There is an old Southern saying that when you
see a turtle on top of a fence post, you know he had some help getting
there. I would like to thank Dr. John Gartland and Dr. Jim Beaty
for pulling and pushing to get me to the top of that post. I'll
leave to your imagination who pulled and who pushed.
My daughter, Haines, and my son, Robb, are here, and I would
like to thank them both for putting up with this dysfunctional,
egocentric, self-centered orthopaedic surgeon posing as a father.
Finally, and most importantly, I am indebted to my wife, Sissie,
who has made countless sacrifices in her career to foster mine.
She has been my inspiration as we have trudged along together for
thirty-three years. Somewhere along the way I have fallen in love
with her again, and she is, in fact, the inspiration for my remarks
to you today.
My message to you today is simple. We need to fall in love again
- fall in love again with our patients and with our reasons for
choosing to be physicians. Managed care is still in front of us, and
we have not yet overcome all of the hurdles. But for the last several
years, managed care has been our focus and our patients have taken
a back seat. It is time we move from the plan to the patient.
When we graduated from medical school, we took the Hippocratic
oath and were willing and dedicated to take care of anyone. As we
specialized in orthopaedics, we wanted to provide the best care
for anyone with a musculoskeletal problem. Ability to pay never
entered the equation. However, in the new order of business, a patient
is first asked what kind of insurance he or she has, not what his
or her medical condition is. We must turn this around and become
aware of who we are. It has been said that the definition of humility
is knowing exactly, precisely who you are. We are orthopaedists
and orthopaedic surgeons - that is what we do best - nothing more
and nothing less. We are not entrepreneurs, not insurance brokers,
not managed-care gurus, and not the landlords of outpatient surgery
centers. We are physicians treating the patient first. We must fall
in love again with the concept of who we are and what we do best
- treat patients who have musculoskeletal problems.
Several problems have eroded the relationship between the physician
and the patient. Personalized service has been lost and replaced
by speed of service. We've become the drive-through fast-care center.
While the members of the public demand speed and impersonalization
in many aspects of life, they want personalized medical treatment
and a personal relationship with their physicians. Because of the
increased financial burden of managed care, we have been forced
to sacrifice quality of care for quantity of care. And we have spent
the majority of our recent educational experiences learning about managed
care at the expense of our orthopaedic education and thus at the
expense of our patients.
How do we solve these problems? How do we make a change in our
relationship with our patients? As you know, awareness is the first
step toward change. If we are aware that impersonalization and lack
of quality care have crept into our system, then we can solve our
problems in two areas: education and communication. If you are aware
that you have been neglecting your continuing orthopaedic education
and are not happy about the manner in which you relate to and communicate
with your patients, it's not too late to get back that "old loving
feeling."
First, we need to fall in love again with learning. We need to
rededicate ourselves to continuing education so that we can learn
the very best treatment options for the musculoskeletal conditions
affecting our patients. Over the last five years, I have spent countless
hours reading journals, articles, trade papers, and magazines and attending
CME courses on managed care. I have become more familiar with Medical
Economics than with The Journal of Bone and Joint
Surgery or the Journal of the American Academy
of Orthopaedic Surgeons. This is okay if you are a rapid
reader and learner and you have time to keep up with managed care and the
diagnosis and treatment of orthopaedic diseases. But if you are
just average and busy like me, it is quite difficult to do both.
As a result, my orthopaedic education has suffered.
It suddenly dawned on me that I haven't read a thing on the glenohumeral
joint in the last five years. New diagnoses and treatments, no doubt, have
come along, but I haven't kept up because my reading has focused
on managed-care and economic issues. The condition diagnosed in
the past as subacromial bursitis has been split into multiple new
diagnoses, such as rotator cuff pathology, impingement syndromes,
SLAP lesions, and the like. For each of these new diagnoses, there
is at least one new treatment. The bottom line is that I am five
years behind, and all because of my focus on managed-care and economic-management
concerns.
As managed care has settled in, all of the difficult jargon,
definitions, and business concepts have become old hat. So, we now
have the time to renew our orthopaedic educational experience, to
expand our scope of practice, and, as Drs. Heckman and D'Ambrosia
have urged, to stay on the cutting edge of orthopaedic advances and
treatment. We can do this by educating and reeducating ourselves
through AAOS CME programs, both electronic and written, and by being open
to new ideas like alternative medicine. Alternative medicine may
not be orthopaedics, but it often pertains to musculoskeletal disorders. We
should be up to date on alternative care in musculoskeletal disease
and be able to advise our patients of the benefits and hazards of
various alternative modalities. We cannot just turn our heads and
look the other way. Our Academy believes this to be so important
that a new committee on alternative care has just been formed. In
2000, it will provide the membership with pertinent up-to-date information
through publications, CME programs, and electronic media, so that
we can inform our patients about the scientific validity of different
forms of alternative medicine. What a loving feeling it is to know that
the treatment you are recommending to the patient is the latest,
most up-to-date orthopaedic care.
The second area in which we can fall in love again is the art
of communicating. We must reeducate ourselves by listening to, communicating
with, and caring for our patients. The Academy is putting forth
a new public-relations program in 2000 in an effort to differentiate
orthopaedists from other musculoskeletal providers and to send a
message to providers as well as the public, at the local, regional,
and national levels, about what musculoskeletal care we provide.
This program is intertwined with physician-patient communication.
In developing this public-relations program, we learned much about
ourselves. The Public Relations Task Force surveyed two groups:
orthopaedic surgeons and members of the general public. We found
that orthopaedic surgeons would like to be perceived as caring,
compassionate, informative (communicative), accessible, and supportive
of the patient, and also as the primary-care physician for patients
with musculoskeletal disease.
When we asked the public how they perceived orthopaedic surgeons,
they replied that they viewed us as highly trained and educated
and held in high esteem. Neither comment elicits a warm, fuzzy feeling!
That is where the love story ended. Patients felt that orthopaedic
surgeons were somewhat impersonal and aloof, listened poorly, and
were costly caregivers who were difficult to see on short notice.
And even more importantly, they believed that we were not necessarily
the only quality musculoskeletal-care providers. The public did
not care so much about how well we were trained and what degree
we held or whether we were orthopaedists, osteopaths, or chiropractors.
What mattered was whether the caregivers were accessible, caring, and
compassionate; whether we listened and communicated with the patient;
and whether we were flexible with the patient's time. There is a wide
discrepancy in how we want to be perceived and how we actually are
perceived. The old adage that applies here is, "If I could buy myself
for what I'm worth and sell myself for what I think I'm worth, I'd
be wealthy."
One of the most important things we learned from the survey is
that we need to change the image of the orthopaedist as perceived
by patients and providers. But the real message is: first we need
to change ourselves. The worst thing that we can do is to try and
sell something to the public that we are not. So how do we turn
this image around? Can we relearn caring and compassion, or has
the world, and have we as orthopaedists, become too impersonal?
Is it too tough a sell? I think not. The public expects the medical
profession, above all others, to be personal, caring, and compassionate.
Can we be taught the importance of these qualities? The answer
is yes, but we don't have to teach these qualities,
we just have to remind ourselves of these qualities that we already
possess or we wouldn't be in the patient-care field to begin with.
We need to emphasize to ourselves and to our members that physician-patient
communication is the mechanism by which the qualities of caring
and compassion are perceived. But how do we make our fellows listen?
It is not easy, and there are many obstacles:
(1) How do we convince ourselves that there can be physician
satisfaction when being "in the office" is now more of a chore than
a challenge?
(2) How do we convince ourselves that there may be a communication
problem when all we have as evidence is one public-relations survey and
the low awareness among orthopaedists of the importance of patient-physician
communication and its relationship to patient satisfaction?
(3) How do we convince our members that medical errors can largely
be prevented by proper communications with patients and medical
personnel?
(4) How do we overcome the idea that "There may be a problem,
but it's not mine; I am a great communicator."
I admit that I suffer from this last egotistical phenomenon.
I have been seeing patients in the office for twenty-five years,
and not once have I stopped to ask whether the methodical approach that
I use daily is correct. I rationalize that it has to be correct
or patients wouldn't keep coming back. I even have the same little
three-minute lecture that I use for the most common conditions,
and I may repeat it four or five times a day. Do you do that? Besides,
I know how to communicate. I, like all orthopaedists, have a proven track
record. We were captains of our high-school football teams, class
representatives, presidents of our fraternities, and the life of
every party after a little ethanol imbibement. What do you mean
we are not experts on communication?
We need to convince ourselves and our colleagues that proper
communication can bring about (1) increased patient satisfaction
and thus an increase in physician satisfaction, (2) better patient
compliance and support of the physician, (3) greater practice efficiency,
and (4) fewer malpractice suits.
The solution may lie in creating the ideal office encounter.
Dr. Wendy Levinson, who is a pioneer in the physician communication
field and is working with the Academy, has started research in orthopaedic
offices. Orthopaedist-patient encounters are being taped and graded.
Exciting work in this field is being done, such as removing the
words and listening only to the tone. Just listening to the tone
of the orthopaedist's voice can give one insight into the interaction
of the office encounter and how the orthopaedist relates to the
patient. Research also needs to be done on how we relate to the
elderly, to people with disabilities, and to other diverse groups
of patients at different socioeconomic levels.
While this research is being done, we can teach some simple practical
concepts. Know your patient's name. Go into the examination room
and sit down. Establish eye contact. Examine, or at least touch,
the patient. Show the patient the x-rays. Involve your patient in
the treatment plan, and, before leaving the room, make sure your patient
is reassured and understands the instructions. It sounds easy, but
built into these mechanical steps are the hard parts of communication:
(1) listening, (2) asking open-ended question, (3) allowing the
patient to discuss the treatment options, and (4) showing compassion
for the patient.
I am as guilty as anyone in being deficient in the last area.
I often ask, "How are you feeling?" or "Are you any better?" Both
questions are an effort at quantitative objectiveness. But I never say
as a statement of compassion or unconditional concern, "I hope you
are feeling better." What a difference just a few words make. It's not
the amount of time but the quality of time that you spend with the
patient that counts.
Our Academy will also be working on ways to improve office-patient
communications. How do we make our office a place of friendly, caring encounters
for our patients? Betsy Springer will continue to work on patient-satisfaction
surveys, and we are going to ask the BONES organization, which is
a strong association of orthopaedic-practice administrators, to
join us in making office communications friendly.
One of the charges of the new Council on Communication is to
determine how best to communicate our educational message via the
World Wide Web. In 2000, the AAOS will put considerable resources
into its Web site, not only for member education but also for patient
and public education. Patient education on the Web isn't going to
go away, so we need to be involved up front. We must give our patients
and the public correct orthopaedic information and make the Academy's
Web site the gold standard for patient satisfaction and information.
Your orthopaedic practices can sign up to link with the AAOS
Web site and give your patients easy access to patient education
on the Web through your own offices' Web sites. As you can see,
these are exciting times in communications.
Al Ingram once told me that, in a leadership position, one should
keep the ship straight with a steady rudder but also, at the beginning
of one's tenure, try to accomplish two or three significant projects.
My presidential year will be dedicated to communication with the
patient. This year, we will institute CME courses in communications
at the graduate level for our fellows; later, such courses will
be instituted at the resident level and, ultimately, in the medical
school curriculum.
This top-down approach is not ideal. It would be better to start
with the medical school curriculum, but this is not possible. So,
we must start the arduous task by educating ourselves. The American
Academy of Orthopaedic Surgeons will be the leader in the area of
patient communication, the resource from which other specialties
can draw inspiration - similar to our role in the effort to prevent
wrong-site surgery.
A symposium will be held on communication, which will emphasize
(1) how to communicate with our patients, (2) office communication,
or how to make the office "patient-friendly," (3) how to handle
patient-education information on the Internet and e-mail with the
patient (is this good or evil?), and (4) how and what the communicative
message of The Bone and Joint Decade campaign means to orthopaedists
and their patients.
The Task Force on Patient-Physician Communication has recommended,
and we have put into place, several ways to improve communication over
the next three years: (1) Instructional Course Lectures, (2) symposia,
(3) articles in the AAOS Bulletin and the Journal
of the American Academy of Orthopaedic Surgeons, (4) a
mentoring program designed to develop orthopaedic communicators
as teachers, (5) new research tools in communication, (6) patient-satisfaction
surveys, (7) the use of videotapes as teaching tools, and (8) workshops
on communication at the regional level.
When we have taught ourselves the art of communicating with our
patients, we can then start to tell the public through our public-relations
efforts that we as orthopaedists are caring and communicative and
the best specialty to care totally for their musculoskeletal needs.
If we are going to fall in love again with our patients and our
profession, we must first rededicate our efforts to provide our
patients the very best and most up-to-date treatment by reeducating
ourselves through CME efforts. Second, we must rededicate ourselves
to the ideals that led us into medicine to start with: caring, compassion,
and communication.
Please join me in making this the year of the patient. Patients
don't care how much you know until they know how much you care!
Thank you.