by James D. Hundley, MD

As we age, we trend toward different functions special to others and ourselves.  Think graduations and weddings when younger.  When you get older, however, memorial services become common.  Sometimes they’re for younger people, and those are really, really sad.  Of particular importance to this message, young people attend the funerals of young people in droves and the conversations and testimonials focus on early accomplishments and potential.  What I suggest, however, is that younger people should also attend some memorial services for old people even if you don’t know them well if at all.  There you can learn what was accomplished in a long life and perhaps discover what is important to those left behind.

While attending a memorial service recently it occurred to me that some great lessons in life could be learned by attending one.  Maybe it should be required of all students.

The fellow who died was an elderly gentleman with whom I had served on our hospital board.  We became friendly then but only rarely saw each other afterwards.  All I really knew was that he was a quiet, intelligent man who cared deeply about others and did his best to make the world a better place.

Upon reading his obituary and then when at his memorial service I learned what was really important to him.  Yes, he excelled at his profession (professional engineering and then management of a large plant of an multinational company) and he was a great public servant (active in his church, chair of our hospital board of directors, and so on) and those were discussed.  What really struck me was that his work, although important, was not the most important thing to him.  His family, other people and his religion came before his work.

He took his work seriously and worked at it very hard.  To rise to the level that he did in such a large company, he had to.  He had balance in his life, however, and never forgot his family.  That was made abundantly obvious by the testimonials made at the service.

Having been in the medical profession for over half a century, I have observed many physicians who act as if the only really important function in their lives is the practice of medicine.  Yes, one must take what we do in medicine seriously, but we must also realize that other aspects of our lives are important, too.  We cannot allow ourselves to be totally consumed b our profession.  If we’re fortunate enough to have a family, we must attend to them, too.  Not only will it be good for our spouses and children, it will be good for us, too.

So, if you want your life to be remembered in a great way by the ones you love and who love you, please take this advice.  Attend a memorial service or two and figure out how to make it happen.  It’s common to speak of planning for “End of Life” these days.  Well, if we look forward long before the end, we’ll be happier at the end of our lives if we like what we did during them.

Dr. Hundley is a retired orthopaedic surgeon and the founder and president of OrthopaedicLIST.com.

by Augusto Sarmiento, MD

The metamorphosis of our profession over the last several decades prompted me to publish an article in the January/February 2015 issue of Current Orthopaedic Practice. Following is a summary of that article:   

The spectacular growth of Orthopaedics in recent decades has primarily been due to mostly-beneficial technical innovations. Much of this growth, however, is threatening our historically high professional standards.

As modern orthopaedics is based mostly on surgical treatments, the teachings of biological foundations have taken a back seat. Thus, the orthopaedist of today is evolving into a “cosmetic surgeon of the skeleton” rather than a surgeon/scientist.

Our orthopaedic discipline has fragmented into sub-specialties. This fragmentation creates problems, particularly in smaller communities where orthopaedists should be prepared to treat most orthopaedic conditions.

Chiropractors, osteopaths, nurse practitioners, and operating room technicians are responding to the impending orthopaedic crisis by seeking to expand their territories, allowing them to perform procedures long considered to be the exclusive domain of medical doctors. The State of Florida’s Health Care Force Innovation is considering a request from Nurse Practitioners to allow them to prescribe medications, including narcotics. In New Jersey, physician assistants with doctoral degrees are lobbying to carry out procedures long under the dominion of medical doctors.

The ongoing Justice Department investigation of what it has called ‘‘egregious unethical transactions’’ and a ‘‘corrupt relationship between industry and orthopaedics” has produced nothing.

We have failed to respond to the increasingly greater control of our destiny by industry, allowing it too much influence over the content of our continuing education and research.

Our discipline has established orthopaedic guidelines, which will encourage complacency by pushing practitioners to accept without question their recommendations. Fear of litigation arising from failing to follow the guidelines will inhibit new ideas and treatments and reinforce the herd mentality.

A number of nations and empires, no matter how powerful and solid they seemed to be, failed not from invasions but from suicide. This could be the ultimate fate of our profession, which is experiencing major changes.  It is our responsibility to resolutely address the challenges that these changes present.

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and Past-President of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com and has guest authored a number of other articles for this blog.

by James D. Hundley, MD

A Case for Encouraging, not Discouraging, Orthopaedic Assistants

            A wise person has been quoted as saying, “For every action there is a good reason and then there is the real reason.”  I wonder if something like that that may apply to the position being taken by the American Academy of Physician Assistants (AAPA) in regards to the American Society of Orthopaedic Assistants (ASOA).  As I understand it, the AAPA has taken a position opposing the licensing of Orthopaedic Assistants based on brand infringement and an inadequate knowledge base.  Is it really about patient care or is it about turf protection?

In the first case, the ASOA has conceded the use of the word “Physician” in the name of their organization.  They are no longer the American Society of Orthopaedic Physician Assistants but are now the American Society of Orthopaedic Assistants.  Thus, that argument has become moot.  If there is an argument against their knowledge, based on my my long-term experience with an Orthopaedic Physician Assistant (OPA) and many years as a member of the National Board for Certification of Orthopaedic Physician Assistants I beg to differ.

The OPA with whom I worked for over thirty years was highly knowledgeable and served as a valuable member of our team.  His services in the operating room, the hospital, and the office were invaluable.  He not only made me more efficient, he made me better, which allowed us to deliver better patient care.

My role on the National Board was helping to update the written certification examination every two years.  This process was directed by a nationally known, professional educator and performed by board certified Orthopaedic Physician Assistants and Board Certified Orthopaedic Surgeons.  The questions and answers were evidence-based, pertinent, and difficult.  As with other boards, candidates were required to have a certain amount of experience before being allowed to sit for the examination.  From my detailed review of the questions, both experience and appropriate education were required to pass it.

The issue that should be getting the attention of all medical organizations is the impending growth in medical manpower needs.  The population is aging; we hear that 10,000 Americans turn age 65 every day.  Population growth is outstripping the growth of medical providers.  Medical schools will not be able to keep up with the number of physicians needed.  New schools are being opened and old ones are expanding, but they simply cannot turn out enough additional physicians quickly enough.  I believe that the void will have to be filled with physician extenders.  The greatest numbers will be physician assistants and nurse practitioners but I believe that there will be an important role for trained orthopaedic assistants as well.

The roles will be different and physician assistants should well know that.  Their roles and, therefore their licenses, are different from physicians.  Orthopaedic assistants will have to perform within their licenses, too, and I believe that they are prepared to do so.

So why is it important for Orthopaedic Assistants to be licensed by their states?  Along with being certain that they are certified and qualified, the issue of payment is huge.  If they are not licensed, third party payers will not pay for their services.  That means that the surgeon would have to pay for the assistant out of the ever-diminishing compensation he receives for a surgical case.  Alternatively, he could use another surgeon as an assistant a level of compensation higher than an OA.  Thus the surgeon is incentivized to involve another surgeon in his case at a greater cost to the system and at reduced efficiency; the other surgeon should be treating his own patients.  If an OA can assist just as well (often better in my experience) the above arrangement makes absolutely no sense.

My message is simple:  Stop obstructing the licensing of Orthopaedic Assistants.  Encourage it!  There is plenty of work to go around now and there will be more in the future.  Our medical system will need all of the help it can get.  We need highly trained Orthopaedic Assistants and they need to be licensed and adequately compensated.

Dr. Hundley is a retired orthopaedic surgeon and a founder and the president of OrthopaedicLIST.com.

by James D. Hundley, MD

As a physician and surgeon, I’m often asked who to choose to do someone’s surgery.  The frequency of these questions has grown since I retired from my orthopaedic practice.  I don’t have any advice about how to pick one’s primary care physician or internal medicine specialist but here’s what I think in terms of how to pick your surgeon.

There are a few ways that we as surgeons can evaluate our peers but in terms of technical abilities, we may not be the best judges.  Here’s where I think we can be useful:

1. Decision-making:  It’s extremely important to know not only how to operate but when to operate and when to not operate.  When we discuss cases with others and hear that they operated on someone we thought would be better treated non-surgically, we learn something important about them.  Likewise, when we think that they should operate but don’t, we have an opinion on that, too.

2. Second opinions:  We learn a lot about other surgeons when we see their patients for second opinions.  That’s a very small number, however, so it’s only a glimpse and not necessarily all that helpful.

3. Complications:  When surgeons’ patients have complications it’s not unusual for those patients to seek other surgeons for opinions and/or resolution of problems.  This is an opportunity to judge decision-making and technical performance.

As for technical expertise, however, you may want to look to someone other than a surgeon.  Although we see one another frequently in the corridors and locker rooms of the surgical suite, we don’t spend a lot of time watching others operate.  We’re busy doing our own work so we’re not necessarily the best critics of another’s skills.  That said, who do you ask?

Here’s my opinion:

1. Operating room nurses (actually the entire OR staff)

a. Pros:  They work in the OR day in and day out and get a broad exposure to surgeons.  They see how they prepare and how well they carry out their procedures.

b. Cons

i. People tend to be complimentary of those they like and/or treat them well and derogatory of those who treat them badly.  You’ll have to work your way through this to get a useful answer but the answer is there if you can tease it out.

ii. Questions like this really put them on the spot and some nurses may be reluctant to give you a specific answer.  Again, it’s up to your own communication skills to learn what you can.  Sometimes you’ll just have to move on and ask someone else.

2. Product representatives

a. Pros:  In orthopaedics especially, manufacturers’ representatives are often physically present during operations where their products are being used.  Thus, they likely observe as many or more different surgeons who use their products as anyone else.

b. Cons:  They are conflicted in that they want surgeons to use their products so they might be incented to recommend those who do.

3. Physical Therapists and Occupational Therapists

a. Pros:  Although they don’t see the operations themselves they see patients in objective ways such as how the incisions look after surgery and the stability and function of the replaced joint.

b. Cons:  None that I can think of unless they work for a particular surgeon or group and then they would at least have a theoretical conflict of interest.

4. Patients who have had surgery themselves and their families

a. Pros:  They have had surgery and thus experience with a surgeon.

b. Cons

i. Tunnel vision:  Unfortunately their opinions are based on a cohort (i.e. a group) of one (i.e. themselves) so if they did well they may be overly happy and if they did poorly they may be unjustifiably unhappy.

ii. Patient opinions can be heavily swayed by how kindly they perceive that they were treated by their physicians.  Thus, their opinions of the quality of their surgery can be swayed by that perception.

iii. Patient expectations are variable.  If they think they should be made “normal” by surgery they will be likely be disappointed.  Realistic expectations go a long way toward satisfaction in the outcome which goes a long way toward satisfaction with the surgeon.

iv. Rehabilitation is extremely important in orthopaedic surgery.  Highly motivated patients tend to do better than those who are passive and unwilling to do what it takes to make themselves better.  Rehab can be arduous and painful.  The ones who want their orthopaedic surgery to be a magic cure are likely to be disappointed.

Dr. Hundley is a retired orthopaedic surgeon, a founder and the president of OrthopaedicLIST.com, a free, open access, resource website for orthopaedic surgeons and related professionals.

The Backbone of the OR

by James D. Hundley, MD

May 6 – 10, 2013 is National Nurses Week.  Please join the OrthopaedicLIST.com team in celebrating them for their extraordinary efforts.

My exposure has primarily been in the operating room, the PACU, and the wards where they do what is necessary to help patients recover.  Surgeons are generally very good at what they do.  Without nurses, however, we would be lost.

OR nurses prepare the patient, the operating room, the instruments, and help us do what we have set out to do.  If we didn’t have them to do that, we may be able to do one or two cases a day and probably not nearly as well.  Above that, they are typically the most compassionate of caregivers in the OR and their goals are in line with ours:  to do everything we can to help patients do better.

After surgery, nurses take care of patients in the PACU, a time of high risk as they awake from anesthesia.  Because of their skills and competence, we can compartmentalize our thinking and temporarily forget about the patient on whom we have just operated so that we can concentrate on the next.

Then patients go to the nursing floors.  Again, we depend heavily on them to do the right things and they aspire to do the same.  Their training, competence, attention, and compassion make the difference.  We can’t be there all of the time.  There are always nurses there and they know what to do.

Here’s hoping that you fellow surgeons will thank every nurse you see every day, especially this coming week.  As for your nurses, we thank you and hope that you’ll give yourselves a pat on the back, even if we can’t reach out and personally do so to every one of you.

Dr. Hundley is a retired orthopaedic surgeon and a Founder and the President of OrthopaedicLIST.com.