As an educator during my entire medical career, I have tried to use the Socratic method of teaching, in which questions, rather than pronouncements, fill the time. I have found this approach rewarding, as I suspected that controversy would have a more lasting effect.
Three episodes, separated from each other by time and place, have made me question whether the Hegelian dialectic approach I had considered most appropriate is of value today with the current generation of residents. These individuals were born and nurtured in a society in which information regarding virtually all events is obtained mainly from television, either as sound bites or in neatly packaged discussions among talking heads who claim Panglossian pedantic wisdom in all topics. The three unrelated events all involved the unexpected reactions I received after making presentations to groups of residents on subjects I had long considered important to the basic education of fledging surgeons.
The first episode, which I have described previously in writing as well as during verbal presentations, occurred during my tenure as chair of the Department of Orthopaedics at the University of Southern California. I was in the process of delivering a lecture entitled "The Effects of the Environment on Fracture-Healing" to a large number of orthopaedic residents in the program. During the course of the lecture, I noticed that a resident, who was soon to become a senior, was in the back row of the conference room reading the newspaper. His efforts to hide his action did not escape me. At the end of the session, I approached the young man and expressed my displeasure with his behavior. I said to him that it was not only disrespectful to be reading a newspaper while the "chief" was talking, but that it also set a bad example for his peers. In addition, I told him that it was difficult for me to understand his disregard for a subject that was so germane to his education as an orthopaedist and scientist.
Much to my amazement, he responded with great candor, "Doctor Sarmiento, with all due respect, I don't care to know how fractures heal. I simply want to know how to fix them." At first, I thought that this bright young man was an aberration and that his colleagues did not share his iconoclastic views. How wrong I was, as I promptly realized he was a spokesperson for his peers. He was the one with the courage to speak aloud the true feelings of his generation1.
The second episode took place ten years later, following a presentation to the residents at the University of Miami. I had spoken to the group about the etiology and consequences of posttraumatic deformities in Colles fractures, emphasizing the fact that the body tolerates well minor deviations from the normal. At the end of the talk, one of the attendees commented that the information I had given was good, but it had no practical applications. "I know," he said, "that if we were to accept those deviations, we would be sued. This is the reason why these fractures are now treated surgically." Obviously, he had learned that position from his teachers. No questions asked.
The third and last example took place only a year ago. I had prepared a talk on the subject of fracture-healing in a manner I thought would be a more challenging one. I titled it: "The Mythological Foundations of Orthopaedics." I deliberately questioned, among other things, the role of the hematoma in fracture-healing as well as that of the periosteum following rigid fracture fixation. It was, I thought, a provocative talk. During the last couple of minutes of the lecture, I dwelled on practical considerations regarding the financial costs resulting from the current belief that virtually every fracture is best treated surgically.
I was appalled when the only question I was asked during the discussion period came from a young faculty member wishing to know how much I was paid in the 1970s for a Charnley total hip arthroplasty. He managed to give his own speech, using the remainder of the discussion time. He wanted to justify the increasing trend for surgical treatment on the basis of the lower payments we receive today for many of the therapeutic modalities we use.
It saddened me to observe that my effort to present a medical topic of importance seemed to have fallen on deaf ears. The retort I received was nonetheless a reflection of the ethos of the times.
I observe similar situations on a regular basis. Attempts to provoke controversy from residents by requesting explanations for their decisions to treat musculoskeletal conditions in a given manner often are simply met with responses indicating that such is the way their mentors manage similar problems. It would be inappropriate to suggest this is the universal response to my dialectic approach to teaching because other residents enjoy getting into a debate from which we both benefit. As a matter of fact, some of them find my gadfly style to be stimulating.
As I am a devoted student of history and philosophy, the above experiences and close observation of the profound societal changes that have occurred during my long career have forced me to wonder how and why certain changes we consider unhealthy are so deeply permeating and altering the medical profession.
I venture to say that the commercialization of medicine, which exploded in the early 1970s, began the trends we now witness. Medicine is no longer considered by a growing number of practitioners to be a profession but, rather, a business. It is dictated, governed, and discharged in the same manner that traditional businesses are conducted. Profit is becoming its raison d'être.
Most discussions around the state of medicine center on pocketbook issues, which appear to dominate the agenda not only of our representative organizations but also of our daily life. The hurdles on the path to maintaining the high financial status to which we have become accustomed have provoked concerns, which have received a variety of responses. Unfortunately, unsavory options are chosen by some physicians, creating a dangerous situation that is likely to seriously damage the medical image. The current investigation by the Justice Department concerning illegal kickbacks given to orthopaedists by the pharmaceutical and surgical implant industry speaks volumes2. The outcome of the investigation should have a major beneficial effect in cleansing a system in need of reform3.
To a great extent, the changes I have perceived in the attitude of a number of orthopaedic residents toward the passive acceptance of prescribed methods of treatment are due to the overwhelming role that industry plays in their education. The vast majority of the thousands of "educational" courses presented around the country on a yearly basis are in actuality produced by industry through the subsidy they extend. Many of the visiting professors and guest speakers the resident community hears are, in various degrees, directly or indirectly on the payroll of industrial concerns. The research publications that the residents read are frequently manipulated by industry, therefore jeopardizing the veracity of their findings2.
I participated in the recent 2007 Annual Meeting of the Orthopaedic Trauma Association in Boston. As usual, it was a well-organized meeting, in which a section was entirely devoted to orthopaedic residents. At the end of the didactic lectures, another session entitled "Cut-No Cut" took place. The moderator presented to a panel of experts a few clinical cases, seeking opinions as to whether a given fracture should be treated surgically or nonsurgically. Before the panelists were asked to render an opinion, the residents, each holding an electronic device, clicked either "cut" or "no cut."
The first clinical case was that of a patient with a simple fracture of the humerus with minimal displacement. More than 90% of the residents clicked "cut." The moderator then proceeded to show a radiograph of the healed fracture, which had had no surgical treatment. The second case was that of a patient with an isolated, minimally displaced fracture of the medial malleolus. If I am not mistaken, >95% of the residents clicked "cut."
It is interesting, if not paradoxical, that an article in a recent issue of a peer-reviewed journal indicated that isolated fractures of the medial malleolus treated nonsurgically do as well as, if not better, than those treated surgically4. Apparently, those in the audience either had not read the papers or had simply chosen cavalierly to ignore them. The overwhelming response of the residents in favor of surgery in every instance was a clear demonstration of the resounding success of the intense and relentless bombardment to which they are subjected with regard to the preference for surgery in the care of all fractures5.
The power of a manufacturing industry that is bent on dominance and eager to enhance its already swollen revenues and an orthopaedic community that is increasingly concerned over reductions in reimbursement for services rendered are perpetuating the problem. To deny the profit-driven reasons behind the trend would be the ultimate example of hypocrisy or naiveté.
Although it appears that Socrates is dead, I hope and pray that he is just sick and waiting for the latest potion to restore his health. His prescription for self-knowledge, integrity, objectivity, and the pursuit of greater understanding seems to have been forgotten or is simply in obeisance. The Socratic method of teaching must be preserved, for its principles spawned and have sustained for over 2400 years our great Western civilization. 