that seems to be so prevalent in our specialty today seems to be more concerned by the appearance of the xrays than what is really best for the patient.

    I have treated many older women who have sustained Colles fractures, by the closed method and by and large they had a very functional wrist in spite of a mild deformity. I remember an anesthesiologist who sustained a very comminuted distal radial fracture, who under went an open reduction. The Xrays looked great, but his wrist was very stiff, almost as bad as if he had the wrist fused.

    Dr. Sarmiento, I agree with your article and the position that you have taken by your statments. I hope that you continue to bring our attention to what we should all should have foremost in our thoughts when we look at patients.

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