Though medicine in general is rapidly removing myths and preconceived notions about the nature of illness and disease, a trend that Hippocrates started over two millennia ago, and was improved and sustained for a millennium by the teachings of Galen, it has not as yet completed the job. Old, erroneous dogmas are often replaced with new but equally false ones. In orthopedic surgery, this is to a great extent due to the fact that an absolute technical approach to musculoskeletal disease is displacing important biological considerations. Across America, neither residents nor practicing orthopedists are any longer being educated to be surgeons scientists but trained to be cosmetic surgeons of the skeleton, skeletal traumatologists. The higher costs associated with such practices do not receive any consideration. Though hard to believe, many residents who graduate from first-class medical schools complete their training without even the most basic knowledge of the nonsurgical treatment of the vast majority of fractures.

Our collective failure to recognize that the current obsession with the technical solution to all musculoskeletal problems will continue to slow down the progress needed to achieve more enduring responses. Despite our enthusiasm and élan with the accomplishments, thus far made possible through technological means, there should be no doubt that within a short time some of those accomplishments will be obsolete. Reaching a balance between the old and the new, as well as between the surgical and the nonsurgical approaches to orthopedic care must be found, not only for sound professional reasons but for economic ones as well. This is exactly one of the things I attempt to do in this book.

Whether we wish to accept it or not, the major underlying causes for the epidemic of surgery are due to economic factors. In countries like the United States, surgical treatments generate higher financial compensation, the manufacturing industry gains enormous profit from the sale of its expensive devices, and hospitals benefit from the admission of patients and collections from the use of operating rooms, laboratory tests, etc.

Many countries are currently facing a health care delivery crisis that has created an unprecedented level of discomfort at various levels of society. The issues surrounding the crisis are many and complex. It is, therefore, 8ludicrous to pretend there is an easy explanation for the current unhappiness in all quarters. It is possible that organized medicine while attempting to address the crisis has frequently focused its attention on issues over which it cannot have a positive influence and in that manner has squandered its moral power and resources. Representative medical organizations, and to a great extent their constituencies, have for a number of years indulged primarily in the exercise of loud protestations against the reduction of reimbursement for the services their members receive. Despite the reality that such reductions have taken place, physicians are still some of the best-paid professionals in our society. To gain the third party's attention to our complaints has been, and will probably continue to be, an exercise in futility. This pocketbook approach has not succeeded and will probably not succeed in the future.

Vivid in my mind is a visit that I, accompanied with the two other members on the presidential line of the American Academy of Orthopedics, paid to the director of Medicare in Washington, DC. We were there to let her know that if further reductions in financial reimbursement were to take place would soon result in not being able to find orthopedists willing to take care of patients whose insurance was limited to that provided by medicare. She smiled as she listened to our message and said, “Doctors, we know that will never happen because no matter how much we cut down reimbursement you will always increase the volume of your services. We know that your average income still goes up every year.”

Rather than wasting time in bringing the economic concerns of the profession to the forefront, it would be better if organized orthopedics were to concentrate primarily on issues where it has the power and moral authority to influence the outcome of the debate; to show a sincere desire to throw its weight behind the true problems facing the delivery of health care, the plight of the uninsured, the imbalanced provision of medical services to the poor, the loss of territory, the harmful exaggerated fragmentation, the out-of-hand medical litigation, and the no longer affordable or sustainable cost of health care.

The current system of medical care delivery has been found wanting. The hope that if given enough time the “invisible hand of the market” will solve the problem has been a futile exercise. For reasons no longer easily understood, the medical profession and the political powers have been reluctant to admit that medicine as a business cannot work.

Another area where medicine can be effective is in regards to the problems created by the deterioration of professionalism within the medical profession; a lack of professionalism easily demonstrated by the ever-growing abuse of nonessential diagnostic tests, the performance of unnecessary surgery and the acceptance of kickbacks from the surgical implant industry. Unfortunately, organized medicine has not made an effort to address this issue in a serious and earnest way. It seems unwilling or unable to indulge in the necessary self-criticism that the situation requires and finds itself on the defensive, giving its critics a clear advantage.

The relativism that dominates our society has effectively extended its tentacles into medicine in a rapid manner. The traditional tenets that had governed medicine for many a generation are vanishing. The hunger for more that characterizes our capitalist ethos applies to medicine as well. In a society where everything is OK, nothing is morally wrong. To an increasing number of physicians, medicine is just another business in which the methods, values, and ethos of the business sector equally apply. Moral deviations do not seem any longer to bring any stigma whatsoever.

Citing the less-than-perfect conditions that exist in other countries regarding health care delivery, ignores the fact that a perfect system will never be developed anywhere. Deeply ingrained democratic ideas in America, as well as in many other nations, should make possible the creation of systems superior to the failed ones we now have. Hopefully, the lull before final implementation of the ultimate changes that governments eventually will impose should be used by the medical profession to advance its ideas in an unselfish and constructive manner.

The viability of medicine depends heavily on the ability of its practitioners to maintain the highest possible level of education. Since the education of the orthopedist is now virtually under the control by the pharmaceutical and surgical implant manufacturing industry, any hope for rapid change in many existing trends and patterns appears unrealistic. The situation is not hopeless, but remains beset with enormous obstacles. The obstacles have not as yet been carefully analyzed; therefore, a precipitous rush to implement change may prove a big mistake. We need to pause and in a serious manner address the very many and complex issues surrounding the problem.

It is for this reason that orthopedic Registries and Guidelines, which are gaining popularity in higher circles of academia in some countries, may not turn out to have the salutary events we envision at this critical time, despite 9the lofty and sincere goals of their current supporters. These projects should be carefully looked upon under the light of history, which is rich in examples where, deliberately or otherwise, religious or systems of government, aiming at improving the life of the people, established rigid sets of beliefs and conduct, that reached degrees of rigidity eventually to be regretted.

These events can be used as examples or metaphors to justify criticism of a precipitous adoption of guidelines for the treatment of every orthopedic condition. The power that guidelines might gain over time could easily result in a system that rather than providing advice, they became “mandates” with resulting unsavory consequences. They will, very likely, fuel the already excessive medical litigation. We are not dealing with children who for a period of time must be told what is right or wrong, but with adults who have available to them a myriad of vehicles of information so they can make whatever decisions they find most appropriate. Neither the academy nor other similar organizations have the power or moral authority to dictate what treatments are good and which ones are not. Their role is to serve as vehicles for the dissemination of information, so the orthopedic community can choose, without pressure, whatever treatments are deemed most appropriate.

Our subordination to the awesome economic and social influence of the pharmaceutical and surgical implant industry seems to have been the consummation of a Faustian bargain that called for medicine compromising moral values in return for financial rewards. The well-entrenched power of industry, if it is to remain unchanged, will result in moral degradation to the medical profession.

There should be little doubt in anybody's mind that the current imbalance in the therapeutic approach to orthopedic conditions is based on the fact that it is inherent in the nature of the orthopedist to enjoy surgical treatments in preference to nonsurgical approaches. Also that the prestige that accompanies “surgery” is, in the eyes of the lay and medical community, much higher. Nothing exemplifies this feature than the commonly heard expression voiced to indicate the “superior” power of the surgeon, “This task is so difficult that it takes the brains of a neurosurgeon.” No one has ever heard the statement, “It takes the brains of neurologist.” Under the current system of financial recompense for services rendered, surgical treatments are always much higher than those from nonsurgical means constituting a tremendously powerful incentive. Finally, the economic gains from the sale of surgical products by the implant manufacturing industry are awesome.

It is well known that industry-sponsored research studies frequently report better results than those whose research is carried out without ties to industry. The fact that a very large percentage of orthopedic research is partially or totally supported by industry makes one skeptical and suspicious of the legitimacy of many publications. I frequently tell students to doubt virtually anything they read or told to believe, and to carefully question and probe into the veracity of publications, no matter how attractive and truthful they seem to be at first glance.

The ongoing investigation of the relationship between orthopedics and industry by the Justice Department in the United States has already found it to be “corrupted”. Thousands of orthopedic surgeons have been identified as receiving financial perks in the tens if not hundreds of thousands or even millions of dollars under the guise of educational grants and other subterfuges. Many of the parties found guilty of wrongdoing have gotten away from punishment by claiming their conflicts of interest had been resolved.

The fact that I had the opportunity to be deeply involved for several decades not only in the practice of orthopedics, but also in administration, education and research, may have provided me with a good panoramic view of the evolution of the profession, and perhaps a sound appreciation of the causes of the trends to which I have alluded. I served for twenty years as a professor and chairman of two major orthopedic residency programs: the University of Miami and the University of Southern California, the latter was then the largest orthopedic residency training program in the United States. In addition, I was involved in administrative and educational matters within subspecialty societies, having been one of the founding members of the Hip Society, and the International Hip Society and served as president of the former. I was elected to the Board of Directors of the AAOS and served in that capacity for eight years, and as its president for one year.

Despite efforts to avoid the prejudices that inevitably afflict me as a human being from becoming too obvious, they will surface with some frequency. My hope is that the readers will recognize my pattern of looking into the past for knowledge, but committed to finding wisdom when looking at the future. I voice opinions and criticism, and raise questions in a manner that will hopefully provoke thought particularly among young readers. I do this 10with the hope that those who read my writings will pause to ponder whether the current gospels should be accepted without questioning their legitimacy.

I have elected to limit the references to publications in which I was the principal author or co-author. After all, this book is primarily an informal text reflecting my personal views on a number of issues. I claim no originality for most of them, and readily acknowledge that in many instances I came to conclusions based on vicarious information.

I have limited topics related to Reconstructive Surgery almost entirely to the hip with which I had significant experience. When it comes to trauma, I covered some subjects where my knowledge varies from moderate to perhaps even advanced. In the second Section Miscellaneous, I address a variety of topics of philosophical or political nature. The Addenda contains a few addresses I have delivered and abbreviated articles I have written dealing on topics that shed light into my overall personal attitudes toward a changing discipline.