President Jackson, members of the Board of Directors, Fellows of the Academy, distinguished guests, and members of the Class of 1998:
It is indeed an honor to have been asked to share my thoughts with you this afternoon. It was eight years ago, in this same auditorium, that I gave an address entitled "The Winds of Change."6 I don't believe that any of us realized at that time just how hard the winds were blowing and how profound the changes in the practice of medicine, and therefore the practice of orthopaedics, in this country would be in the ensuing eight years.
We have seen the control of clinical practice wrested from the hands of physicians by the managed-care administrators and the entrepreneurs of the for-profit health-care industry. We have seen the length of hospital admissions and the parameters of hospital care pass from control by the physicians to control by the giants of the insurance industry. As a result of these changes, we have seen the quality of care diminish, ostensibly in the interest of containing the accelerating costs of health care. However, the costs have only increased, with the profits going to the business interests of the health-care industry and to the stockholders instead of being passed back into the system to lessen the financial impact of health care on consumers. There has been a shift of income from quality high-technology medicine, with its necessary research and education, to the pockets of entrepreneurs and investors. Also, and probably most important of all, we are seeing increasing efforts to change the art and practice of medicine into a business, with cold cost-cutting efficiencies and attendance to a profitable bottom line becoming higher priorities than the quality of care and the sensitivity of the caregiver. The magnitude of these changes has been enormous and frequently at the expense of the providers and the institutions that offer the best health care in the world. Health care, with revenues at one trillion dollars a year, has become one of the largest industries in the United States.
The purpose of these remarks is not to belabor these changes but, rather, to give you a single important message, a message that is essential if you are to enjoy a satisfying and productive career in orthopaedics such as I have been fortunate enough to enjoy in the past forty years. There is, and always has been, one constant in medicine and in orthopaedics, and that constant is caring for your patients. No changes in the business of health care and its ensuing profits, no efforts in cost containment, no financial gain by providers can change that constant. The difficulties of providing care under managed-care systems do not change the responsibility of the caregiver to maintain a doctor-patient relationship that is based primarily on caring for the patient.
A very disturbing story was published in the Wall Street Journal last year about a nine-year-old boy who had a stick driven through his cheek to the base of his brain in an accident3. The parents called their health plan for permission to go to a hospital, where, ten hours later, surgeons removed the stick and attended to the laceration. Days later, the youngster was still feeling ill and despite the parents' queries about a relationship between the illness and the previous trauma and their request that a magnetic resonance imaging study be performed, the gatekeeper gave the patient Advil and advised waiting. Two days later, when the child complained of a severe throbbing headache, the parents took him to the hospital and twice asked if he should have a brain scan. Twice they were told that he had a form of meningitis, and they were sent home. Weeks later, because his condition had worsened, he got the scan, which revealed a brain abscess. He ultimately had stunted intellectual development, spasticity, and blindness. This story graphically illustrates how physicians are losing control of their patients because of a corporate bureaucracy that weakens the doctor-patient relationship. An executive from a health maintenance organization was quoted as saying, "We see people as numbers, not patients. It's easier to make a decision. Just like Ford, we're a mass-production medical assembly line, and there is no room for the human equation in our bottom line. Profits are king."3
A strong doctor-patient relationship is essential to successful treatment. A recent survey showed that today doctors spend eight minutes talking with a patient at each visit, which is less than half as much as they did a decade ago. Without a stake in their practice under the managed-care system, some doctors show up and do their job but are less likely to take a personal interest in their patients. An article in AMA News stated: "Medicine is, at its center, a moral enterprise grounded in a covenant of trust. Today, this covenant of trust is significantly threatened. From within, there is growing legitimation of the physician's materialistic self-interest; from without, for-profit forces press the physician into the role of commercial agent to enhance the profitability of health care organizations. Such distortions of the physician's responsibility degrade the physician-patient relationship that is the central element and structure of clinical care."1
A guest editorial in the January 1998 issue of The Journal of Bone and Joint Surgery was written by a pediatric otolaryngologist who related a very negative experience with the orthopaedic surgeon who performed a total knee arthroplasty on her eighty-year-old mother2. The author was extremely disappointed with the lack of communication with her mother's surgeon. The surgeon's side of the story was not told, but it doesn't matter. What matters are the perceptions of the patient and her family in the course of communication or the lack thereof. The author brought out the valid point that there is a difference between fixing and healing, between being a technician and being a physician. We have moved away from being physicians who listen to and look at a patient as a person and not just as an anatomical problem to be fixed—that is, we have moved away from being physicians who care. I urge all of you to read that editorial and never forget the message as you go through your years of clinical practice. It was in the twelfth century when the philosopher and physician Maimonides prayed, "May I never forget that the patient is a fellow creature in pain. May I never consider him merely a vessel of disease."4
Bernard Lown, in his book The Lost Art of Healing, which should be read by every young clinician, quotes a Russian physician as saying, "Every time a doctor sees a patient, the patient should feel better as a result." Often the real problems of the patient are far beyond his or her presenting symptoms, and it is the responsibility of all physicians to recognize this—even if it takes more time than is necessary. It is rare that patients search for alternative therapies when physicians focus on healing as well as on fixing. If one just listens, it often takes very little to make someone feel better.
Advances in technology, which have been the driving force in the practice of orthopaedics in the second half of the twentieth century, have also resulted in increasing subspecialization and an emphasis on fixing the mechanical problem as an entity unto itself rather than as a part of the whole. A diagnosis now is frequently made by exclusion, with the use of expensive tests and procedures that, of course, maximize the incomes of those who do the procedures and also take the attention away from the patient as a person who has a problem; in other words, the problem rather than the human being becomes the focus. We, as physician providers, will never reform our health-care delivery system until the patient again becomes the central figure in the doctor's agenda.
Healing requires a doctor-patient relationship of mutual respect, a respect that needs to be earned by both parties as in any other human relationship. It is only with respect that the doctor gains the patient's trust, and without that trust the doctor cannot heal, regardless of how well he or she fixes. In The Doctor's Dilemma, George Bernard Shaw noted that "all professions are conspiracies against the laity."4 The physician must give the patient an accurate and truthful picture of his or her condition as well as realistic expectations of the result of management. There is no place for unreal expectations or unnecessary black crepes.
The single constant that must remain the bottom line and the keystone of all decisions that you make in your professional life is the physical and mental welfare of your patients. You have become physicians and orthopaedic surgeons because you care about more than your own self-interest. By becoming members of this still distinguished profession, you have incurred a lifelong debt to society, a debt that can be repaid only by keeping the physical and mental welfare of your patients as the prime motivation for every clinical decision you make, every research project in which you become involved, and every medical educational effort that you undertake.
Orthopaedics is a wonderful specialty, and it has given me more than I dreamed possible when I decided to enter the specialty. The American Academy of Orthopaedic Surgeons has given me opportunities to meet and work with people who are extremely productive, to visit and experience many professional activities that otherwise would not have been available to me, and to involve myself in discussion, debate, and education in the broadest sense. This afternoon, you have seen and must have been impressed by the current activities of this Academy. It is an association from which you will gain much during your career and that will ask little from you in exchange. I urge you to participate in its activities and, if not, at least to partake of them. The practice of medicine and of orthopaedics is a continuum of education throughout your entire professional life. The Academy provides the ideal milieu for fulfillment of this responsibility.
I would like to close with a poignant comment that was published in The New England Journal of Medicine in December 1996, a comment that I think applies to our professional life regardless of how far the winds of change take us: "I am still a doctor, destined for more uncertain times, unmanageable days, undeserved rewards, and the inexhaustible opportunity to touch the lives of those I treat. And to change their lives as they have changed mine. Our work bears the stamp of a centuries-old tradition and is carried forward by each new class of physicians … Yea, though we walk through the valley of managed care and our business (if not our soul) is traded on the floor of the New York Stock Exchange, we are lucky to be here, doing what we do, still students of medicine, tending to the afflictions and infirmities of those who call us doctor."5
Welcome to the Academy. Good luck and Godspeed!
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