Looking at Ourselves
Author’s Disclosure Statement: The author reports no actual or potential conflict of interest in relation to this article.
Dr. Sarmiento is Professor and Chairman Emeritus, Department of Orthopedics, University of Miami, Florida; and University of Southern California, Los Angeles, California.
Address correspondence to: Augusto Sarmiento, MD, 200 Harbor Walk Drive, Suite 335, Punta Gorda, FL 33950 (email, email@example.com).
Am J Orthop. 2018;47(5). Copyright Frontline Medical Communications Inc. 2018. All rights reserved.
The genesis of the ongoing debate on healthcare is complex, in part because of the perceived flaws within the proposed systems. Denying the guilt that the medical profession has had is a disingenuous exercise in futility. In fact, orthopedics is possibly the most egregious among the culprits. Such a charge, supportable or not, calls for serious objective criticism.1 No one would dare question the fact that from the orthopedic point of view, the cost of healthcare delivery is an important factor because of the critical level this issue has reached. The use of expensive technology and frequent surgery are of major importance.2,3 However, I submit that it is not the high cost of the technology and surgical procedures per se but their frequent abuse.
As I look at orthopedics in an objective, critical manner, I have the uncomfortable feeling that the profession is rapidly becoming a business where greater and greater profit is its primary raison d’etre. The discipline has lost much of its traditional scientific/biological foundations, and is converting itself into a technical trade heavily controlled in its educational duties and the subsequent conduct of its members by industry. This metamorphous evolution has shown ill effects as demonstrated by the loss of traditional territory to other disciplines and a borderline ridiculous fragmentation into a multitude of subspecialties that contribute to the erosion of the profession. Orthopedics is no longer a solid eclectic body of knowledge and expertise in the care of musculoskeletal conditions, but a fragmented body of techniques independent of each other. This statement is not a criticism of fragmentation per se, because fragmentation in most human endeavors is a natural evolutionary phenomenon that occurs in virtually all walks of life, and to our profession it has brought much progress. My concerns are over the apparent exaggerated degree it has reached.4
The fragmentation and erosion of orthopedics took a relatively short time to occur without any evidence of concern among the orthopedic community, which apparently assumed that the advances made by other disciplines would not compromise the security and independence it had enjoyed for generations. The spectacular advances in joint replacement began to occupy a large segment of orthopedists’ professional time. The attractive reimbursement accompanying these procedures further justified the complacency regarding the shrinking of the discipline, while the previous outsiders expanded their territory. Critical objectivity of this issue is important in the event we decide to address the consequences of further erosion and fragmentation of our profession.
There should be no question that if all, or the overwhelming majority of, orthopedists become subspecialists who take care of only a limited number of pathological conditions, the cost of care will grow exponentially. The poor, regardless of the outcome of any legislation addressing their problems, will suffer most.
In small communities there are not enough patients with conditions requiring subspecialized orthopedic services to satisfy the emotional and economic needs of the fellowship-trained orthopedists. Other physicians and allied health practitioners will fill the void and provide the needed services. However, the facts facing us today suggest that if the current trends continue unabated, orthopedics as a distinct branch of medicine may not survive. Nonetheless, people in need of musculoskeletal care will receive it from a variety of medical and paramedical people, who will gradually develop skills and knowledge in a manner comparable to that possessed today by orthopedists.
Of major significance in the overall issue of critical objectivity is the unquestionable fact that orthopedics voluntarily relegated to the surgical implant industry the control of many of its traditional educational responsibilities to the point where, at present, it is assumed that educational programs cannot be conducted without the financial support of industry. Hundreds, if not thousands, of conferences; grand rounds; local, state, and regional society meetings; the American Academy of Orthopaedic Surgeons’ (AAOS) annual meeting, and its many other educational activities take place with the financial support of industry. Such a dominance has placed the orthopedic profession in a relative subservient position, since the “generosity” provided by industry must be reciprocated. This explains the rapid and overwhelming favorable response given by the practitioners of the medical profession by seeming to accept whatever new products appear on the market. The issue has become even more complicated by the growing acceptance of kickbacks and perks for cooperation with the manufactures, simply for the use of the industrial products and assistance in advertising them.5,6.
I have previously described episodes in which I was personally involved. The one I now describe consisted of a visit by an industrial representative who approached me during my tenure as Chairman of Orthopedics at the University of Southern California.1 He offered me what he called “a very good deal” where I was to be given $200 for every one of his total joint implants I were to use, as well as from those used by any of the orthopedists working at any and all 5 hospitals affiliated with the department. I was to receive a monthly check at home, so no one else would be aware of the transactions. When I asked him what had prompted him to think I was a prostitute, all he could say was, “But Doctor Sarmiento, we do that all the time.”
I am certain that episodes of the nature of my experience occur every day of the week. Had it not been aware of their frequent occurrence, the United States Justice Department’s investigation of the “egregious unethical transgressions” and the “corruption in the relationship between the industry and orthopedics”, and the search for a solution would not have been initiated.6 What can we expect to come out of such investigations? As far as I am concerned, those who may have been accused unfairly, as well as the guilty ones, have probably stated that “all conflicts of interest have been resolved.” I insist that the orthopedic profession, and particularly its representative organizations, should stand up and, as loudly and clearly as possible, protest the despicable practice and bring about a cure for the festering ulcer.
The power of industry in controlling orthopedics has reached a previously unsuspected level. In a commentary I published in the Journal of Bone and Joint Surgery,7 I described an episode where a powerful industrial concern had prevented the release of a book I had written. The product had reached its final form in hardbound and softbound editions in English, as well as in Spanish. After much struggle to find out why at the last minute the marketing had not begun, I learned that an industrial firm had “convinced” the publishers to cancel the release of the book. Though I considered the litigation route, I realized that I did not have the financial resources for such a venture. I have experienced similar problems with other publishers in the past.7 When our representative organizations will seek involvement in this delicate issue and try to bring about a solution is as yet unknown.
A fact influencing the decline of professionalism in our ranks is the now well-known lack of credibility in an increasing number of publications.8 Some respectable journals are making a serious effort to overcome the problem, but they realize how difficult it is to see the truth, since distorting data is not that difficult, and exposing the culprits is even more so. What possible solution can be structured to resolve this embarrassing situation? It is an issue of morality that cannot be legislated; however, it can be positively influenced by the example set for the younger generations, especially by our representative officers. Unfortunately, the latter group has failed to do a very good job, since we frequently observe individuals with obvious conflicts of interest occupying positions of leadership and power.
In the United States another move, supported by a number of well-qualified authorities in the field of medical economics, advocates the establishment of a system where all physicians would be salaried hospital employees.3 For some time I have felt inclined to support the concept, as I saw it as a logical and practical one. However, my mind has been rapidly changing, particularly after observing the growing number of hospitals employing physicians throughout some regions of the country. I ask myself, how will the number of subspecialists in each hospital be able to enroll? It cannot be open-ended, since the cost of providing a salary, malpractice insurance, secretarial support, vacation time, health insurance, and other benefits can amount to degrees the institutions cannot afford. Another discouraging find was related to the fact that the salaried doctors would receive bonuses according to the amount of work they did. This is a logical and well-intentioned move. However, it would perpetuate one of the major problems besetting the current situation: the rendering of nonessential expensive services and the performance of unnecessary surgery in order to increase the size of the bonus. Would this be a return to the current dilemma?
For the various issues I have identified and for which critical objectivity is necessary, it is essential that our representative organizations assume a leading role, concentrate on fundamental issues, and set aside time-consuming projects of questionable importance. Among those projects I identity 3 important ones: The Joint Replacement Registry, The Orthopedic Guidelines, and Evidence-Based Orthopedics. The Joint Replacement Registry can wait, since its foundations as presented today are weak and based on the illusion that the alleged success of the Scandinavian Registries can be easily duplicated in this country. I envision that 15 years from now the only thing the Registry will give us is millions of pieces of data that were already available through the traditional methods of publications and other means of dissemination of information.9
The recent infatuation with The Orthopedic Guidelines may be a temporary success that will die before they reach maturity. It is a noble effort, since it proposes a mechanism by which to provide “advice” to orthopedic surgeons regarding the degree of benefit that various treatment approaches have to offer. The problem, as I see it, is that soon the “advice” will become, in the eyes of many, “dictates” to be followed. The fear of litigation for not following the “guidelines” could result in deprivation of the independence that is acquired from experience and lessons from others. We are not children in need of instructions regarding behavior. Rather than making changes with new but probably imperfect projects, we should emphasize the credibility of publications and oral presentations. The authors of the Guidelines are appointed individuals who, like all human beings, are afflicted with the innate biases and prejudices that make them see things according to their personal perceptions, and their views are not necessarily representative of ideal situations.10
Evidence-Based Orthopedics is another noble effort to improve matters. I find in this effort the same flaws I have identified with Registries and Guidelines. There is not yet any evidence to suggest that the profession will be helped from the time and expense they require. Any publication should be based on evidence; otherwise it should not be brought to the orthopedic community. Emphasizing credibility is more likely to be beneficial to the profession and to the people we represent. To have 2 different types of articles in our journals where some are based on evidence and others lack evidence does not make sense.
In summary, orthopedics is confronting situations that require critical objectivity as we search for solutions. Some of the situations I have tried to identify may not be “problems” but examples of normal evolution or transient developments that time alone would resolve. On the other hand, some others may be of a serious nature and require our involvement. To ignore them will bring about problems for the next generation who will wonder what precluded us from seeking answers before it was too late.
1. Sarmiento A. Bare Bones: A Surgeon’s Tale. Amherst, NY: Prometheus Books; 2003.
2. Callahan D. Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System. Princeton, NJ: Princeton University Press; 2009.
3. Relman AS. Doctors as the key to health care reform. N Engl J Med 2009;361(13):1225-1227. doi:10.1056/NEJMp0907925.
4. Sarmiento A. Subspecialization in orthopaedics. Has it been all for the better? J Bone Joint Surg Am. 2003;85-A(2):369-373.
5. Sarmiento A The relationship between orthopaedics and industry must be reformed. Clin Orthop Relat Res. 2003;412:38-44.
6. Five Companies in Hip and Knee Replacement Industry Avoid Prosecution by Agreeing to Compliance Rules and Monitoring. Newark, NJ: US Dept of Justice, US Attorney, District of New Jersey; 2007.
7. Sarmiento A. Infringing on freedom of speech. J Bone Joint Surg Am. 2011;93(2):222. doi:10.2106/JBJS.J.00888.
8. Carr AJ. Which research is to be believed? The ethics of industrial funding of orthopaedic research. J Bone and Joint Surg Br. 2005;87(11):1452-1453.
9. Sarmiento A. Orthopedic registries: second thoughts. Am J Orthop. 2015;44(4):159-160.
10. Sarmiento A. Thoughts on orthopedic guidelines. Am J Orthop. 2010;39(8):373-374.