Extract
"No one in his right mind would wish to relinquish the benefits
of the expert technical skills that are the products of concentrated
specialist training, but only a general education in surgery can safeguard and
direct the use of these skills. It thus becomes an essential part of all
specialist
education."1—E.D. ChurchillSpecialization within medicine as well as within orthopaedics has rapidly
expanded in the last thirty years. In this article, I attempt to review a
brief history of specialization; why specialization has developed and
continues to expand; the barriers to specialization; what role, if any, the
generalist has today and in the future; what the risks are to our specialty
without specialization; the criticism of specialization; and, finally, some
thoughts about the future relationship of the American Academy of Orthopaedic
Surgeons with the numerous orthopaedic specialty societies. Sir William Osler,
at Oxford on May 16, 1910, stated the following:
"No one in his right mind would wish to relinquish the benefits
of the expert technical skills that are the products of concentrated
specialist training, but only a general education in surgery can safeguard and
direct the use of these skills. It thus becomes an essential part of all
specialist
education."1—E.D. Churchill
"No one in his right mind would wish to relinquish the benefits
of the expert technical skills that are the products of concentrated
specialist training, but only a general education in surgery can safeguard and
direct the use of these skills. It thus becomes an essential part of all
specialist
education."1
—E.D. Churchill
Specialization within medicine as well as within orthopaedics has rapidly
expanded in the last thirty years. In this article, I attempt to review a
brief history of specialization; why specialization has developed and
continues to expand; the barriers to specialization; what role, if any, the
generalist has today and in the future; what the risks are to our specialty
without specialization; the criticism of specialization; and, finally, some
thoughts about the future relationship of the American Academy of Orthopaedic
Surgeons with the numerous orthopaedic specialty societies. Sir William Osler,
at Oxford on May 16, 1910, stated the following:
"The extraordinary development of modern science may be her undoing.
Specialism, now a necessity, has fragmented these specialties in a way that
makes the outlook hazardous. The work loses all sense of proportion in a maze
of
minutiae."2
"The extraordinary development of modern science may be her undoing.
Specialism, now a necessity, has fragmented these specialties in a way that
makes the outlook hazardous. The work loses all sense of proportion in a maze
of
minutiae."2
But I do not believe that specialization has made our outlook in
orthopaedics "hazardous," and I do not think that workers today,
that is, orthopaedic surgeons or physicians in general, have lost "all
sense of proportion in a maze of minutiae." However, there is still
tension between the generalist and the specialist that is best expressed in
the words of Frank Lewis, who in 2002 wrote the following:
"There is an inherent and irresolvable tension between the need to
maintain broad competence in practitioners versus the need to develop and
exploit new knowledge or new technology that promises better outcomes, less
morbidity, or greater
efficiency."2
"There is an inherent and irresolvable tension between the need to
maintain broad competence in practitioners versus the need to develop and
exploit new knowledge or new technology that promises better outcomes, less
morbidity, or greater
efficiency."2
In my opinion, this is one of the two important issues regarding
specialization, the tension between maintaining broad competence in
practitioners and the need to develop and exploit specialization. Generalist
training is essential for any orthopaedist who must have a broad understanding
of musculoskeletal problems and their medical and surgical management.
However, specialization continues to increase as the number of generalists
declines. This article discusses the reasons for this trend and why the trend
will continue. The second important issue is an unintended consequence of
specialization. It is not fragmentation of our specialty, but it is a systems
issue—a patient safety issue. It is fragmentation in the care of
patients—fragmentation of their care because patients commonly have more
than one physician and more than one medical problem. Care is an episodic,
isolated event delivered without full knowledge of the patient's history and
complete current medical status. This fragmentation in care results from poor
communication, a problem that physicians and their professional organizations
must address.
Specialization is a way of
life3. It is
everywhere in our society, in all professions. For example, I was interviewing
residents recently and one of our applicants was a member of a NASCAR
(National Association for Stock Car Auto Racing) crew. He wasn't a generalist;
he was a specialist. His specialty was the clutch and brakes. That is all he
dealt with. Why? Because each NASCAR crew needs experts who are knowledgeable,
precise, and accurate in their work as well as fast and deliberate. Frank
Lewis reviewed the development of specialties in medicine. In the first half
of the twentieth century, specialties developed around organ systems. Why?
Because the specialties were obvious and easy to justify. There was tremendous
growth in knowledge, and new surgical procedures were being developed.
Examples of organ systems specialization included orthopaedics as well as
ophthalmology, cardiology, urology, neurosurgery, and the other major
specialties in medicine today. There was also a need to develop care for
specific populations, and again specialties developed. Examples included
pediatrics, trauma, and geriatrics. Finally, explicit services were needed,
and specific specialties developed, including plastic surgery and physical
medicine and
rehabilitation2.
In the latter half of the twentieth century, according to Lewis,
specialization was more difficult and specialty delineation was even finer.
The reasons for further specialization included the continued expansions of
the body of knowledge in certain specialties as well as the growth in scope of
practice. Herein lies a problem for physicians and patients with the
development of specialties. Why? Because with the expansion of scope of
practice in some specialties there have been major turf issues with two or
more specialties claiming the same clinical expertise. Everyone knows of
specific examples of practice expansion; they are continuing to occur in some
specialties. Currently there are twenty-four boards approved by the American
Board of Medical Specialties, each with their own approved standards and
requirements, as well as 155 "self-designated" boards.
Specialization within orthopaedics has increased as it has in other
specialties and more than in most specialties. The American Academy of
Orthopaedic Surgeons has documented the changes in the number of generalists,
the generalists with a subspecialty interest, and the number of specialists
over the years4.
Figure 1 demonstrates the major
decline in the number of generalists and the increase in specialists since
1988. This is a substantial change in just fifteen years. Today there are
twenty-seven specialty Residency Review Committees that meet the requirements
of the Accreditation Council of Graduate Medical Education. These specialty
Residency Review Committees include over ninety-five subspecialties of which
eight are in orthopaedic surgery. Just last year alone, eight new specialties
have been approved for training purposes within the Accreditation Council of
Graduate Medical
Education5. They
include molecular genetics pathology, clinical neurophysiology,
neurodevelopmental disabilities, endovascular surgery neuroradiology,
interventional cardiology, procedural dermatology, psychosomatic medicine, and
developmental behavioral pediatrics. Turf issues immediately become apparent
with several of these new specialties. For example, endovascular surgery
neuroradiology obviously includes the interests of vascular surgery, surgery,
radiology, and neuroradiology. Interventional cardiology includes the
interests of internal medicine and cardiology as well as cardiac surgery.
Procedural dermatology overlaps dermatology and plastic surgery.
Why has there been such a rapid and continued growth of specialization in
medicine and specifically in orthopaedics? There are many reasons. One
significant reason is financial. Medical students often choose specialties
based on potential future income earnings. Medical students graduating last
year had an average debt of
$103,8556,7.
Although I have not seen any literature related to residents choosing
specialties within orthopaedics, having been a department chairman for many
years, I know that a number of residents have chosen a particular specialty
because of the financial remuneration or because they felt they needed to
control their specialty practice choice in order to meet their lifestyle
needs. Witness how difficult it is to get individuals interested in pediatric
orthopaedics or trauma today. As in other specialties, procedural specialties
are often chosen over primary care. Weeks and Wallace reported on the return
of investment in medical education in contrast to that of law and
business8. It was
less in primary care but was similar to law and greater than business in the
procedural specialties.
Another major force toward specialization has been the
consumer9. Cooper et
al. showed a strong correlation between the size of the economy as measured by
gross domestic product per capita and the number of physicians in the United
States (R2 =
0.94)10. There
appears to be a correlation between income and demand for physician services
that is stronger in specialties than in primary care. Cooper et al. predicted
that the need for specialty services will continue to increase faster than the
need for primary care services, and future workforce deficits may be dramatic
in specialties and
subspecialties11,12.
Consumers bear the major responsibility for driving this movement into
specialization with their increased awareness of specialists and by seeking
out specific specialty-focused physicians to meet their demands. For example,
a patient with a shoulder problem will often see a sports medicine physician
or a shoulder specialist directly and not his or her general physician or an
orthopaedic surgeon—this is what Ricardo called the "invisible
hand of the
market."13
There has been a rapid growth in new technology—another force toward
specialization—including implants, instruments, robotics, and the
current movement toward minimally invasive techniques as well as new
discoveries and the potentially powerful uses of biologics. During an
orthopaedic residency program, there is insufficient training in many of the
complex technical procedures in some specialties, which will be further
impacted by the residency work-hour restriction (eighty hours per week). I
doubt that any residency program today, for instance, provides enough
experience in the surgical care of spine diseases, injuries, and deformities
with the multitude of new complex instrumentation systems and artificial discs
to allow a person to become an independent spine surgeon without fellowship
training. Sure, they have exposure to conservative management of back pain and
simple trauma and should be able to manage patients with these problems in
their practice, and they should be able to remove a herniated L4-5 disc. They
should be able to do a routine posterolateral intertransverse process
arthrodesis of the lumbar spine, but I doubt that they will be skilled enough
with sufficient experience to approach all levels of the spine from any
direction as well as be familiar with the new implants and instruments that
are the routine armamentarium of a practicing spine surgeon. This is just one
example; obviously there are many others.
Additional factors responsible for specialization within orthopaedics
include situations such as that of a young orthopaedist entering the
marketplace who has a need to provide value for his or her services and
experience in order to be an effective competitor in the marketplace. Such
individuals need training and skills that are either limited or not available
in a community and yet are required in the marketplace in which they have
chosen to practice. They provide this value by specialization. As groups of
orthopaedic surgeons grow in size, they experience increased demands to ensure
that all specialties are represented within their group to prevent patients
from seeking specialty care elsewhere. No one wants to lose a long-standing
patient because his or her group lacks a certain specialist. Today our younger
generations, especially those younger than the baby boomers, want control of
their length of training, residency lifestyle, and work and lifestyle after
residency, including more time for family and
recreation14.
Specialization, especially in some specific specialties, allows more control
over lifestyle expectations. Surgeons today, with the rapidly expanding new
knowledge and technology, find themselves unable to keep abreast of advances
and new procedures in the numerous specialties in orthopaedics, often forcing
a selection of one, two, or possibly three, but obviously not all, specialties
in orthopaedic surgery. It is no longer possible, as Dr. Alfred Blalock
believed and stated over fifty years ago, that "these surgical
specialties are greatly overrated. You can take any well-trained general
surgeon and give him a few months of specialty training and he can do it just
as well as anybody
else."15 As
orthopaedic surgeons age, there is a tendency to limit their practice to an
area of specialization because of their special interests, their comfort level
in taking care of certain types of patients, and their surgical care as well
as their desire to maintain reimbursement expectations. There is pride in
knowing that one's knowledge and ability is something that others do not
have—it is natural among competitive people. Specialization allows
individuals to gain more experience and therefore a greater comfort level in a
shorter period of time. For those interested in creating new ideas and new
techniques and being challenged by greater skill requirements, specialization
is an obvious choice. Some individuals enjoy being a resource for high-risk
complex or relatively rare procedures. Others do not—or are forced to
avoid high-risk procedures because of the professional liability climate. For
those who do, specialization is an avenue for them. Specialization is
encouraged by mentors in specialty services of residency programs as well as
specialty societies. There is a continued effort to recruit individuals into
one's favorite
specialty16,17.
An increasing force toward specializing is the use of data that suggests
that outcomes are improved if certain procedures are done in hospitals by
surgeon with larger volumes of those procedures. With some procedures, data
support similar outcomes if the specific operation is performed by a general
surgeon or a specialty surgeon. Appendectomy is such an example. However, only
those specialists with high volumes have improved outcomes in certain complex
procedures such as carotid endarterectomies, coronary artery bypass grafts,
pancreatic cancer operations, esophageal cancer operations, and elective
repair of an abdominal aortic
aneurysm18-21.
In orthopaedic surgery, there is some evidence that suggests a minimum number
of total hip arthroplasties by surgeon and by hospital is needed to reduce
morbidity, including readmission, dislocation, and
infection22. Recent
articles have suggested that there may be a certain volume of shoulder
arthroplasties required to minimize
morbidity23. More
studies will follow these early reports. I think we should anticipate that, in
the future, studies will show that the outcomes of certain procedures are not
improved by specialist management, but others are. Such data will push the
specialty movement even further.
"Because of [its] specialization....in health care, as in most
industries, cost and quality can improve simultaneously as providers prevent
errors, boost efficiency and develop expertise. As we have learned in many
businesses `doing it right the first time' not only improves outcomes, but can
dramatically cut
costs."24
"Because of [its] specialization....in health care, as in most
industries, cost and quality can improve simultaneously as providers prevent
errors, boost efficiency and develop expertise. As we have learned in many
businesses `doing it right the first time' not only improves outcomes, but can
dramatically cut
costs."24
The effect of work-hour reduction, both in Europe and the United States,
also has the potential to increase the number of residents entering a
specialty25. In
England, program directors in obstetrics have already determined a need to
increase the training period by one additional year because of residents'
decreased exposure to deliveries with the decrease in work hours. Residents in
the United States have commonly worked long hours, in some specialties often
between 100 and 120 hours per week, and an eighty-hour workweek represents a
20% to 33% decrease. An example of what this means to surgical experience in
one specialty—foot and ankle surgery—is as follows. According to
the Residency Review Committee for Orthopaedic Surgery, the estimated number
of operative procedures (calculated from 2001 to 2003 data) performed by a
resident during his or her four-year orthopaedic residency includes a total of
119 leg or ankle procedures and sixty-eight foot or toe procedures—a
combined total of 187 cases. If there is a 20% decrease in work hours,
assuming a linear relationship, the number of cases would be reduced to 150.
With a 33% decrease, the number of cases would decrease even further to 125
total cases or thirty-one cases per year— that is, less than one foot
and ankle case each week. I do not believe that this limited
experience—less than one case per week over four years—would
enable an individual to be comfortable and experienced as a specialist in foot
and ankle surgery. Therefore, if foot and ankle surgery is the individual
resident's career choice, he or she will have to take a fellowship to gain the
experience, knowledge, and skills needed to practice comfortably.
Recently, the Health Care Advisory Board produced a volume entitled
Future of Orthopaedics—Strategic Forecast for a Service Line Under
Siege."26
The drivers for change listed in this document predicted the future of
orthopaedic surgery as a service line and suggested that specialization will
continue to be required or at least be a consequence of these drivers for
change. These drivers for change included implant technologies, use of growth
factors, minimally invasive techniques, outpatient migration, nonhospital
competition, decreased length of stay, demographics, lifestyle factors,
penetration of existing technologies, medical prevention, biologic treatments,
and new procedures. The only drivers for change that did not, in my opinion,
require specialization or result in specialization were Medicare and
commercial reimbursement.
There are barriers to specialization, including managed care, but I do not
believe that they have had a major impact upon the specialization movement.
They do limit the entrance of certain individuals to a specialty field but not
enough to have had a major impact on a specialty. However, the most
significant barrier, i.e., the financial one, is beginning to influence the
choices made by individuals. Poor reimbursement is currently limiting entrance
into pediatric orthopaedics, orthopaedic oncology, and foot and ankle surgery
as well as hand surgery. If poor reimbursement were to be extreme (what level
that is I really do not know), it might be enough of a barrier that the
specialty would not grow and could even cease to exist. Another financial
barrier is a limited need or the lack of need for a particular specialty in
some markets. The lack of mentoring during residency training by a specialist
or a specialty society in certain fields becomes essentially a barrier to
entrance to that specialty. Some residents may not even be aware that a
potential specialty exists for them. Another barrier is the desire by many
residents to do "big" or "high-risk" surgery. In the
foot and ankle specialty, a barrier to entrance exists because of increased
competition by podiatrists. If certain markets are saturated by podiatrists,
for example, there may not be a need for an additional foot and ankle surgeon.
Other specialties have inherent deterrents that effectively act as barriers.
They include repetitive stress to the surgeon, escalating litigation,
demanding patients, as well as lifestyle issues.
There are certain risks to the medical profession and the care of our
patients if specialization does not continue. Advancement of any specialty
field is at risk without specialization. New technologies and new techniques
will not occur without specialization. Clinical and basic research in a
specific field is at risk without specialization. And finally, without
specialization there would be no mentors to foster growth in the
specialty.
Is there a role today for the generalist? As E.D. Churchill stated almost
fifty years ago, "only a general education in surgery can safeguard...
[expert technical] skills and... [is] an essential part of all specialist
education."1
Generalist training provides the critical foundation in musculoskeletal
medicine and surgery upon which specialization is built. Today generalists
with or without specialty training are needed and practice in rural areas.
Often in small practices individuals may have a specialty interest but still
practice general orthopaedics in order to cover their colleagues as well as
cover emergency consultations and trauma call. Also, many patients remain
unwilling or are unable to travel to suburban or urban centers to access the
specialist.
There are many critics of specialization within orthopaedics and in
medicine in general. They make good arguments giving us pause to consider the
extreme. For instance, many past presidents of the American Academy of
Orthopaedic Surgeons have expressed the need "to keep the family of
orthopaedics together." No one in a leadership position wants to see
fragmentation occur in orthopaedics as it has in other major national medical
professional societies. It is incumbent upon the leadership of all
professional organizations in orthopaedics to continue to maintain strong
relationships for the common good of continuing education, professionalism,
ethical standards, communication, patient safety, and patient-centered care as
well as to supply major advocacy issues and continued maintenance of
competence.
The development of specialty examinations, although the natural consequence
of a formal education, can result in fragmentation if our colleagues' use of
those specialty examinations limits access of patients or limits access of
physicians to practice in that field. Just considering the number of specialty
board examinations that are not under the aegis of the American Board of
Medical Specialties gives one pause. How can individuals be specialists in a
single orthopaedic technique, certified by an examination in a procedure,
without a core body of knowledge? Medicine has historically used other ways to
develop surgical expertise and teach new procedures including training with
mentors and/or requiring certain courses or training periods by the originator
or industry, or both, before one is allowed to perform such procedures.
Credentialing by a hospital that allows a physician to do a procedure or use a
new technique is the proper mechanism—not a specialty certifying
examination. There are many accepted methods to learn new technology and to
ensure the desired outcomes for our patients, but the specialty examination
does more than that. It is not designed to identify turf in order to keep
others out of a specialty field. It is an evaluation of one's knowledge and a
demonstration to the public that an individual has acquired the necessary
knowledge in a specialty field.
Specifically criticizing specialization in orthopaedics, Sarmiento stated
that the "technology revolution fostered fragmentation of our
discipline" and "the availability of new techniques and devices
seduced us into a spiral of
over-specialization."27
He went on to state: "Then came the most fashionable medical irrelevant
of them all—sports medicine. Surely we do not wish to ignore both the
patient and the condition and base treatment only on the environment in which
the condition
occurred."27
I do not agree that the technology revolution has "foster[ed]
fragmentation of our discipline" or that we are in a "spiral of
over-specialization," just as I do not agree with Sir William Osler. I
think that time has demonstrated that specialization has not made the
"outlook hazardous" or that we workers have "lost all sense
of proportion in a maze of
minutiae."2
However, fragmentation in care does occur because caregivers, despite their
best intentions, are often unaware of other caregivers' treatments for their
common patient. It is a patient safety issue, an unintended consequence of
medicine's success. Communication problems exist between caregivers as well as
between the patient and the physician. Multiple caregivers who are not
communicating, a patient who often does not understand, and the lack of a
common medical record available to all is a setup for potential error—a
systems error. Since the benefits of specialization outweigh the costs, we
need to fix this systems issue. It is possible—we must do it. "It
begs for improvement... it will not go
away."28
Avoiding specialization is not the answer. In reality, however, there remains
a tension that Frank Lewis described as the "inherent and irresolvable
tension between the need to maintain broad competence in practitioners versus
the need to develop and exploit new knowledge or new technology that promises
better outcomes, less morbidity, or greater
efficiency."3
The American Academy of Orthopaedic Surgeons (AAOS) and our numerous
specialty societies have terrific opportunities to continue to work together
and avoid any division in orthopaedic surgery. Consider education, for
example. Both the Academy and the specialty societies will continue to offer
outstanding continuing medical education programs and publications. Together
each organization is stronger if they cooperate. A good example is using the
AAOS learning center to learn about new technology and surgical techniques.
The Academy is also developing a lifelong learning program as it begins to
collaborate with the American Board of Orthopaedic Surgery, which is
implementing the American Board of Medical Specialties' requirements for
maintenance of certification. It is an ideal time for the Academy and
specialty societies to partner to ensure the development of a lifelong
learning program for our generalists and specialists as well as to provide
important needed self-assessment examinations. The Academy has the expertise
and staff and is fully available to work with each specialty society to ensure
everyone's success in this endeavor. The Academy's Annual Meeting Program
Committee is actively pursuing methods to make the meeting valuable for both
specialists and generalists. The Academy wants to leave no orthopaedist
behind, by providing continued cutting-edge education at this flagship
educational event for all orthopaedic surgeons regardless of interests or
practice type.
When it comes to professionalism, again the Academy and specialty societies
have an opportunity and, in my opinion, a need to work together. Specialty
societies should partner with the Academy's Expert Witness Program. I believe
that it is the right thing to do for our profession. As society moves forward
toward quality assessment of not only physicians but also hospitals, it is
important to be united in this effort. Small specialty societies may be
ineffectual. The entire orthopaedic community needs to work together as the
public increases its demands for evaluation of all physicians regarding
ethics, professionalism, and, most importantly, outcomes. The Academy and the
orthopaedic specialty societies should lead this agenda together. If we are
fragmented in our approach, others—the public and the payers—will
do it for us.
An example of professionalism that benefits everyone is the Academy's
extensive program of patient safety initiatives that is available to every
orthopaedic surgeon. The Academy, all specialty societies, and our nursing
colleagues have formed an active coalition, which is an ideal way for
physicians to lead an initiative that patients expect, identify with, and are
beginning to demand—that is, actions by physicians to reduce medical
error and ensure patients' safety as they enter the health-care system. The
Academy has an educational program under development for all residents. There
is an alert mechanism to ensure that all orthopaedists are made aware of
problem drugs, implants, and instruments. In addition to educational programs
for all orthopaedic surgeons, "Your Orthopaedic Connection"
()
is a web site available to all patients to help them to understand what is
required of them to ensure their safety as they receive care in our offices
and hospitals. This resource is invaluable as well as expensive to reproduce.
The Academy has implemented the program and, hopefully, specialty societies
will participate in this active and important patient safety movement.
Regarding advocacy, it is essential that we speak with one voice, all
orthopaedic surgeons together. There are over 20,000 orthopaedic surgeons in
the Academy. A larger voice can be more effective in changing policy. Smaller
voices often fail and, most importantly, divided voices always fail. If we are
not united in our advocacy efforts, if we are fragmented and have multiple
opinions and agendas, it is unlikely that we will be successful in making our
case for change with the federal and state governments. One example of such
unity is the Doctors for Medical Liability Reform, a coalition of high-risk
specialties that has developed both federal and state campaigns. Our goal for
state and national-level legislative relief for medical liability will be
successful only if we have enough physicians working together and enough
physicians continuing to contribute money to support this campaign as long as
it takes. Now is not the time to be an observer, as we have been in the past.
As Catherine Crier stated in her address to the Academy in San Francisco
recently, "Nineteen people changed the world on September
11."29 Surely
physicians together and orthopaedic surgeons specifically can influence
necessary change if we work together. Regulatory issues such as the Health
Insurance Portability and Accountability Act (HIPAA), a faulty Medicare
reimbursement formula, and the current assault on specialty hospitals require
a unified and strong approach. Our Academy office has six staff members who
are very actively supporting all of our interests in Washington. Recently the
Academy has partnered with the American Association of Hip and Knee Surgeons
to support a position in the Academy's Washington office to deal with
regulatory issues affecting reconstructive surgeons. Rather than each
specialty society having its own Washington office, it is far more important,
and we are much stronger, if all orthopaedic surgeons are represented in
Washington by a single group of dedicated individuals.
With advocacy as well as with education, we have a Council of
Musculoskeletal Specialty Societies (COMSS) that needs to identify new ways to
increase its involvement within the Academy and within specialty societies. I
do not see how we can do this without the leaders of each organization making
a commitment and actively participating within such an organization—and
the AAOS needs to be responsive to the specialty societies' needs. I can think
of one example regarding patient safety where we have not been as successful
as we should—the "Sign Your Site" program. A recent study
reported that 30% of orthopaedic hand surgeons have never heard of the
Academy's "Sign Your Site"
program30. Surely,
through COMSS we should be able to make the changes necessary to help all
orthopaedic surgeons reduce medical error. In my opinion, we need to improve
relationships by creating a true partnership between the specialty societies
and the Academy. We need to move beyond only sharing knowledge and
information. We need strategies and plans to move our orthopaedic profession
forward on all fronts. Not only should the specialty societies, in my opinion,
ensure the active participation of their leaders and other elected officers,
but the Academy needs to actively share all common activities equally with our
specialty society partners. Both the Academy and the specialty societies need
to develop a new vision as well as strategies to partner, to create win-win
relationships for everyone. Figure
2 is a diagram of the American Academy (Association) of
Orthopaedic Surgeons and the specialty societies together; we need to stay
together where necessary and remain independent where necessary, but it is
important, if not essential for our professional survival, to provide a
unified front and speak with one voice on issues of importance. Especially,
for the overall safety of our patients, we need to eliminate fragmentation of
their care with the associated potential for medical errors by improving
communication among physicians and all health-care providers. We need to unite
and insist on a common electronic current medical record available to all
physicians as well as to lead the effort to improve all communication with our
colleagues and our patients electronically. Shame on us if we do not.
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