Mr. President, members of the Board, fellows and guests of the Academy, and, most importantly, members of the Class of 1999:
It is a rare privilege and a great honor to have been asked to address you on this important occasion. It is common at times like this to remind you that you represent the future of medicine and of our specialty, and indeed you do. But it is just as true that your own future will be determined by the future of medicine and that of orthopaedics. Today, as you become a member of one of the largest and most respected medical organizations, you assume increasing responsibilities for the stewardship of your profession and, thus, of your own professional careers.
You have inherited a troubled profession and a specialty confronted with problems that are not of your making. Medicine has not been immune to the materialism and greed that have increasingly characterized society for the last thirty years or more. Some of our own, before your time, weakened medicine by wanting too much, and now the greed of others preys upon our profession and threatens its future.
When I was a child, I learned Aesop's fable about the goose with the golden eggs3. Many of you may recall it as well. It goes like this:
One day a countryman going to the nest of his goose found there an egg all yellow and glittering. When he took it up, it was heavy as lead and he was going to throw it away, because he thought a trick had been played upon him. But he took it home on second thoughts and soon found to his delight that it was an egg of pure gold. Every morning, the same thing occurred and he soon became rich by selling his eggs. As he grew rich, he grew greedy; and thinking to get at once all the gold the goose could give, he killed it and opened it, only to find nothing.
The moral of this story is that greed can eventually destroy one's source of wealth.
Like the countryman, we, too, have our metaphorical geese, or sources of wealth. They may not be readily apparent, for too often we are blinded by the day-to-day issues at hand—issues such as trying to take proper care of all of the patients who come our way; trying to balance our responsibilities to our patients and to our families; fighting with managed-care entities in the interest of good patient care and for our own economic well-being; and, through all of this, trying to keep up with the advances in orthopaedics in order to stay competitive. Unlike my generation, you must deal with a host of health-care-delivery systems; you have a need for business acumen that rivals that of a corporate CEO; and, increasingly, you require a knowledge of coding that could qualify you as a medical-record librarian. Before long, you may become convinced, unfortunately, that medicine really is a business and not a profession.
I suggest to you that the true source of our economic well-being is not the health-insurance companies, the HMOs (health-maintenance organizations) or the MCOs (managed-care organizations), or even the Health Care Financing Administration. Rather, as physicians, our underlying source of wealth relates more to the professional ethic than the business ethic of medicine.
The essence of professionalism in medicine is the willingness of the physician to value the patient's welfare above his or her own and to provide care, when necessary, without remuneration or at personal inconvenience7. It is unselfish attention to the welfare of others and advocacy for our patients that earns the public's respect and trust. These, in turn, have caused the public to support the autonomy of medical practice, including the privilege of self-regulation through licensure and specialty boards and medical peer review. However, this autonomy has begun to erode1,6.
It is true that there has always been a business side of medicine; financial return and economic security are important to us. But if and when the commercial ethic in medicine becomes so predominant that it is perceived by society as greed replacing altruism, we will certainly face an accelerating loss of autonomy and ability to self-regulate and an even greater loss of income. Some believe that we are nearing the point when society will view medicine as a trade rather than as a profession and will treat us accordingly6,11. The recent recommendations of the Pew Health Professions Commission10, if implemented, would require at least one-third of every state licensure board to be composed of members of the public. Further, all physicians would be compelled to pass relicensure examinations every three to five years and would be required to allow state regulators to monitor their work and to periodically inspect their patients' records. This attempt at consumer protectionism through regulation is symptomatic of a deepening public distrust of our professional values as physicians.
Although you are specialists, I urge you to always remember your roots as physicians. Despite the frustrations that you may be experiencing, stay in touch with your profession and your professional values. Do not allow the current invasion of medicine by entrepreneurs to make you, too, indifferent to your patients' needs. Now, more than ever, you need to be their advocates. Failure to do so will destroy the credibility of medicine and the public's trust. Take time to understand what is going on in the battle between commercialism and professionalism in medicine. Advocate for your patients: be a good doctor first and a good orthopaedist second. From time to time, think about how fortunate you are to be so well rewarded, even now, for your service to your fellow man2.
Consider with me now the specialty of orthopaedics as opposed to orthopaedic surgery. In his farewell address to the Academy fellowship in 1985, Dr. Charles V. Heck, former executive director of this Academy, recommended changing the name of our specialty from orthopaedic surgery to orthopaedics5. He did so because he feared the loss of musculoskeletal patients to other disciplines if we were regarded as surgeons only. As early as 1933, Dr. Joel Goldthwait addressed this issue in a paper, published in The Journal of Bone and Joint Surgery, entitled "The Backgrounds and Foregrounds of Orthopaedics."4 In the concluding paragraph, he stated that "…if we choose the operative work only, which is the easier, instead of the harder and more general, some other specialty … will take this over." How very true this turned out to be. In recent years, we have witnessed a virtual migration of musculoskeletal patients to other specialties, including primary care, emergency medicine, physiatry, neurology and neurosurgery, podiatry, and rheumatology8,9.
I urge you not to ignore nonoperative orthopaedics. Our specialty exists to provide care for all patients who have musculoskeletal problems, not just those who are referred for operative treatment. Primary care and rehabilitation of orthopaedic patients within your area of expertise are a part of your obligation as a good orthopaedic surgeon and are even more important than operative procedures in creating the bond between you and your patients. An exclusive focus on operations and operative technology, although more financially lucrative in the short term, will ensure a diminishing scope of orthopaedic practice and will imperil the blood supply of the specialty. Do not allow greed to constrict and attenuate your specialty.
Your success in orthopaedic practice will be determined in large part by the products of orthopaedic research. In the mid-1950s, a few orthopaedic surgeons of vision created the Orthopaedic Research and Education Foundation (OREF). They realized that research is the lifeblood of any specialty and that depending entirely on outside funding for this important function was risky. Thus, today you have the opportunity, if not the obligation, to donate directly to your own research foundation and to be assured that these funds will be invested in the future of orthopaedics and of your orthopaedic practice. Think about how your practice has been enriched by individuals who were supported by OREF during their early investigative years: Akeson, Blount, Brighton, Chapman, Coleman, Enneking, Fielding, Glimcher, Harris, Hughston, Kettelkamp, Mankin, Moe, Perry, Sledge, Sutherland, and Urist, to name just a very few. The products of orthopaedic research are truly golden eggs, and you should forever nourish and cherish these magnanimous geese!
Absolutely essential to the success of your practice and, hence, to your economic well-being, is your continuing education in orthopaedics. Today, you become a member of the premier educational organization in all of medicine. From the beginning, this Academy has always led the way in continuing medical education—from our original sound-slide and film libraries, to the first continuing-education programs, to being the first to produce in-training and self-assessment examinations, to being a major medical publisher, to being the leader in CD-ROM educational programming, and to being the first in surgical-skills education (which has culminated in the establishment of the Orthopaedic Learning Center). You will find that the Academy can serve you in many different ways—as a source of scientific and health-policy information, as an advocate for you and your patients, and as a guidepost for professional and ethical behavior. But the heart and soul of this great organization is education, not only of physicians and health professionals but also of our patients, the public, health policy-makers, and those who pay for health care. The educational products of the Academy help you to be a better doctor and orthopaedist. In addition, income from these products has enabled the Academy to pursue other activities, including legislative and regulatory advocacy roles for better patient care, for the funding of orthopaedic research, and for a host of policy issues such as professional liability and physician compensation. Many of the latter functions will now be assumed by our new sister organization, the American Association of Orthopaedic Surgeons.
Always remember that it is the educational role that not only justifies the name "Academy" but also projects the image of this organization and that of the specialty to the public and to policy-makers. Our accomplishments in the public arena have been possible because we are respected as an organization that is dedicated to the improvement of our patients' health and our ability to care for them. Should we ever be perceived as primarily a self-serving organization or even as self-serving organizations, we will become far less effective in the public domain. I urge you, as new stewards of this Academy, to guard against the greed of self-interest, which could easily divert the majority of our resources from the functions of an Academy to those of a trade association.
Finally, one of your greatest sources of wealth is your family and significant others. Cherish and protect these relationships, which, far more than you may realize, enable your success as a physician and surgeon. You may have many demands on your time, but none are more important than time spent with loved ones, for they will sustain you.
It is now my distinct pleasure to welcome you to the American Academy of Orthopaedic Surgeons. I have reminded you of a few not-so-obvious sources of wealth: the professional ethic, the diversity of orthopaedic practice, orthopaedic research, your continuing education, and the sustenance derived from family and friends. To these, you may now formally add your membership in this grand Academy.
My advice to you is simple: remember, always take good care of the geese!
*Read at the Opening Ceremony of the Annual Meeting of the American Academy of Orthopaedic Surgeons, Anaheim, California, February 4, 1999.
†Shriners Hospital for Children, P.O. Box 31356, Tampa, Florida 33631.