The Orthopaedic Forum   |    
An AOA Critical IssueThe Future of the Orthopaedic Surgeon–Proceduralist or Keeper of the Musculoskeletal System?*
Scott D. Boden, MD1; Thomas A. Einhorn, MD2; Tamara S. Morgan, MA3; Laura L. Tosi, MD4; James N. Weinstein, DO, MS3
1 The Emory Spine Center, 59 Executive Park Drive, Suite 3000, Atlanta, GA 30329. E-mail address for S.D. Boden: scott.boden@emory.org
2 Department of Orthopaedic Surgery, Boston University Medical Center, 720 Harrison Avenue, Suite 808, Boston, MA 02118. E-mail address for T.A. Einhorn: thomas.einhorn@bmc.org
3 Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756. E-mail address for T.S. Morgan: tamara.s.morgan@dartmouth.edu. E-mail address for J.N. Weinstein: james.n.weinstein@dartmouth.edu
4 Department of Orthopaedic Surgery, Children's National Medical Center, 111 Michigan Avenue, N.W., Washington DC 20010. E-mail address for L.L. Tosi: ltosi@cnmc.org
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They 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 authors are affiliated or associated.
This report is based on a symposium presented at the Annual Meeting of the American Orthopaedic Association on June 23, 2005, in Huntington Beach, California.

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Dec 01;87(12):2812-2821. doi: 10.2106/JBJS.E.00791
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During the second half of the twentieth century, the specialty of orthopaedic surgery has completed its evolution out of general surgery and into its own maturing specialty with multiple subspecialties. The practice of orthopaedics has never been more exciting. We continuously discover new ways to relieve the burden of pain and to restore function for our patients. More research is being done than ever before, and we are answering both basic epidemiological questions as well as complicated questions, such as those about the pain response at the molecular level. We are beginning to genetically engineer repair processes that may eventually alter the aging of our joints and intervertebral discs. As these technologies further our treatments of musculoskeletal disorders, the orthopaedic operations of yesterday are replaced with newer, less invasive, and more sophisticated procedures—some of which may not actually require surgery or surgeons. In fact, advances in molecular biology and gene therapy may prevent certain musculoskeletal conditions from ever reaching the point of requiring a surgical procedure. This evolution, driven by technology, will present fundamental challenges to orthopaedics as a specialty. In an era of subspecialization, the leadership of the American Orthopaedic Association thought it wise to stop and reflect on this evolution and to be proactive in defining the future of the specialty of orthopaedics rather than letting the specialty be a victim of the future as we have seen in some other areas of medicine.
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    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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    Scott F. Dye, M.D.
    Posted on February 22, 2006
    The Future of the Orthopaedic Surgeon
    University of California, San Francisco, CA

    To The Editor:

    I read with interest the recent article, “The future of the orthopaedic surgeon-proceduralist or keeper of the musculoskeletal system” by Boden,et al. In discussing the impact of imaging technology on orthopaedic surgery, magnetic resonance imaging was cited as an example of a technique that "... remove(d) the diagnostic aspect of patient care and transferred it to the non-operative physician.” While this phenomenon may, in fact be occurring, I would argue (and I imagine the authors would agree) that no matter what imaging studies may have been performed or what diagnosis may have been formulated by the referring physician, the orthopaedist is responsible for arriving at an independent assessment of all pertinent data prior to arriving at a diagnosis upon which treatment decisions, especially operative, depend.

    Many physicians often assume that the MRI findings (by a radiologist who has neither interviewed nor examined the individual) are equivalent to the actual diagnosis responsible for a patient’s symptoms. I often see patients with an MRI-based diagnosis of a “torn meniscus” that is, in fact, an incidental finding, having no connection to their symptoms. Further, many diagnoses of clinical significance are unimageable by any current technology (including synovial impingement and neuromas) that can only be made by one who is thoroughly knowledgeable in the complex anatomy and pathophysiology of the musculoskeletal system. An independent, thorough history and physical examination provides an invaluable data base from which to properly assess the validity of any ancillary information including that provided by imaging. Of all physicians with an interest in the musculoskeletal system, we orthopaedic surgeons must resist the temptation to become over-reliant on the radiologists’ opinion, thus leading inevitably to the atrophying of our own diagnostic skills.

    As an important and perhaps crucial, aspect of remaining the “keeper of the musculoskeletal system” we must not abrogate the diagnostic responsibilities to others. We can do this by practicing the essential principles of orthopaedic surgery, i.e. lifelong study of anatomy and pathophysiology, performing a thorough history and physical examination prior to the consideration of imaging data, no matter how advanced, and to integrate all information prior to arriving at a diagnosis and treatment recommendation.

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