Make the call to consider environmental sustainability in orthopedics
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Key takeaways:
- The orthopedic specialty generates significant waste and emissions.
- Surgeons can promote sustainability in the operating room by reducing single-use items, redundant trays and opening of unused materials.
A wide-reaching discussion has emerged in most major economic sectors surrounding the drivers of climate change and the opportunities to mitigate our negative impact on the planet.
In response, a sustainability movement has gained traction in most industries around the world, from small businesses and Fortune 500 companies to higher education institutions. Environmental sustainability means considering and acting in accordance with an effort to reduce negative human impact on the environment and climate. This includes reducing emissions (carbon dioxide and other greenhouse gases), waste and pollution.
Many medical specialties are considering their environmental impact, with anesthesia and internal medicine leading the way and orthopedics only beginning to discuss it. Orthopedic surgery is one of the highest-volume surgical subspecialties and one of the most energy-intensive. That means that orthopedics has a substantial environmental impact within the health care sector’s contribution of 10% of the U.S. annual greenhouse gas emissions. Stopping to see the amount of trash generated and trays in need of sterilization from a single case is a day-to-day reminder of that impact.
The top priority for orthopedic surgeons is — and should remain — excellent patient care. Nonetheless, sustainability can and should be incorporated into practice patterns and discussions surrounding resource utilization — by individual surgeons and more widely by health systems and national organizations. We surgeons should consider and engage with environmental sustainability efforts because, as physicians, we serve as stewards of the health of our communities. Climate change and pollution have a significant impact on human health. Climate change-related temperature changes, including disruptions of food and water supply and worsening infectious diseases, cause 5 million deaths annually. U.S. health care emissions alone lead to up to 614,000 disability-adjusted life-years lost annually.
Further incentive for surgeons to consider sustainability is its symbiosis with cost savings. Using less equipment and producing less waste achieves goals of both reducing cost and reducing environmental impact — something that both surgeons and administrators support. Dubbed the “triple bottom line” in medicine, patient outcomes, cost and environmental impact are closely connected.
Sustainability challenges in orthopedics
Health systems around the world must reckon with the mounting waste and emissions these systems create, directly through energy and resource consumption and indirectly by way of supply chains. Current reimbursement and compensation patterns prioritize productivity, which has become synonymous with volume. Few U.S. centers offer incentives to align with more sustainable, resilient practices. For this to change, surgeons must offer their clinical and academic expertise and partner with their health systems, industry and policymakers.
The widespread culture of disposability in the U.S. is a problem. Initially justified by concerns in avoiding contamination, disposable products have become mainstream in the orthopedic OR. With increasing reliance on such single-use items, we have seen increased vulnerability to supply chain disruptions, higher volumes of landfill waste, particularly nondegradable plastics, and a growing resignation toward waste generation in the OR. Research is required to better quantify the impact of such products via life cycle assessment studies, which provide a more comprehensive measure of the impact of a product, from initial materials extraction to disposal.
Promote sustainability in practice
Orthopedists are in a unique position to lead a transition to a more sustainable health care system. We often enjoy significant autonomy, deciding how and when we see patients, what instruments to use, and when to operate. We are team leaders in a variety of settings, and our decisions influence those around us. With this in mind, we can design our practices to minimize the environmental impact of the care we deliver and set an example for others to do the same.
We may begin in how we see patients. The COVID-19 pandemic has accelerated our familiarity with video and telehealth visits, which have been shown to drastically reduce the carbon footprint of patient encounters in addition to providing added convenience for patients. Establishing satellite clinics and prescribing physical therapy only when necessary may also decrease patient travel.
In the OR, where our largest environmental impact lies, we can minimize disposables whenever possible, including drapes, towels, positioners and instruments. We can consolidate our instruments to minimize the number of trays that need to be sterilized for each case, given that the energy required in the sterilization process is immense. We can minimize the number of implants that we use.
Orthopedists should act as influential leaders in discussing this topic. We should interface with our implant representatives and companies and hold them accountable for the environmental impact of their products. Seeking out leadership roles in our hospitals, health care organizations and professional societies gives us the opportunity to bring sustainability to the forefront. Even having casual discussions in our OR can foster change in our team members. Finally, we should collaborate with our anesthesiology colleagues to minimize the use of potent greenhouse gases, like desflurane and nitrous oxide, and to deploy regional anesthesia when possible.
Promote sustainability in the specialty
Surgeons look to our specialty societies to set priorities and the standards of patient care. If our societies consider sustainability among the tenets of best practice, we can effectively create a culture that prioritizes energy/waste reduction and considers sustainability within our daily clinic and OR. Societies and medical journals can raise awareness and help share best sustainability practices across surgeons, minimizing the burden on each surgeon to design changes to their practice.
To be clear, focusing on sustainability in orthopedic surgery and “greening the OR” does not lead to inefficiency, higher costs or patient safety concerns. Prioritizing sustainable practices is truly beneficial for all stakeholders, decreasing costs and increasing efficiency. As the government and hospital systems recognize this and consider requirements toward reducing emissions, surgeons can and should be a part of the discussion to create strategies that work for surgeons and patients while promoting sustainability.
While continuing to prioritize patient outcomes, orthopedic surgeons should consider environmental sustainability in their practice and push all members of our specialty to contribute to the effort of decreasing our environmental impact.
Key points:
- Environmental sustainability should be considered by orthopedic surgeons because of the present impact of climate change on population health and because our specialty generates significant waste and emissions.
- Surgeons can promote sustainability in the OR by reducing single-use items, redundant trays and the opening of unused materials. They can also lead relevant discussions with colleagues, health systems, subspecialty societies and industry partners.
- Assigning value to sustainability efforts will be critical to leading change and will benefit from orthopedic society, journal and industry-led collaborations.
References:
- Eckelman MJ, et al. Am J Public Health. 2018;doi:10.2105/AJPH.2017.303846.
- Eckelman MJ, et al. PLoS Med. 2018;doi:10.1371/journal.pmed.1002623.
- McMichael AJ. N Engl J Med. 2013;doi:10.1056/NEJMc1305749.
- Zhao Q, et al. Lancet Planet Health. 2021;doi:10.1016/S2542-5196(21)00081-4.
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