Still vivid in my mind is a visit I paid to the director of Center for Medicare and Medicaid Services in Washington, D.C. in 1990 in the company of the president and second vice president of the American Academy of Orthopaedic Surgeons. I was then its first vice president. The president spoke on behalf of the organization emphasizing that further reductions of reimbursement for services provided to Medicare patients would easily create a scenario where there would not be orthopedists available to treat those patients. The director smiled and said, “Doctors, don’t try to scare us, because we know how you operate: every time we reduce reimbursements you increase volume.” She then proceeded to remind us that orthopedic surgeons were the physicians in the United States with the second highest mean annual income of $250.000.
Two decades later the battle for the “unfair” reimbursement continues unabated, despite the fact the orthopedist is no longer the second highest earner physician, but the first, with an annual mean income of $514.000. A campaign to convince a larger number of orthopedists to decline acceptance of Medicare patients is making inroads across the land.
I believe that the project is ill-conceived and, if successful, likely to have catastrophic consequences to the orthopedic discipline and to the public at large. Common sense and past experiences will show that even though orthopedists will not be the ones caring for Medicare patients, others in the medical and paramedical community will step up to the plate and take advantage of the new opportunities and provide orthopedic services.
To assume such a scenario is unrealistic, one needs only remember that, for example, podiatry was as recently as three decades ago a discipline with a very limited scope and territory. Through a deliberate effort and careful planning it evolved and structured its educational and administrative functions to such a degree that at this time podiatrists are certified doctors serving a large number of patients with pathological conditions in the distal leg, previously the exclusive domain of orthopedic surgeons. A similar framework could easily appear if nurse practitioners, physicians assistants, operating room technicians, prosthetists and orthotists, and others, were to qualify themselves to provide care of a number of musculoskeletal conditions that have been the province of orthopedic physicians.
The orthopedic discipline has chosen to give great importance to subspecialization to the point that with very few exemptions every graduating orthopedic resident extends his or her institutional training by a year devoted exclusively to a segment of the profession, such as surgery of the hand, foot, spine, hip, or many others. Having a system that provides young surgeons with opportunities to overcome perceived deficiencies in their residency, or simply to become experts on a given field, is commendable. However, thus far the outcome of the project has taken a different course.
The vast majority of residents currently choose a fellowship year primarily in anticipation of finding jobs with better financial opportunities. Medical students entering residency education quite often say that eventually they will take a fellowship in order to become super-specialists, not just orthopedic surgeons.
There is nothing basically wrong with subspecialization in orthopedics or in any other branch of medicine. Quite the contrary, it has contributed enormously to the attainment of the progress. Though I managed to keep my fingers into the overall subject of the discipline, I became a specialist in hip replacement and for 35 years devoted my entire surgical practice to that area.
The existence of over 25 officially recognized orthopedic subspecialties and other health care providers seeking to provide care for orthopedic conditions could result in the disappearance of the traditional eclectic orthopedic surgeon. This likely event will create a situation where a relatively small number of patients suffering from specific musculoskeletal conditions will be forced to have nonorthopedic providers administering orthopedic care. There will be too few of these patients for the super-specialist.
Of late, much has been said about an impending shortage of orthopedists. The concern is probably ill-founded. The real problem is a growing loss of professionalism, the trivialization of the profession, the obsession with subspecialization, and the blind seeking of greater and greater wealth. To many, orthopedics is no longer a profession but a business, where the ethos of commerce is replacing the traditional Hippocratic one. Address this situation and the predicted shortage of orthopedists will cease to be an issue.
Augusto Sarmiento, M.D., 85, is an orthopedic surgeon. A former professor and chairman of the Department of Orthopaedics and Rehabilitation at the University of Miami and the Department of Orthopaedics at the University of Southern California, he is currently professor and chairman emeritus at the University of Miami. He is also past president of the Hip Society and the American Academy of Orthopaedic Surgeons and a recipient of the Kappa Delta Award, the Nicholas Andre Award, and the Elmer and Rosemary Ethics Award of the Clinical Orthopaedics Society.