Orthopedic surgery is going through a time of remarkable change. Health care reform, heightened public scrutiny, shifting population demographics, increased reliance on the Internet for information, ongoing metamorphosis of our profession into a business, and lack of consistent high-quality clinical evidence have created a new frontier of challenges and opportunities. At heart are the needs to deliver high-quality education that is in line with new technological media, to reclaim our ability to guide musculoskeletal care at the policymaking level, to fortify our long-held tradition of ethical responsibility, to invest in research and the training of physician-scientists, to maintain unity among the different subspecialties, and to increase female and minority representation. Never before has understanding and applying the key tenets of our philosophy as orthopedic surgeons been more crucial.
The changing landscape of orthopedic practice has been an unsettling topic in many of the American Academy of Orthopaedic Surgeons (AAOS) presidential addresses in recent years.1-11 What are the challenges and what can we learn moving forward? In this article, we seek to answer these questions by drawing insights from the combined experience and wisdom of past AAOS presidents since the turn of the 21st century.
Education
Education is the cornerstone of providing quality musculoskeletal care12 and staying up to date with technological advances.13 The modes of education delivery, however, have changed. No longer is orthopedic education confined to tangible textbooks and journal articles, nor is it limited to those of us in the profession. Instead, orthopedic education has shifted toward online learning14 and is available to patients and nonorthopedic providers.12 With more patients gaining access to rapidly growing online resources, a unique challenge has arisen: an abundance of data with variable quality of evidence influencing the decision-making process. This has created what Richard Kyle15 described as the “trap of the new technology war,” where patient misinformation and direct-to-consumer marketing can lead to dangerous musculoskeletal care delivery, including unrealistic patient expectations.3 To compound the problem, our ability to provide orthopedic education in formats compatible with the new learning mediums has not been up to the demand, with issues of cost, accessibility, and efficacy plaguing the current process.3,5 Also, we have yet to unlock the benefits of surgical simulation, which has the potential to provide more effective training at no risk to the patient.4,13 By adapting to the new learning formats, we can provide numerous new opportunities for keeping up to date on evolving practice management principles, which, with added accessibility, will be used more often by orthopedic surgeons and the public.13
Research
Research is vital for quality improvement and the continuation of excellence.5 It is only with research that we can provide groundbreaking advances and measure the outcomes of our interventions.2 Unfortunately, orthopedic research funding continues to be disproportionately low, especially given that musculoskeletal ailments are the leading cause of both physician visits and chronic impairment in the United States.2 For example, the National Institute of Arthritis and Musculoskeletal and Skin Diseases receives only 10% of what our country spends on cancer research and 15% of what is spent on heart- and lung-disease research.2 To compound the problem of limited funding, the number of physician-scientists has been dropping at an alarming rate.2 As a result, we must not only refocus our research efforts so that they are efficient and effective, but we must also invest in the training of orthopedic physician-scientists to ensure a continuous stream of groundbreaking discoveries. We owe it to our patients to provide them with proven, effective, and high-quality care.
Industry Relationships
Local and national attention will continue to focus on our relationships with industry. The challenge is twofold: mitigating the negative portrayal of industry relationships and navigating the changes applied to industry funding for research and education.9 Our collaboration with industry is important for the development and advancement of orthopedics,15 but it must be guided by the professional and ethical guidelines established by the AAOS, ensuring that the best interest of patients remains a top priority.8,15 We must maintain the public’s trust by using every opportunity to convey our lone goal in collaborating with industry, ie, improving patient care.9 According to James Beaty,7 any relationship with industry should be “so ethical that it could be printed on the front page of the newspaper and we could face our neighbors with our heads held high.”
Gender and Minority Representation
The racial and ethnic makeup of the United States is undergoing a rapid change. Over the next 4 decades, the white population is projected to become the minority, while women will continue to outnumber men.16 Despite the rapidly changing demographics of the United States, health care disparities persist. As of 2011, minorities and women made up only 22.55% and 14.52%, respectively, of all orthopedic surgery residents.17 This limited diversity in orthopedic training programs is alarming and may lead to suboptimal physician–patient relationships, because patients tend to be more comfortable with and respond better to the care provided by physicians of similar background.3 In addition, if we do not integrate women into orthopedics, the number of female medical students applying to orthopedic residency programs might decline.3