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Keep the family together
CA Rockwood
J Bone Joint Surg Am. 1984;66:800-805.



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Publisher Information          The Journal of Bone and Joint Surgery
                               20 Pickering Street, Needham, MA 02492-3157
                               www.jbjs.org
                                                                                           Ciip     right     I 984 h     The Jo,rp,al       ii!     Biipie and   Jiii,it      Surgery.      IPii(irp(iraIed




                                                                                        Keep                       the Family                                                Together*
                                                                        BY CHARLES                     A.      ROCKWOOD,                           JR.,     M.D.t,                 SAN        ANTONIO,                   TEXAS


              Fellows,                  guests,          ladies,            and       gentlemen:                   It is both                    a        ogy,              rehabilitation,                      and      prosthetics              and      orthotics            (Fig.       1).
pleasant                    and      a humbling                 experience                 to appear                    here       today                  This is not to say that our Academy                                                      fellows specialize      only
and address     you as participants                                                 in the Fifty-first     Annual                                         in these areas,  for over 70 per cent                                                  of the Academy       fellows
Meeting   of the largest organization                                                 of orthopaedic     surgeons                                         practice general  orthopaedics.      However,                                                     it is fair to say that
in the world.    It is indeed  sobering                                                to consider     my respon-                                         there are a large number        of our fellows                                                      who do predomi-
sibilities                  in the        coming            year        and         to maintain                 the       traditions                      nantly practice  within the specialty      areas                                                  and herein     lies the
of The             Academy                     which           have         been        developed                  by my            most                  potential     for                   a  ‘family”
                                                                                                                                                                                                    ‘          crisis                   -  a crisis that can lead to
distinguished                        predecessors.                    I promise               to do          my       best       during                   fragmentation                        within    orthopaedics                         and this is something
                                                                                                                                                                                                                                              -

the coming        year to assist     the committees,         the Academy                                                                                  that I believe                      we must avoidjust                         as much as we would avoid
office,    Board    of Directors,     Board     of Councilors,       and you                                                                              fragmentation                        within our homes.                            Progress     within                every      field
as fellows     in efforts  to maintain      the traditions     of The Acad-                                                                               of medicine                        will invariably  lead                          to specialization                    and     I be-
emy.                                                                                                                                                      lieve             that      this         is desirable               for    the         welfare        of our           specialty
      I would like to dedicate    this presentation    to the fellows                                                                                     and especially                          for our patients. The problem for The Acad-
of the class of 1984 and to my wife, eight sons, one daugh-                                                                                               emy to solve                          is: how do we foster and encourage     progress
ter, one daughter-in-law,      and mother,       who are all here to-                                                                                     in orthopaedics                           by helping  the specialty                           groups           and yet keep
day.                                                                                                                                                      them as a part                           of the musculoskeletal                             family?
              While            the orthopaedist                       faces         many external       challenges                                                     Philosophers                            say that      if you          want        to predict             the future
which           are            likely   to change                       the         traditional   patient-doctor                                          all you have to do is review         the past. Let us review        the past
relationship,     I am particularly   concerned    over a dangerous                                                                                       of the practice      of medicine.      In the late 1800’s       physicians
internal    trend within the musculoskeletal     field. The question                                                                                      took care of all medical          and surgical    problems.     Later they
before     us is: how can unity       in purpose    of organizations                                                                                      segregated    themselves     into surgical     and non-surgical      arenas.
within orthopaedics.      as a part of the larger musculoskeletal                                                                                         Further                  divisions                   led     to the       specialties  of pediatrics,      ra-
system,                be preserved?                     How          can      the family                   of orthopaedists                              diology,                  anesthesia,                      obstetrics      and gynecology,      pathology,
and special    interests     be held together    -                                                 without              being        held                 psychiatry,   and                             dermatology.         In 19 1 2 the surgeons        orga-
down -      without      being forced    to leave                                                 home?                                                   nized the American                                  College    of Surgeons    and surgeons        were
              I use the simplistic                         orthopaedic                  family              concept             because                   dedicated   to the                             treatment      of all of the surgical      problems.
I can relate it to my own family.        Certainly,    in our society,                                                                                    At one time the                               surgeon,      known    as a general    surgeon,       was
the family     is the most important    unit and each of us strives                                                                                       responsible    for                             the chest,       abdomen,     brain,    extremities,
to maintain      unity in our family   and will fight anything         or                                                                                 spine, eye,                     ear, plastics,                   and so on. Even before                               the Amer-
anyone that will try to split us up. In the same way, I believe                                                                                           ican College                      of Surgeons                     was formed,  surgeons                              had started
we must     fight to keep our musculoskeletal       family   intact and                                                                                   to drift                 into distinct                   anatomical      areas of surgery                               and    later
strong. Things are usually rather simple with just a husband                                                                                              worked                   exclusively                   in their selected      ‘ specialty’                       ‘    areas.    Re-
and wife. However,    issues begin to get rather complicated                                                                                              member    that The American     Orthopaedic      Association                                                                    was
when large numbers      of children  come   along,  especially                                                                                            formed  in 1887. Later the general     surgeons   developed                                                                    their
when            the          children              grow         to maturity                   and           seek        their       inde-                 own societies   and even developed       their own specialty                                                                       ex-
pendence.                     Unity           oforthopaedics                      was      not      a problem                   in 1940                   aminations      and board certifications.                                              The first surgical   spe-
because                 essentially                all    of    our         fellows           practiced               general              or-            cialty    board    was developed        by                                          the American      Board    of
thopaedics,                       but           60’s, orthopaedics
                                          in the 50’s              and      began to                                                                      Ophthalmology                                 in 1917, and later came                             the Boards              of Oto-
note          its  ‘growing
                        ‘     offspring’    ‘ , the   specialty    societies,     and                                                                     rhinolaryngology                                in 1924, Orthopaedics                               in 1934,             Urology
now           in 1984 the offspring      number      even more children          than                                                                     in 1935,                 Plastics in 1937, Surgery                                 in 1937, and Neurological
I have            in my                 own       family!             Our      orthopaedic                    offspring              now                  Surgery                  in 1940. The American                                     Board   of Orthopaedics                           is
include               with such
                       societies                                      names      as hand, foot and ankle,                                                 celebrating                   its fiftieth                   anniversary               this year,   and we offer
spine,    neck, hip, shoulder                                         and elbow,       knee,      sports    medi-                                         them our                   congratulations                       and best              wishes   for the future.
cine, pediatric
microsurgery
                    orthopaedics,
                , rehabilitation                                       ,  scoliosis,
                                                                         arthroscopic
                                                                                         research,
                                                                                             surgery
                                                                                                         trauma,
                                                                                                           oncol-            ,                            programs
                                                                                                                                                          education
                                                                                                                                                                       The
                                                                                                                                                                    , board

                                                                                                                                                                      courses,
                                                                                                                                                                                     development
                                                                                                                                                                               examinations
                                                                                                                                                                                   and specialty
                                                                                                                                                                                                 annual     meetings
                                                                                                                                                                                                     journals      came
                                                                                                                                                                                                                        of the
                                                                                                                                                                                                                        , continuing

                                                                                                                                                                                                                           about
                                                                                                                                                                                                                                    ,
                                                                                                                                                                                                                                    specialty


                                                                                                                                                                                                                                     be-
                                                                                                                                                                                                                                                           societies,            residency



          *    First        Vice-President’s               Address.          Read       at the     Annual          Meeting         of The                 cause of the progress       of surgery    and the fact that surgeons
American               Academy            of Orthopaedic               Surgeons.           Atlanta.           Georgia.           February
12. 1984.
                                                                                                                                                          realized  that they could not remain     competent    in the over-
          t   University                of Texas         Medical        School.         San       Antonio.         Texas          78284.                  all broad   field of surgery. So, in reviewing     the past of the

800                                                                                                                                                                                                                  THE JOURNAL            OF    BONE       AND        JOINT      SURGERY
                                                                                                         KEEP      THE        FAMILY       TOGETHER                                                                                            801




                                                                            --       .          ;I%vt.




                                                                                                                                FIG.   1


specialty         of surgery,               we see that                  the domain   of the general                                   research           and      study,      they     have      brought       brilliant           new      ideas
surgeon          has greatly                diminished                   over the past fifty years.                                    of treatment,                surgical        procedures,         and         discoveries            to the
The so-called    loss of the                              territorial          rights of the general                                   field of orthopaedics:                        total joint    arthroplasties,         complex
surgeon   led to an editorial                             in 1982            by Dr. James   Handy,   a                                 hand    reconstructions,                       correction     of spinal        deformities,
past-President       of the American       College     of Surgeons.      He                                                            mending      the crippled                   child,     and special     treatment      of bone
said that the threatened       species   include    the great whales       of                                                          tumors    are just a few such contributions.
the ocean,     the elephants   ofAfrica,     the snow leopard     of Asia,                                                                    Another    mechanism    whereby   we generate                                  an increasing
the two-inch      snail darter fish in Tennessee,        and the general                                                               number      of specialists  is because  today   most                                  of the ortho-
surgeon    of the Western       world.                                                                                                 paedic          residency        education         programs          have      faculty          members
       Can this same      pattern      of fragmentation                                                    represent    a              who have had fellowships                            in specialty         fields.   They    teach
threat   to the specialty      of orthopaedics?         The                                               answer     is a              and stimulate their residents                        in this new        knowledge,      and the
resounding              yes. Many of us have recognized  it as a serious                                                               residents,     in turn,              want to be able to do the newer                          and more
problem,              and I am asking  you to use all of our efforts     to                                                            highly     developed                 operative  procedures  like their                         teachers.
promote       a family type of unity as opposed     to fragmentation.                                                                  Two       other      factors         seem      to be pushing          residents          into      fellow-
         When     you ask how did subspecialization,          superspe-                                                                ships and specialty     areas. First, they realize                                    that      the field
cialization,      or just simple   specialization    occur   within     the                                                            of orthopaedics    is now so immense      that they                                  can’t      possibly
field of orthopaedics,        the                     answer   has to be just about  like                                              master          it all; and second,              they believe         that     a fellowship             will
it did in general      surgery.                        Of course   World   War II had a                                                provide           greater  practice             opportunities.
great       effect         on   specialization                 as        large       numbers                of     patients                      All      of these          reasons       for specialization               within    ortho-
with        common              anatomical                injuries           were            treated             in special            paedics           are indeed           a part     of orthopaedics               today.     Our very
wards         in the hospitals.                 For example,                      those         who treated                   the      own teachers,                  you and I, can’t ignore specialization,                             for we
hand        injuries  formed                  the American                       Society         for Surgery                    of     have caused                 it. Progress  has led to specialization                             and spe-
the Hand             in I 946.        Most        of you         have            observed                orthopaedists                 cialization           is desirable           for the welfare           of our         patients.
who develop       a special    interest  in a special   area,  such as                                                                           The current            Affiliation        Agreements           between             The    Acad-
hand surgery,      the foot, the spine,     the hip, the knee,    sports                                                               emy and            five of the specialty      societies     now appear                           to be an
medicine,     or the shoulder,       and before   long,  they develop                                                                  outmoded              method   of maintaining         our relationships.                            These
expertise            in that     certain          area.       Next         come              a few        publications                 agreements             consist   of a five-page         document      that                       outlines
on the subject       and before      long colleagues                                               begin to refer                      the responsibilities,          how              we could help each other,                       and some
patients    with that special    problem    to their                                          friend because    of                     very specific         guidelines                and restrictions  concerning                        publi-
the expertise.     Later,  because     they become                                              so busy with the                       cations,    continuing        education       courses,   and so on. In the
special   problems,      they sort of become     trapped     and limit                                                                 mid-l970’s       the affiliates     needed     guidance,   maturity, and the
their practice    to that one anatomical    or special   area. Then,                                                                   help of The Academy               to get their fledgling      groups off the
the individuals         of the ‘ ‘special     interest’                                  ‘ group    meet at in-                        ground     and running.          Now,      they are quite capable      of di-
formal get-togethers          to discuss     common                                      problems,     and later                       recting their own                    societies   and planning            their futures.               They
to develop      specialty    societies    with annual                                     meetings,    officers,                       need and deserve                       their independence              and autonomy.                   The
committee              structures,           and so on. The                      members                 ofthe      society            Academy      has             hosted      three      workshops     to discuss                   the roles
become           known           as    ‘   ‘specialists’             ‘   and       through                their     intense            of the various               organizations          and to identify    areas                  of mutual


VOL. 66-A,           NO.   5, JUNE         1984
802                                                                                                  C.   A.     ROCKWOOD,                                 JR.




                                                                                                                                                                                                             . .    .   :




                                                                                                                               ,.       .   .   1.   i..   ..    ‘     .   ..v’i.    ..     .                 ,,.       .    .



                                                                                                                       FIG.         2

interest and conflict.
year. There
the specialty
                       A fourth is scheduled
              was general   agreement
                         society
                                         that
                                         meetings          and         the,i     The
                                                                                        in March
                                                                                     the time-frame
                                                                                         Academy
                                                                                                    of this
                                                                                                          of
                                                                                                               meet-
                                                                                                                                entitled
                                                                                                                                -     ‘ ‘The
                                                                                                                                                     Dr.
                                                                                                                                             ‘ ‘Twisted

                                                                                                                                                crooked
                                                                                                                                                            Trees
                                                                                                                                                            tree,
                                                                                                                                                                     David           Murray,               in his
                                                                                                                                                                                                    and Tempests’
                                                                                                                                                                                                   identified    for
                                                                                                                                                                                                                                     1982       Presidential
                                                                                                                                                                                                                                                 ‘   ,
                                                                                                                                                                                                                                                    stated, and I quote
                                                                                                                                                                                                                                               so long with the field
                                                                                                                                                                                                                                                                          Address



ing    was    too        long      -      it could         be   and that
                                                                  up      to ten       days      -                              of orthopaedic          surgery,                                    first appeared                               in Nicholas   Andry’s
a plan was needed      to hold concurrent        meetings,   all within                                                             two-volume      work published     in 1743.                                                               This tree figures prom-
a five or six-day over-all    time-frame.      I am pleased    to report                                                            inently   in our symbolism     today.   Has                                                               it ever occurred    to you
that to date all of the specialty         groups    have expressed       a                                                          that if we were good at our profession                                                                       that tree should   have
need to maintain   their solid footing       in The American       Acad-                                                            been              straightened                        out     by        now!’                ‘    (Fig.          2).     1 submit        to you
emy      of Urthopaedic                   Surgeons          and         a need         to preserve             unity                that we are good                                  at our profession                            and that today the symbol
among     orthopaedists.                                                                                                            of orthopaedics                                  is not a skinny                             crooked   tree, but a heavy,
        We must continue        to support      specialization,     as it rep-                                                      strong,                     and         sturdy         tree        -       a tree of good balance       created
resents   progress.      To discourage      the special-interest        groups                                                      by our specialty   societies                                             (Fig. 3).
will lead to disappointment          and dissatisfaction        and will drive                                                           The first challenge,                                              then, to the specialty   societies,      is
them      away         from      our     family      and        lead     to fragmentation,                  which                   to let us continue our open communication                                                                               and trust in each
must      be avoided              at all costs.            Specialization                 is here         to stay.                  other   so that we can assure  future    unity                                                                          of our musculo-
The     job      for     The           Academy         is to continue                    to support              spe-               skeletal     family.                              Simply               stated,                   let us keep                 the family         to-
cialization            and      work      toward       keeping                 the   specialty        groups            a           get her!
part    of our         musculoskeletal                 family.                                                                               The   second                                 challenge                     is           to       resolve            the     issues      of




                                                                                                                        FIG.        3


                                                                                                                                                                                                rUE JOURNAL                          OF BONE               AND   JOINT    SURGERY
                                                                                                             KEEP       THE        FAMILY          TOGETHER                                                                                             803

certification of fellowships     and the questions                                                          as to whether                    of your residency       until admission    to fellowship                                    in our Acad-
or not separate      board   examinations     and                                                         separate   board                   emy.
certificates should                                 be created                for our specialty     societies.                                      Even though        each orthopaedic      resident                                 now receives
While 700 residents                                  complete              their educational    process     each                             personal   correspondence        from The Academy                                     office, through
year       from              185 residency                        programs,                there      are over           180 fel-            a formal resident      tracking    system,  I am going                                 to recommend
lowships  listed  in the third edition      of the Advisory      Com-                                                                        to the Board   of Directors                         that we establish   an ad hoc com-
mittee on Orthopaedic    Education      book on fellowships.       Are                                                                       mittee to re-evaluate     the                      possibility  of a “candidate   mem-
there too many fellowships?        Shouldn’t     all fellowships    be                                                                       bership”            status         to bring        the     young         orthopaedist            into      The
evaluated,                   approved,                     or    disapproved                  through          some            mech-         Academy    at the earliest      possible     date.    I am also going    to
anism?            I personally                       support             a proposal                whereby           the Ortho-              recommend     that this committee        evaluate    our entire Academy
paedic        Residency                        Review                 Committee               would          work       together             admissions    procedure      to see if we can’t shorten          the time
with       the             specialty                societies             to first          establish          the      required             from completion         of the residency          to induction  into The
criteria for fellowships        and                                     then have             the RRC evaluate                         all   Academy.
of the orthopaedic       fellowship                                        programs.             This task could                       be         Another                 recommendation                  concerning             the needs           of the
carried           at the time of the review  of the residency    programs.                                                                   young         orthopaedist              came    from            the Board      of            Councilors,
Further,            when indicated   and when requested,      I would hope                                                                   when        they strongly              recommended                 that a special             continuing
that the American                              Board of Orthopaedic                                 Surgery    could work                    education            course          for the       young       orthopaedist                be developed
with the specialty                              societies to develop                               the specialty     exam-                   and added    to our                  continuing      education  course                       schedule.   It
ination,          and finally,                       that the American                        Board       of Orthopaedic                     will include   such                  things     as how to locate     and                     set up your
Surgery,   again with                                  the cooperation      of the                         specialty             soci-       office,   the use of office computers,              dealing      with workers’
eties, would develop                                   a certificate   that would                          comefrom                the       compensation       cases     and litigation       cases,      writing   reports,
ABOS.                                                                                                                                        how to determine        charges,   understanding           PSRO’s,      HMO’s,
          I believe                 that this mechanism                                     will work for most of                            PPO’s,     DRG’s,     government       intervention         and regulation       of
our      orthopaedic                   specialty societies                                 and will help to create                           the practice    of medicine,      and many other subjects.                Such a
continuity    of orthopaedics       and prevent    fragmentation.     Let                                                                    course        has been          developed              and will        be produced            in Decem-
us create an implosion        of orthopaedics    and not an explosion                                                                        ber.
of our parts!    I realize    that this proposal    can produce    some                                                                              Challenge              number    four is to increase                         our     support        for
special           problems                 for the Hand                       Society,            which       has members                    research      funding            in the field of musculoskeletal                             diseases.        It
in general                  surgery,                plastic           surgery,          and       orthopaedics.                How-          is estimated              that between          35 and 50 million    dollars  is needed
ever, negotiations      are currently    underway         between     the three                                                              each       year     to support          research     in the field of musculoskeletal
sponsoring      boards       plastics,   general-     surgery,     and ortho-                                                                diseases,           and      we are far short              of that        goal.     For example,                in
paedics         to cooperate
                   -               with each other to form a single                                                                          1983 the primary    source                          of 16.5            million  dollars           was the
examination.       Then the successful         candidate       will receive     a                                                            Musculoskeletal  Diseases                          Program            of the National           Institutes
certificate                 from         the board                of the candidates’                       basic       specialty             of Arthritis,     Diabetes,  Digestive                              and Kidney       Disease.      One
designating                    special                interests            or       qualifications,                 etcetera           in    million     came from the Orthopaedic                                  Research     and Education
hand   surgery.                                                                                                                              Foundation,      and roughly     800,000                              dollars   from practice          in-
      Challenge   number     three is to let us meet the needs of                                                                            come and from local institutional                                    grants.    You can see that
the young orthopaedist.      While there are over 1 1 ,000 fellows                                                                           the funding      is grossly  inadequate                               for our research        efforts.
of The American      Academy      of Orthopaedic  Surgeons,    there                                                                         However,    there may be light at the end of the tunnel                                           because
are roughly                    a total              of 2,700       orthopaedic                        residents  and an-                     for the past three years intense    efforts have been                                             made to
other  2,600                    young                orthopaedists         who                     have finished    their                    create       a new           and     separate          institute.        Bills      submitted           to the
residency                   who          are         not        yet      eligible           for     fellowship             in The            Ninety-seventh                 Congress            came        very       close      to passing,           and
Academy.                     This     latter figure can expand                                     up to 3,000    young                      I’m       happy       to report         that    on November                  17,     1983,      Bill     2350
orthopaedists,                      depending     on the number                                    of people   who take                      of the Ninety-eighth         Congress       did pass the House       of Rep-
a specialty    fellowship                                   -      which            does not count as part of                                resentatives,    creating       a separate      National   Institute   of Ar-
the continuous       two-year                                   practice            requirement  before taking                               thritis     and Musculoskeletal           Diseases.      We are anxiously
the American                      Board  of Orthopaedic     Surgery       examination.                                                       hoping            for the passage              of this       new        institute       by the         Senate
This means                     that there are approximately         5,000     young    or-                                                   -    Senate Bill 773.
thopaedists,                   or almost half                            of the total fellowship                          of The                    In addition,    the Orthopaedic             Research     and Education
Academy,                     who are not yet,                            but hope to someday                            become,              Foundation       has greatly      expanded       its activities    and requests
fellows        of The Academy.       I believe    that we need to get these                                                                  for orthopaedic       solicitations.        They     have been able to in-
young         orthopaedists  involved       in The Academy     at an earlier                                                                 crease their yearly available           research      funding    from 100,000
date.        For            example,                  the        new        fellows           in the         audience,              the      dollars        in 1981 to over                 one million  dollars    in 1983.                          Their
class      of 1984                 who         did      not       take      a fellowship,                 completed              their       Board         of Trustees  has                 been very active     in increasing                           the
residencies                   in    1980!              Those            who         took      a fellowship               finished            voluntary            contributions              from       Academy               members         and,      im-
in 1979                -    almost five years ago! I believe                                                that this is far                 portantly,     from     public     corporations.       OREF     has                               recently
too long               a period of time to have to wait from                                               the completion                    formed     a long-range        planning      committee    to study                                the fea-

VOL.      66-A,            NO. 5. JUNE              1984
804                                                                                                         C.         A.    ROCKWOOD,                JR.


sibility         of    creating              a public          foundation             for      orthopaedic                      re-   submitted              to Congress,                  would           apply            DRG-type            federal            and
search. However,                         before     the OREF                     or a public    foundation                            state      controls           to all patients,               notjust                 Medicare        and Medicaid
can seek further                      contributions      from                   public corporations        and                        patients.              The House   Ways      and Means    Committee                                                 recom-
foundations,                  there          must       be     an      increased            participation                    and      mended                forcing all physicians     who serve Medicare                                                   bene-
commitment                    from       individual             orthopaedic              surgeons             .    Neither            ficiaries           to accept Medicare’s     rates                                  as full payment,    without
private           industry             nor      the        public        will      support           our          research            allowing             them to charge   the patients                                   for costs incurred   above
effort      if we do not                     support          it ourselves.                                                           these       rates,          and       this      was      just         narrowly              defeated.             Further,
           The      fifth challenge                    to the fellowship                     is to become                     in-     there is consideration                         underway  to reimburse  the physicians
volved           with socioeconomic                        and legislative                     issues. This                  ac-      on a DRG-type         plan                    and to have them collect   their fees for
tivity cannot     be done completely         by your Academy        you                                            -                  inpatient             services           from       the hospital!
personally    must get involved.         The days of the pragmatist                                                                              The        reason          I present           this         socioeconomic                      information
who says,     ‘ ‘I’ll just continue     to practice   good quality   or-                                                              is to alert             you       that       you      must           get        involved          with         legislative
thopaedics    and I’ll ignore       the influence   of government    in-                                                              processes               to understand                 the tremendous       changes    which    are
tervention,  and somehow                                  everything               will turn out okay”,                               in store              for you.      You               must   make    plans     for the ‘ ‘future
are long gone. Certainly                                there have               been many changes      in                            shock’  ; that is, increased
                                                                                                                                                      ‘              competition    between    physicians;
the practice     of medicine,      but I believe     there will be more                                                               what will be in store for us if “gate      theory”    is successful,
changes     in the practice    of medicine     in the next two to three                                                               whereby    all patients   must be seen first by the family        prac-
years   than there    have    been   over  the past     100 years! There                                                              titioner and then, if indicated,                                    referred     to the specialist;    an
is an old             saying,          “Fat         Cats      Don’t         Hunt”.           I believe                 for   the      increase  in the risk of liability                               actions     coupled    with the rising
most       part        that     orthopaedists                  have       been       and       are     “fat            cats”.         cost or malpractice     insurance;                                 an increase       in the number     of
Traditionally         we have     had excellent        practices,    good     in-                                                     allied health-care     providers      and limited        licensed       practition-
comes,        and belonged     to the right clubs,         but have not had                                                           ers; an increase     in the number       of free-standing,             across-the-
the time to involve           ourselves    in the socioeconomic             and                                                       country  chains of walk-in        emergency       centers;        financial      prob-
legislative      processes.                                                                                                           lems and competition           between      hospitals;         competition          be-
        Most      Academy      manpower       studies,       the Mendenhall                                                           tween   private    hospitals     and teaching          institutions;        and the
study,      the GMNAC        report,    and AMA         surveys   reveal    that                                                      gradual             erosion          of your          practice             referral         base       because           your
there are too many                             doctors,          including            orthopaedists,      and                         patients            now       have       to see Dr.              ‘   ‘X’    ‘   ,    the orthopaedist                for the
that the availability                           of the         health-care            dollar     is going   to                        PPO         who        looks         after      the employees                         of the company                  where
steadily    decrease.      The national                              bill for health care for 1983                                    your patient     is employed.        Decreased      funding      and DRG caps
is estimated       to be 360 billion                                dollars.   This is 10 per cent                                    will produce        a decrease       in money      for the design        of new
of our gross        national   product                              and more than the national                                        orthopaedic       surgical     implants.      All of these        future  shocks
defense           budget.            The     cost of medical care                      for the past twenty                            along      with a decrease         in the over-all        availability     of the
years       has       risen       12       to 14 per cent a year,                      which is triple the                            health-care     dollar     will produce      some very real problems.
4 per cent               increase   in the over-all consumer                                       price index.                               Please  remember        that despite     the fact that there is and
Health-care               costs have been the fastest    rising                                   cost of doing                       will       be       more       and        more         government                       intervention              into       the
business  and the most inflationary       factor  in our American                                                                     practice            of medicine,                more         competition,                   and more              changes
economy.    Big and small business       and corporations   who in                                                                    in the way                  you practice  medicine,      we still                                   have the best
the past have paid ‘ ‘carte blanche’ ‘ for all of the health care                                                                     health-care                system  in the world.    Throughout                                      all of the new
of their employees   are asking    themselves,     ‘ ‘Can we afford                                                                   changes      that will come upon us we must maintain          our in-
to continue paying     medical   bills on a fee-for-service                                                   basis?”                 tegrity,    honesty,    and dedication    to medicine.    We must re-
Chrysler   Corporation      pays 373 million        dollars                                                a year for                 member        not to stretch     the principles     laid down  in the
health-care     insurance,        which adds 600 dollars      to the cost of                                                          Hippocratic       Oath.
every     car that they produce.          More and more corporations                                                                          The sixth and final challenge           to the musculoskeletal
are now asking,         ‘ ‘Should     we not put the health-care     benefit                                                          family     is to urge you to maintain      your activity     in continuing
package     out to bid to PPU’s           and HMU’s            like we put out                                                        education.        Our Academy       is a band of scholars          working
for bid our paint,     bolts,     light bulbs,      tires, etcetera?”                                                                 together      in the pursuit of possession       of knowledge.       Fellow-
       How much      longer      are physicians          and hospitals     going                                                      ship in The Academy           means    a lifetime     of learning.     Think
to be paid on a fee-for-service               basis?       Probably    not very                                                       of the operations and treatments   that you are                                                            performing
long! In an effort for the government                to curb rising hospital                                                          today that you did not learn in your residency!                                                             This came
costs,   payments   to hospitals        for Medicare          patients  are now                                                       from        your          continuing               education               efforts,         of whatever                  type.
based   on 468 diagnosis-related           groups;      the DRG reimburse-                                                            The        primary            goal       of our        Academy                      is to offer          you      the very
ment        schedules!       Even   with                        this      mechanism                  in place,               the      best annual       meeting,       instructional        course     lectures,      contin-
DRG         system     is expected       to                    delay        bankruptcy                of the             Med-         uing education        courses,      video programs,           psychomotor         skills
icare      hospital     trust fund by                         only a few years - to 1990 at                                           workshops,       self-assessment           examinations,        and publications.
best!      Most legislators        believe                        that even more drastic    mea-                                             The    latest     development           in continuing           education         is
sures      must be taken to reduce                                the costs of health care. The                                       known      as “Orthopaedic           Knowledge           Update     I, Home Study
Health        Care     Cost Control                           Act of 1983,     which   has been                                       Syllabus”.      To date, over 8,000 copies have been distributed


                                                                                                                                                                                   THE      JOURNAL              OF BONE          AND     JOINT         SURGERY
                                                                                        KEEP    THE      FAMILY          TOGETHER                                                                                           805

and       per cent of the orders
           80                            have been from Academy                                                   will     operate           on a repeating           three-year           cycle.            A document
fellows!   This is a special    project     developed     by an ad hoc                                            recognizing            the educational             achievement                  will       be presented
committee      of the Committee     on Education.        We are greatly                                           to Academy               fellows    who          successfully                 fulfill       the require-
indebted   to Dr. Marc Asher and his ad hoc committee,                  who                                       ments.
produced     the Home     Study    Program.        It is a thoughtfully                                                  There   are three steps to participation:                                   First,    the mdi-
prepared review                      of the orthopaedic            literature of the past four                    vidual    must obtain   the Academy’s         new                              Home       Study    Syl-
years and was                       developed     to use         as a personal,     self-paced                    labus    and the Orthopaedic      Self-Assessment                                      Examination
continuing               medical     education                program. It is an excellent                         and then return     the completed     score-sheet                                from the exam-
review     of           orthopaedics        and             will be of immense    help to                         ination   for anonymous         scoring.     Second,       you must accu-
prepare           you         for     the    Orthopaedic          Self-Assessment               Exami-            mulate   1 ,000 continuing      education      credit points in the three-
nation          which      will be sent            later this year to each person   who                           year cycle     between     January       1 , 1984 , and December        3 1,
ordered           the     Home    Study             Program.    Both the Home     Study                           1986.   Third,     you will be responsible             for completing   the
Update    and             the Orthopaedic                  Self-Assessment               Examination              form documenting         your educational         achievements.
are designed                to be available                to the fellowship              every three                      Complete     details    for participating     in this voluntary                             pro-
years.                                                                                                            gram      are described       in the January       1984 issue of The                               Acad-
           Another  significant                    innovation      in education                has     also       emy’s          Bulletin.        I hope       that     each           fellow         will      choose           to
come        from the Committee                       on Education.      Beginning                in Jan-          participate          and     thereby     continue        and         expand         his or her          com-
uary 1984, Academy             fellows                      became      eligible     to earn rec-                 mitment       to lifelong      learning.
ognition      of their   continuing                         education       efforts    by partic-                         Ladies    and gentlemen,           while I have                    presented      six chal-
ipating     in the new voluntary                               Urthopaedic          Educational                   lenges,     I believe      that the single         most                 important       challenge
Achievement        Program.        The                     OEAP       was developed           in re-              has to do with maintaining                   unity    in                the musculoskeletal
sponse     to requests     from the                        fellowship       and the Board          of             family.      A strong       loving      and trusting                    family      is the single
Councilors      for a meaningful                           way to demonstrate            and doc-                 most important           unit in our society                     -       it means      more than
ument the efforts      of the fellows                          to maintain       knowledge       and              fame          or fortunes.         We     must       always            keep        a place        for     the
keep       abreast            of advances          in orthopaedic            surgery.        This      vol-       family    around     the dinner table.   Please join me in an effort
untary           program,             in conjunction           with    the   Home          Study       Pro-       to continue      our open communications           and trusts so that we
gram            and     the         Urthopaedic            Self-Asessment               Examination,              can keep the orthopaedic        family    together.




VOL.     66-A,        NO. 5, JUNE           1984

				
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