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There is too much fragmentation in orthopedics
Aware of my long-held interest in the fragmentation of orthopedics, Douglas W. Jackson, MD, invited me to write my views on the issue.
It goes without saying that fragmentation is a logical evolutionary process in virtually all human endeavors. Medicine is not — and should not be — an exception.
Nevertheless, I expressed my concerns in the Journal of Bone and Joint Surgery in 1991 and 2003 on what I perceived as exaggerated fragmentation. Fragmentation of our discipline must be addressed not in isolation but as a component of a broader picture, where its healthy and unhealthy consequences must be considered together.
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The fragmentation of orthopedics began in earnest in the 1970s when major technological developments exploded onto the national scene. The sudden introduction of new knowledge into the orthopedist’s armamentarium prompted many to seek subspecialization.
Academic institutions emphasized the need to recruit individuals committed to a medical practice that was exclusively devoted to specific surgical areas. I personally embraced the trend and did my best to accommodate it into the two departments I consecutively chaired at the University of Miami and the University of Southern California. Within a short time, the departments had representatives from all of the emerging subspecialties.
Reasons for fragmentation
The argument in favor of subspecialization was, and currently is, based mainly on the claim that the suddenly enlarged body of knowledge is so great that no one individual can possibly be sufficiently competent in all areas.
However, I question the validity of this in light of the fact that knowledge — particularly that of a technical nature — is not cumulative. New knowledge has simply replaced old knowledge and in the process has made the practice of the profession easier.
I see no better examples of this than in the care of the arthritic hip and the management of fractures. The large number of surgical procedures that the orthopedist needed to master two generations ago (eg, acetabular and femoral osteotomies, endoprosthetic replacement, neurectomies, muscle releases, fusions) have been replaced almost completely by total hip arthroplasty, a rather simple surgical procedure.
Likewise, the care of fractures, which included closed and open reductions, cast application, wedging procedures, tractions of various types, and a multitude of immobilizing devices, currently consists of nailing, plating and, to a lesser extent, external fixation. Sophisticated imaging technologies have dramatically simplified their use.
However, there is a downside. The obvious financial benefits that surgical approaches bring to surgeons and hospitals alike have resulted in an abuse of surgery, best depicted by the growing preference of operative procedures over conservative treatment for simple fractures of the clavicle, distal radius, ulna, nondisplaced malleoli, metacarpals and phalanges.
Likewise, there are unnecessary surgical procedures performed in the spine, shoulder, hip, knee and wrist to treat conditions that often respond well to simple therapeutic modalities. The fact that a growing number of residents complete their training without having treated many of these fractures with nonsurgical methods illustrates this trend.
Still, it is worth remembering that prior to the modern era of subspecialization, many orthopedists chose not to cover all aspect of the profession and consciously elected to limit their practice to areas where they felt most comfortable. We have always had orthopedic subspecialists.
An epidemic of fellowships
The addition of subspecialized faculty in teaching programs has splintered residents’ education to a point that may prove detrimental. The 5-year training “pie” is no longer divided into a small number of time slices but rather into additional ones, resulting in a shortening of the training necessary to achieve greater competency.
It is likely that this perception is related to what may be considered an epidemic of fellowships. Their popularity has reached the point where fourth-year medical students applying for residency positions assert that, after residency, they will pursue an additional year of fellowship.
Some residents should be encouraged to indulge in fellowship training, such as those who plan an academic career, as well as those who find it necessary in order to accept a special position in the community.
However, I suspect that the vast majority of graduating residents are sufficiently competent to enter the rough-and-tumble world of private practice and perform their duties in an appropriate way.
Creating barriers
It is therefore paradoxical, if not hypocritical, that once these residents enter the workforce, they encounter artificially created barriers that keep them from performing procedures that they can handle appropriately, or they feel obligated to obtain membership in subspecialty societies, which often require fellowship training and the possession of Certificates of Added Qualifications (CAQs).
The number of fellowship-trained orthopedists will soon reach a saturation point in many large communities. It has already occurred in some cities, forcing the newly graduated fellows to practice orthopedics in areas in which they have no interest.
The problem becomes more serious in smaller communities because the limited number of people in need of subspecialized care is not sufficient for the practitioner to generate the income he or she anticipated. Many such physicians, in order to survive financially, may perform unnecessary surgery.
Subspecialty societies
The Council of Musculoskeletal Specialty Societies (COMSS) now recognizes 26 orthopedic subspecialties, and we expects that number to grow. One cannot help but wonder: What have been their accomplishments? Are they all scientific societies or are some simply social clubs?
Some of these groups are elitist organizations that require fellowship training, CAQs and yearly membership dues. I am convinced that such requirements are unnecessary, discriminatory and divisive. Finding redeeming features to justify such structure is virtually impossible.
The role of industry
There is no doubt that the survival of many societies is dependent on industry support. These industrial concerns use their economic power to subordinate the profession to their economic goals. Such dependency prompted me long ago to conclude that the education of the orthopedist today is structured for the primary purpose of satisfying the marketing needs of industry.
The evidence of the iron-grip control that industry has gained over the orthopedic discipline is best exemplified by the corruption now being investigated by the U.S. Justice Department. The widespread practice of kickbacks to orthopedic surgeons has become public knowledge, and the credibility of publications heavily sponsored by industry is being seriously questioned.
The resulting increase in costs that benefits industry is forcing us to address the possibility of having a government intervention that imposes a salaried medical profession. Though such a scenario seemed impossible until very recently, it is now a real probability. The time left for us to prevent such a drastic development is running short.
It behooves us to address these challenges and create an environment that will restore the integrity and high moral values upon which our profession rested for many generations. We must seriously reconsider if the current system of residency education, fellowships for everyone and the exaggerated fragmentation of the profession should be left unharnessed.
I suspect that such an effort would bring about healthy benefits to all concerned. Equally if not more important is the possibility of putting back into our hands the education of the profession and the shaking off the yoke that industry so skillfully has laid on our shoulders.
For more information:
- Augusto Sarmiento, MD, is a past president of the American Academy of Orthopaedic Surgeons. He can be reached at the Dept. of Orthopaedics and Rehabilitation, University of Miami School of Medicine 13-27, P.O. Box 016960, Miami, FL 33101; 305-666-3310; e-mail: asarm@bellsouth.net.
References:
- Sarmiento A. Staying the course: First vice president’s address. J Bone Joint Surg. 1991;73-A:479-483.
- Sarmiento A. Subspecialization: Has it been all for the better? J Bone Joint Surg. 2003;85-A2:369-373.