Monthly Archives: September 2016

It’s (More Than) OK to Do the Right Thing

by James D. Hundley, MD

            As a retired orthopaedic surgeon, I miss the hallway consultations where colleagues discuss cases while trying to determine the best course for our patients.  Fortunately I am still consulted from time to time and get to enjoy sharing ideas and opinions.

A few weeks ago I was called by a young surgeon who was perplexed by what would be best for his patient, an elderly, emaciated, osteoporotic woman with end-stage Parkinson’s Disease.  She had suffered a displaced, four-part fracture of her proximal humerus from a fall.  He had been taught that these need open reduction and internal fixation (ORIF) if the patient is to regain good function and felt obligated to offer that as a choice.  When so offered, she had stated that she did not want surgery but would think about it.  When he called me, he was dreading that she would call him in the next day or two saying she wished to proceed with ORIF.  How should he respond?

For me the answer was easy.  Treat her with a sling and swathe until the acute pain had subsided and then begin gentle range of motion exercises.  Sure, she would never regain function anywhere near normal but she could still use her elbow and hand to eat and for other similar activities.  Even better, she could bypass the possibility of anesthetic complications and surgical ones such as infection, blood loss, loss of fixation, nerve injury, and so on.

Being the one “in the trenches”, however, and having been taught that the proper treatment was operative, the decision-making for him was more stressful.  He felt that the right thing to do was non-surgical, but feared that that would not be acceptable morally and could put him at risk for a lawsuit.  That’s when I reassured him by saying, “It’s OK to do the right thing.”

I’ve always felt that decision-making is the most difficult part of orthopaedic surgery.  Sure, you must have a significant degree of core knowledge to understand the disorder and have an array of treatments at your disposal.  Probably the biggest decision is whether or not to operate and when if ever to do it.  If you don’t do surgery, how else would you best treat the patient?  If you do surgery, what is the best procedure?  If you run into surprises during surgery, what do you do then?  In every instance, the best decision is what is best for that particular patient at that particular time.  Sometimes, “doing the right thing” requires you to swim against the tide of current opinion and/or what you learned during your training years.  Over time, however, with personal experience and through seeing a variety of perfectly acceptable ways that our colleagues manage similar problems, we can and must learn to trust our judgment as to what is best for our patients.  Thus, no matter which way the fads are pointing at the time, when you include the patient’s wishes and do the right thing, it is always OK.  In fact, it’s more than OK.  It’s what should be done.

Epilogue:  In case you’re wondering, the patient remained steadfast and decided to not have surgery.  Had she requested it, I don’t know what he would have done, but I’ll bet he would have declined to do it.  Thus, although the whole conversation was moot it was interesting and will hopefully help him the next time he is conflicted by what he thinks he should do vs. what he thinks others would have him do.

Dr. Hundley is a retired orthopaedic surgeon with forty years of experience.  He is also a founder and the president of OrthopaedicLIST.com, a free and open-access directory of orthopaedic products and services that was established in 2003 and currently lists over 10,000 products and services for orthopaedic surgeons and related professionals.

Book Review: barebones. A Surgeons’s Tale. by Augusto Sarmiento, MD

 by James D. Hundley, MD

barebones is the inspirational story of a bright, ambitious young man imbued with an iron will and an unwavering inspiration to benefit society through Medicine in general and Orthopaedic Surgery in specific.  This review is not intended to be comprehensive nor do I expect book reports to become a routine of the OrthopaedicLIST.com blog.  It’s simply that Dr. Sarmiento’s life history and his views are so interesting and compelling that I wish every orthopaedic surgeon and resident in training, indeed every physician in the United States, would read it.  As for immigrant physicians, Dr. Sarmiento’s story could well become their Bibles.

The story is well written and describes Dr. Sarmiento’s life and his family struggles when he was a young man through his medical training in Colombia to his orthopaedic residency in the U.S. as an immigrant who could barely speak English to his rise to prominence as an innovator, researcher, academician, and chair of three departments of orthopaedic surgery (two in the U.S. and one in Scotland).  Being elected President of the American Academy of Orthopaedic Surgeons, the largest and among the most prestigious of orthopaedic surgeon associations is evidence of the esteem by which he was held by his fellow surgeons.

As a resident in orthopaedic surgery in the late 60’s and early 70’s I well remember his innovative, dynamic treatment of long bone fractures as it rose to prominence.  I was fortunate to have received my training in a conservative program where the closed treatment of fractures was the first consideration and ORIF was simply one of the choices.  Moving from a long-leg cast to a PTB one for tibia fractures was a huge advance for our patients.

Dr. Sarmiento’s interest and expertise in the treatment of adult hip problems was not as well known, but he contributed significantly to that field as well.

The most compelling message from the book relates to Dr. Sarmiento’s observations of the changes in focus by some orthopaedic surgeons during his career.  Dr. Sarmiento was steadfast in putting the interests of his patients first and foremost while having to fight bureaucrats in hospitals and academic centers as well as politicians and observing and feeling the effects of powerful, fellow orthopaedic surgeons who put self interest before that of their patients and medical centers.

He also documents the efforts and effects of the powerful orthopaedic companies whose “good business” practices were not necessarily “good for patient” practices and believes that these companies have almost taken over the postgraduate education of orthopaedic surgeons.  He believes that the spiraling cost of medical care is one of the unfortunate side effects of that particular shift in source and surgeons practice “cosmetic bone surgery”, surgery that is not indicated for human function.

My only criticism of the book is that Dr. Sarmiento tends to paint our profession with a broad brush of negativity and, like most of us, is concerned that our medical profession will not continue to attract the best and brightest to become physicians.  Fortunately, the numbers and academic qualifications for those applying to medical schools have never been higher.  Hopefully those people will also make good doctors, a concern also addressed by Dr. Sarmiento.

I wish that I could require every orthopaedic surgeon, resident and practitioner, to read Dr. Sarmiento’s barebones.  As that is not within my power, I can only hope that this brief review will entice more to do so.

barebones.  A Surgeon’s Tale by Augusto Sarmiento, MD, Prometheus Books, 59 John Glenn Drive, Amherst, New York 14228-2197, www.prometheusbooks.com, Published 2003, 379 pages

Dr. Hundley is a retired orthopaedic surgeon living in Wilmington, NC and president of OrthopaedicLIST.com.

Own The Bone

by Douglas Dirschl, MD

In the fall of 2008, I wrote an article for OrthopaedicList.com about the high prevalence of fragility fractures in the United States, how only 20% of Americans sustaining a fragility fracture received the appropriate evaluation and treatment of their underlying osteoporosis, and how the American Orthopaedic Association had successfully piloted a program called “Own the Bone” to help improve patient care and change physician behaviors related to this issue. Today I write to communicate to you that the AOA’s Own the Bone™ program has been launched nationally and is currently accepting enrollment by hospitals, physicians, and/or communities of practitioners. I encourage you to read on and to visit www.ownthebone.org for additional information.

Own the Bone™ is an evidence-based quality improvement program for patients with fragility fractures. The program endeavors to bring together hospitals, providers, patients and communities around improving the lives of patients with osteoporosis and fragility fractures. Own the Bone™ is designed to prevent future fractures in patients who have sustained fragility fractures by increasing the application of current evidence-based guidelines set forth in the National Osteoporosis Foundation Clinician’s Guide to the Prevention and Treatment of Osteoporosis and highlighted in the 2004 Surgeon General’s Report on Bone Health and Osteoporosis.

The goals of Own the Bone™ are to assist clinicians in identifying, evaluating, diagnosing, and treating patients with poor bone health after a fracture and improving awareness of the fracture risk. In this program, adherence to evidence-based treatment guidelines is measured. Ultimately, Own the Bone™ endeavors to reduce the risk of secondary fragility fractures in participating patients.

Participation in Own the Bone™ makes it easy for physicians and hospitals to do the right thing for these patients. The program facilitates patient education efforts by providing a downloadable library of patient education materials and promotes guideline-based care through the use of computerized reminders based on patient characteristics. The easy-to-use web interface streamlines submission of data and retrieval of educational materials, as well as completion of the easy-to-use electronic case report form. Data submitted to the Own the Bone™ program is used to develop confidential benchmarking reports for sites to evaluate progress and improve systems of care based on evidence-based guidelines. These reports also allow sites to compare their results against the aggregate results of other program participants.

Participating in Own the Bone™ requires the following:

  1. Enrolling as a site in the program;
  2. Identifying patients > 50 years of age presenting with a fragility fracture;
  3. Screening, educating, and treating patients as appropriate;
  4. Entering patient information into web-based quality improvement registry;
  5. Following up with patients after 60-90 days via a letter or phone call (this is a recommended, not mandatory, step).

The Own the Bone™ registry constitutes a Limited Data Set under HIPAA requirements. The only elements of potentially identifiable Protected Health Information included are date elements and patient ages, so the program may not require full IRB approval at many institutions.

Subscribers are provided with many benefits. Some of the benefits include:

  • Comprehensive start-up materials to help simplify the implementation of the program (available both in hard copy and online through a secure, subscriber-only section);
  • Access to a national Web-based registry, with reporting and benchmarking capabilities;
  • Best practice library;
  • Patient education tools;
  • Physician education tools;
  • System generated Patient and Physician letters documenting the patient’s risk factors;
  • Public relations tools (press release/communication templates and access to a “participating member”);
  • Web-based training;
  • Ongoing best-practice sharing;
  • Electronic newsletters.

The Own the Bone program has been designed to enable a healthcare community – hospitals, orthopaedists, and other physicians and providers – to improve the care of patients in their own backyard. The program can make it very easy to do the right thing for these patients, improve their lives, and reduce their risk of subsequent fractures. I encourage you to refer your hospital administrators, practice partners, and other physicians in your community to the Own the Bone™ website. Additionally, please don’t hesitate to call on me; I will assist you any way I can in convincing your hospital and the physicians in your community that ‘owning the bone’ is in their best interest and that of their patients.

Also, please check out the informational webinar available on the “provider” link at the Own the Bone™ website.

Dr. Douglas R. Dirschl is Frank C. Wilson Distinguished Professor and Chair of Orthopaedics at UNC School of Medicine. He also serves on the Own the Bone Steering Committee and chairs the Critical Issues Committee for the American Orthopaedic Association.

Osteoporosis

by Rebecca Yates, CNM, MN  

            Osteoporosis is the most common bone disease in humans. It is a disease characterized by low bone mass and structural deterioration leading to bone fragility and increased risk for fracture of the spine, wrist, hip, and other bones.  Currently 1.5 million Americans experience an osteoporotic fracture each year which represents 700,000 vertebral (spine) fractures, 300,000 hip fractures, and 250,000 wrist fractures. The number of people with osteoporosis and the resulting fractures are expected to increase significantly in the next 20 years. Every year the healthcare costs related to osteoporosis increase. In 2000 in North Carolina alone the healthcare costs for osteoporotic fractures was $455 million; the projected amount for 2025 is almost $800 million.

The consequences of osteoporotic fractures are serious. Approximately 20% of those who suffer a hip fracture will die within the first year post-fracture. Half of those who experience a hip fracture will never be able to return to their previous level of physical function. Vertebral fractures result in chronic pain, respiratory and digestive problems, changes in body image and physical function, and difficulty fitting into usual clothing.  An osteoporotic fracture is a significant risk factor for another fracture within a year.

One of the major risk factors for osteoporosis for both men and women is age; women are more affected by this disorder than men once they go through menopause and lose the hormone, estrogen. One in two postmenopausal women will experience an osteoporotic fracture in her lifetime. Ethnicity plays a role also as those of Caucasian and Asian descent are at greater risk than those of darker skin races who have heavier skeletal structure. Genetics influence individual skeletal development; therefore, family history of osteoporosis and non-traumatic fracture are risks. Other risks for osteoporosis include: low body weight, inadequate calcium and Vitamin D intake, inadequate physical activity, excessive alcohol intake, smoking,  long-term use of steroid medications, and the presence of certain medical conditions.

The skeleton is living tissue that is being continuously “remodeled” through a process of cells which destroy old bone and other cells that build new bone. This process is balanced in the young adult; however, beginning in the third decade bone begins to be slowly lost. This process accelerates with certain conditions, such as loss of estrogen in women, certain medical conditions, use of some medications, and nutritional factors. The “bone building” cells can no longer keep up with the amount of bone that is being removed.

Osteoporosis is diagnosed by DEXA which stands for “dual-energy x-ray absorptiometry”, a quick, painless, minimal radiation test which evaluates the density of the mineral in the bone. The results of the test help predict fracture risk by demonstrating whether the bone mineral is normal, low, or in the osteoporosis range. Another tool to help predict fracture risk is called FRAX which utilizes data about certain known risk factors to generate the 10 year probability of fracture.

Adequate nutritional intake of calcium and vitamin D is critical to bone health; studies show that intake of both of these nutrients is inadequate in most American diets. It has been recognized that most people are vitamin D deficient; vitamin D is essential for the absorption of calcium and is critical to other body functions. Supplementation of both calcium and vitamin D can compensate for daily dietary deficiencies.

Exercise, particularly weight-bearing or resistance exercises, such as strength training with weights or machines, is important for bone and muscle strength. It has a positive effect on bone growth and improves balance and muscle strength which improves balance and decreases fall risk.

If nutrition and exercise fail to maintain bone health, pharmacologic therapy is available and proven to improve bone density and decrease fracture risk. One category of medications is the bisphosphonates which include Fosamax, Actonel, Boniva, and Reclast. These medications help to slow bone loss. For women, hormone therapy with estrogen may be used for osteoporosis prevention if she also needs estrogen for menopausal symptoms. Evista is a medication called a SERM (selective estrogen receptor modulator) which acts in a similar way to estrogen on bone but is not an estrogen. Forteo is a unique medication that actually helps to build new bone very rapidly and is indicated for people with severe osteoporosis or prior fracture.

Once osteoporosis is present, early diagnosis is critical followed by any needed changes in nutrition and exercise. A healthcare provider can recommend the appropriate regimen of pharmacologic therapy.  Fortunately osteoporosis is a preventable disorder!! By practicing proper nutrition and participating in exercise that promotes bone health, bone loss may be prevented. When low bone mass is detected early, lifestyle changes and pharmacologic therapy can prevent progression to osteoporosis and significantly reduce risk of fracture.  Osteoporosis does not have to be an inevitable outcome of post-menopausal status in women and aging for both genders.

The North Carolina Osteoporosis Foundation (NCOF) is a non-profit organization whose mission is to raise awareness of osteoporosis through education with a particular emphasis on prevention. In 2008 the NCOF funded six educational projects for consumers around the state. In addition to funding organizations to provide education about osteoporosis, NCOF also has a Speakers Bureau of knowledgeable individuals who can participate in community events.

Rebecca Yates, CNM, MN is in private practice in Albemarle, NC and is a member and the secretary of the Board of Directors of the North Carolina Osteoporosis Foundation.

A Case Study: How Park Nicollet Methodist Hospital Implemented Own the Bone™

In a recent Webinar, Dr. Marc F. Swiontkowski describes his experiences working alongside rheumatologist Dr. John Schousboe to integrate Own the Bone at Park Nicollet Methodist Hospital. Prior to enrollment, only 12% of Park Nicollet Methodist Hospital patients admitted for a hip or pelvic fracture received appropriate screening and subsequent care. 

Within Park Nicollet Methodist Hospital’s first year of enrollment in the program, the percentage of patients receiving follow-up care increased to 80%, assisted by the appointment of a discharge-planning nurse to handle appropriate patient screening and data entry.

For more information click on Own the Bone.

Addition information available at OrthopaedicLIST.com.

Implant Identification: An Opportunity for You to Participate

           Having been in the orthopaedic profession for a long time, I have occasionally been confronted with an implant that I did not recognize and either did not have enough time or was unable to find out what it was.  Who hasn’t seen or heard of a bent femoral rod from trauma?  How about the intramedullary rod that had been in a femur for thirty years and had to be removed for a total knee replacement?  There have been a few knee and hip prostheses that had been implanted at “Elsewhere General” and needed to be revised.

                When I looked for a source that listed implants, I couldn’t find one.  That’s when OrthopaedicList.com was conceived.  It has proved to be immensely popular and useful for finding sources of implants, but we needed more.  You still had to know what you were looking for.  The next evolution brought “X-Ray Identification”.

As orthopaedic surgeons and operating room nurses know only too well, removing implants can be tricky and is not always as easy to do as the x-ray might “suggest”.  Various rods have a variety of cap screws, removal threads, locking screws, etc.  You must have compatible instruments.  If you are revising a total joint replacement implant and don’t need to revise all components, it is essential to know the brand and model of the device.  That way you can match compatible components and preserve that which seems better left in place than removed.

It’s always good to get the operative notes from the original surgery, but too often they don’t describe the implants.  The best source I’ve seen are the implant package labels that the OR nurse affixes to the operating room record, but they are not always available either.

For these reasons, at the suggestion of an orthopaedic professor, we started collecting x-ray images of identified implants on OrthopaedicList.com a few years ago.  Since this is something that will always be evolving and since we wish to provide free access to our colleagues throughout the world, we chose the Internet as our venue.  Our library of implants has grown quite a bit, but to reach its true potential it needs to grow a lot more.  To do so, we need your help.  Why would you wish to go to the trouble?

1. More devices are being implanted in younger as well as older patients.  Many will live into old age.  When the time comes to do something, records may be unavailable, the surgeon may no longer be in practice, the surgeons and product representatives who could  recognize these implants may be gone, and so on.  By going to our library of X-Rays (“Implant Identification“), you have a fighting chance of figuring it out.

2. Please remember that what is familiar to you in your time and locale may very well be unfamiliar to someone else in another place or time.  Thus, we are not just looking for what you consider uncommon, but we’re looking for what you implant in your everyday practice.

3. Some implant companies have their own library of images of their implants, but they are predominantly specific to their implants and not necessarily available to everyone.

4. Privacy rules are making it harder to obtain records, even with signed releases from our patients.  I know about that from experience.

5. The world population is aging and people move around.  There will be more and more people with implants.  Add those and you’ll realize that a growing number will need second surgeries in places different from the original hospitals.

6. The educational benefit has been an unanticipated bonus.  We have word that nurse and technical schools use our images to train their students.  We hear that medical schools in some countries do the same.  We even know of at least one large orthopaedic manufacturer who uses our service to train their new representatives.  Furthermore, surgeons can send their patients to the site to see what various implants look like, including some cases that they have performed.

7. Those who give presentations need illustrations for their slides.  You/they can copy the images from “Implant Identification” for those presentations.

8. You can post “unknowns” yourself in hope that our colleagues will help you identify your inherited, troublesome implants.

So, how does one submit an x-ray?  Go to www.orthopaediclist.com and “roll over” “Implant Identification” on the blue navigation bar near the top of the page.  Click on “Submit an X-Ray”.  The rest should be easy.  If you have problems, please let us know at info@orthopaediclist.com.

Oh, what about HIPPA and patient privacy?  Before submitting images, please crop out any information that may identify the patient.  That way we protect patient privacy.  We have a legal opinion that Implant Identification does NOT violate HIPPA policy.

Thanks for your help.  We’re all in this together to the benefit of our patients.

Dr.  Hundley is a retired orthopaedic surgeon with forty years of experience.  He is the president and a founder of OrthopaedicList.com.

How “Implant Identification” Simplified a Total Hip Revision

by Andrew Walden

Ed Note:  The following article is from an e-mail re´ how using Implant Identification helped in a total hip revision case.  We couldn’t have said it better.  Reprinted with permission of Mr. Walden.

I wanted to inform you of a situation in which your website helped us during a hip revision.  I’m sure you already know how valuable your x-ray registry is and it only continues to get stronger with more additions.

I was doing a case in which the surgeon was revising a prosthesis that had no op report and he couldn’t identify the components.  He was planning on revising the stem and shell and was convinced that they were loose.  However, and I think you know where I’m going with this, the stem was solid and would have required an ETO and lots of time to bang out.  I happened to locate the stem on OrthopaedicLIST and from there we contacted the company’s rep and got head options and liner options.  What could have been a long and very difficult revision turned out to be a head and liner exchange and most likely a better outcome for the patient.

Just to offer some feedback…what might make it easier to locate implants would be to subcategorize even further than just primary hip replacemet.  For example, pressfit vs cement, collar vs collarless, taper vs cylindrical, etc.

There used to be a site called that had a good number of x-rays but it appears to be gone.  Now OrthopaedicLIST and xrayregistry.com are the only x-ray identification sites that I’m aware of and orthopaediclist has a much larger database.

Thanks for the site.  I will continue to help add more x-rays and encourage others to do so as well.

Regards,

Andrew Walden

Andrew Walden is an orthopaedic manufacturer’s representative based in Wilmington, NC, USA.  Click on Implant Identification to see the aforementioned “x-ray registry”.

Nicholas Andry’s Symbolic Tree

by Douglas W. Kiburz, MD

Nicholas Andry    Lyon 1658 – Paris 1742

Nicholas Andry holds an important place in the history of orthopaedics and medicine as it was Andry who first used the word “orthopaedics” in a book published in 1741.  Within the text he illustrated the “crooked tree” which has become the symbol for many orthopaedic organizations around the world.  Although many related agencies have taken to modifying or customizing the tree, the essential design remains.

Andry was born in Lyon in 1658 and started his studies in theology but was drawn to the field of medicine.  In 1697 he defended his thesis:  The Relationship in the Management of Diseases Between the Happiness of the Doctor and the Obedience of the Patient.  He became well known for his stand against the “bleeding barber surgeons” and worked tirelessly to limit their venues.

His fellow faculty members depicted him as “superb, spiteful, confused, scornful, irascible and jealous” as described by R. Kohler in the European Orthopaedics Bulletin.  Andry was creative and prolific in his writings.  In 1700 he wrote his first book in which his explanations earned him the title “Father of Parasitology”.  At the age of 80 he published his famous work L’Orthopedie, a two volume set, in Paris in 1741 and it was translated in Brussels in 1742, London in 1743 and Berlin in 1744.

The book had artistic chapters on external proportions, methods of preventing trunk and spine deformities and had suggestions for physical therapy.  In a section addressing limb deformities, Andry recommended a bent leg be corrected by bandaging it to an iron plate as was commonly done to straighten the crooked trunk of a sapling.  From there came the orthopaedic crooked tree symbol, which has stood the test of time, translation and modernization.

Andry died in Paris at the age of 84 not long after having written his famous volume L’Orthopedie.  Kohler reminds us that Nicholas Andry neither deserves to be scorned nor to be revered.  “He produced fundamental ideas on methods of prevention, the plasticity of the child and the importance of gymnastics” and was known for his astute observations and colorful personality.  Few of Man’s whims or drawings or scribblings have survived to become as internationally recognized as the “Tree of Andry”.

Dr. Kiburz is an orthopaedic surgeon practicing in Sedalia, MO, USA and specializing in foot, ankle, and arthroscopic surgery.  He is also an accomplished sculptor who has produced a beautiful, three-dimensional, copper interpretation of the 1741 Tree of Andry.

Operating Room Nurses = Patient Advocates

by Susan Langlois, R.N.

May 22nd, 2009

       I think that operating room nursing is a specialty that is often overlooked as a legitimate form of nursing because our patients are not perceived as being “in our care” but rather in the care of the surgeon and the anesthesia personnel. Therefore, our role is diminished somehow. In all honesty, that way of thinking shows a lack of awareness of the mind set of OR nurses who see themselves as the ultimate patient advocates for patients who cannot speak for themselves.

In truth, to be capable patient advocates OR nurses need to be forceful team members in that operating room. To do this, we really need a comprehensive knowledge of all aspects of operating room patient care. This includes an understanding of the impact on the patient of the anesthesia care as well as an understanding of the anatomical and physiological effects of the actual surgical procedure being performed. This is especially important in orthopaedic surgery, where, in many cases the surgeon is going to “take it apart and then put it back together”. We want to understand how this is going to be done and the expected outcome and challenges for our patient.  I remember many years ago when non-reamed intramedullary nails were first available. Some surgeons continued to ream anyway. I thought to myself, I must not understand the purpose of this reaming – I had always thought it was so the surgeon could get such a snug fit for that nail that it would not rotate in the canal since, in those days, locking that nail was not an option. So I did an informal study of the surgeons and found out that they continued to ream because that was what they had always done and were just in a learning curve for these new locked nails. I did notice that, over time, these surgeons did stop reaming but the explanation was not as scientific as I was thinking it might be!!!

Susan Langlois, R.N. recently retired from active nursing after forty years as an OR nurse.  She has had a vast experience at several hospitals, starting with a U.S. Army hospital in Fort Benning, GA and ending with the Cape Fear Orthopaedic Center in Wilmington, N.C.  She has been a tremendous resource for OrthopaedicList.com for many years.

 

Graduate Medical Education: Issues and Options

by Frank C. Wilson, MD

March 22nd, 2010

Graduate medical education, still in the process of being born, was not mentioned in Flexner’s 1910 landmark treatise on medical education.  The existence now of 8500 residency programs and 127 specialties and subspecialities would, a century ago, have seemed preposterous.

Movement in GME prior to 1985 was largely academic and specialty specific. Curriculum, accreditation and certification, and duration of training were issues for resolution within the house of medicine.  Since the mid-1980s, influences outside of medicine, fueled by explosive population growth, technologic innovation, and social concerns have become dominant players, threatening the foundations of the educational bridge between student and practitioner.  An expanding and aging population and a panoply of therapeutic options have created overriding problems of access and expense.

Among the major challenges facing contemporary graduate medical education are issues related to teaching and learning, evaluation, professionalism, supervision, research training, funding, and manpower.  This book considers the issues in these areas and offers options for their resolution.

Following are excerpts from a few of these topics:

Teaching and Learning

“The search for ways to improve medical education should include a re-examination of the values underlying the profession.  Values shape the world; they should hold pride of place in the intellectual community and drive the educational enterprise.  Unfortunately the ethos that determined them in the past has been blurred by contravening trends of the present.  Propelled by the explosive escalation of knowledge and technology, too little attention has been given to the humanistic values that should determine their use.”

Professionalism

“Among the core competencies, professionalism is the most critical and among the most difficult to quantify. It is the competency which, possessed in full measure, gives rise to the others.  A professional possesses and maintains a unique body of medical knowledge and uses it to provide effective, safe, compassionate and ethical patient care, including the communication skills necessary to help patients navigate through a complex health care system.”

… “professionalism is founded on the pillars of science and service, upon possession of a specialized body of knowledge and skills, and the obligation to use that expertise to serve others before self.”  … “at the heart of this obligation is ethics, and at the heart of ethics is the welfare of the patient.”

“Professionalism is not just a philosophical ideal, nor can it be marginalized by the need for efficiency or productivity. It should be defined according to its characteristic traits, its cognitive base made clear, and opportunities provided to gain experience in its application to daily medical care.”

Manpower: Supply and Distribution

“With specialty choices determined largely by issues of income and lifestyle, fewer students are choosing careers in primary care.  High-tech specialities offer exciting opportunities for cure; but older patients having chronic conditions, are often more in need of care than cure – for someone to be there to guide them through the complex world of health care and to manage multiple diseases and depression. Despite the fact that most of the problems for which a physician is consulted can be handled by generalists, they have become an endangered species.”

“Medical care for the aged drives and will continue to drive, health care in the U.S. for the foreseeable future. By 2020, some 20% of Americans will be over 65, and people over 85 constitute the most rapidly expanding segment of the population, for which all physicians must be prepared.”

“Population trends must be studied, and planning for anticipated growth closely coordinated with the capacity of the U.S. health care system for expansion.  Since resources are finite, and expansion of the physician pool is very costly and time consuming, joint planning…is essential to meet short- and long- term needs for medical services.”

****

 In his Foreword to the book, David C. Leach, Executive Director Emeritus of the ACGME, said: “This is an important book about this most formative time in a physician’s life, the history of graduate medical education, the key issues that consume present interests of medical educators, and the options that the profession and society have for going forward.  It is timely.  Workforce shortages, financial constraints, new knowledge and technologies, and dramatically changing demographic patterns in society pose challenges.  Changes are needed; will wisdom or reflex actions inform the changes?”

 Dr. Wilson is Kenan Professor and  Chief Emeritus of Orthopaedics at UNC.  He is a past President of the American Orthopaedic Association, the American Board of Orthopaedic Surgery, the Association of Orthopaedic Chairmen and the Thomas Wolfe Society.  He received the Thomas Jefferson Award from UNC, and the Distinguished Clinician-Educator Award from the American Orthopaedic Association.  His book, Graduate Medical Education:  Issues and Options, can be found  on OrthopaedicLIST.com.