OrthopaedicLIST.com Blog

 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.

 by Augusto Sarmiento, MD

 The meaning of certain events in our lives often escapes careful consideration as they appear at first glance to be inconsequential. Much to our regret, when later on we find ourselves reflecting on those episodes, we painfully recognize the blindness that kept us from appreciating their importance.

Because of the rapid and spectacular advances made in Orthopaedics over a relatively short period of time, we have grown accustomed to seeing virtually all changes as natural and acceptable phenomena. This rapid acceptance explains why it is that so many new ideas, techniques or surgical procedures come into the scene where they stay for only a brief time, then to be replaced by new ones also likely to undergo the same fate.  The short life span of some techniques and surgical operations not infrequently results in harm to an unknown number of patients. It is possible that this particular problem will eventually be assuaged through better mechanisms of surveillance before implementation.  

We must be aware that change does have to become thoughtless complacency. There are instances when opposition to change is mandatory since every change is not necessarily beneficial. The history of the world is replete with situations where change was accepted without careful scrutiny leading to disastrous consequences. If one feels that evolving changes are wrong and likely to lead to future problems, there is an obligation to express those feelings in a manner that sometimes even loud protestations against them become a must. I have previously described the time when as a resident I was fired from the job for refusing to follow orders to perform a certain surgical procedure which I felt was inappropriate and likely to be harmful to the patient.  Fortunately, a few weeks later I was called and asked to return to duty.

I have for the past several decades expressed, even in harsh terms, concerns over trends of a metaphysical nature that without solid empirical evidence seem to have found a comfortable niche in the practice of the profession. Some of them relate to the erosion of the moral fabric of the profession, which is likely to have deep, meaningful consequences.   

          Since medical care is a microcosm of the larger society, unhealthy forces that oftentimes dictate the evolution of our society regarding health care issues have found a home in our professional lives. In the world of economics, commerce stands and prospers on the premise that suggests that in order to increase profit everything is O.K. and therefore nothing is morally wrong Gaining greater and greater financial benefits is the name of the game.

          There should be no argument over the reality that the ethos of Orthopaedics today is quite different from the one that governed for many a generation. From being primarily a profession, Orthopaedics is becoming a business to the point that to many practitioners “profit” is its true raison d’etre.

          The relationship between Orthopaedics and Industry has been described as “corrupted” by the Justice Department of the United States, which is currently conducting a formal investigation hoping to correct the myriad of widespread commission of “serious ethical transgressions.” Wondrous kickbacks, perks and dishonest transactions are reported throughout the land, not only in the academic sector but in the large private practice component.

          In trying to define the genesis of the problem one most conclude that a most important unhealthy feature is the imbalanced relationship between Orthopedics and Industry since Industry is in virtual control of the education of the orthopaedist and related research. For all practical purposes, the orthopaedic curriculum at the residency level as well as in the private sector is in Industry’s hands. This fact has not escaped residents whom I suspect are beginning to react to it.

          I witnessed a few weeks ago an episode that in a major way contributed to my displeasure with the trend, while at the same time bringing hope for a better future. I walked into a clinic room where two residents, one a senior one and the other a third-year, were discussing an episode that the junior resident had experienced a few days earlier. An elderly lady, a friend of his family, had fallen and injured her wrist. He took her to a hospital in the neighborhood where she had x-rays of her wrist taken. Indeed, she had sustained a simple fracture of the distal radius, of the type that readily lends itself to nonsurgical treatment and requires nothing more than a cast for a few weeks.  The resident called the hand surgeon to whom he described over the phone the benign nature of the fracture. The expert surgeon immediately responded, “I will have my secretary schedule her for surgery to be performed tomorrow morning.” He had decided on the surgical treatment without even seeing the patient, examining her wrist or reading the films.

Obviously, the reason for this wrong, unprofessional and unethical performance was the product of a deeply ingrained belief that a most important goal in his practice was to make as much money as possible. The financial compensation for his proposed surgical approach was much higher than what he would have received from a simple, uncomplicated, nonsurgical approach. I know that the two residents were well aware that there are many wrist fractures when surgery is the treatment of choice, but others, like the one they were discussing do not fall into that category.

While the conversation was still in progress, a third resident joined the group. He took the floor and discussed the fact that at a certain sports-medicine expert had in his office a standard order that any new patient seeking a consultation had to have an MRI prior to meeting the surgeon. The residents’ comments were an expression of their resentment of the ongoing trends to which they were being exposed every day and the manner in which unprofessional, unethical habits were being instilled in their minds. 

This episode where three residents were expressing concern over the ongoing evolving ethos in the profession was highly rewarding to me. It lead me to believe that there is a hope that the next generation of orthopaedists might continue its revulsion of the ways the profession is being practiced with greater frequency, and will retain that attitude for the rest of their lives. Wondrous, wishful thinking? Perhaps, but I will try to keep alive the dream for as long as I can.

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 Augusto Sarmiento, M.D

A close working relationship between Orthopaedics and Physical and Occupational therapy is in the best interest of all parties. Patients benefit immensely from the allied health professionals services they provide to the point that a scenario where they are absent is inconceivable. I state this premise at the outset of this commentary to shed light into remarks I make in subsequent paragraphs, which might be misconstrued as negative to the relationship. I also briefly summarize my personal history as it relates to my involvement with rehabilitation during my long career in orthopaedic surgery in order to emphasize my serious commitment to the cause.

While still a young faculty member in the Division of Orhopaedics at the University of Miami, I began to develop interest in rehabilitation. My interest was triggered by a presentation made by Doctor Howard Rush, the leading rehabilitation authority in the United States in the 1960s. He presented to the audience his experiences with the rehabilitation of spinal cord injury patients. It was an unforgettable event since up to that time I was convinced that people who sustain the devastating injury were condemned to die within a short time from a variety of complications.

I made up my mind that very same evening that a similar program could be developed in Miami. After a four-day visit to the Rusk Institute in New York City and a struggle with the hospital administration, we succeeded in obtaining funds to recruit registered Physical Therapists and to occupy a condemned hospital ward to accommodate patients with paraplegia or quadriplegia. We had succeeded in establishing the first Spinal Cord Injury Center in the city; as a matter of fact in the State of Florida. A few years later an entire building was devoted to Rehabilitation. ^{1, 2.,} When in 1970 I was appointed the first chairman of the newly created Department of Orthopaedics, I suggested and got approval from the Dean of the School to name the department “Orthopaedics and Rehabilitation.” It was the first such department in the country. However, by that time I had already realized that the rehabilitation of spinal cord injured patients requires a great deal of objectivity and the realization that functional ambulation for them is still an unrealized dream. ²

Similar type of objectivity is needed in the relationship between orthopaedists and physical and occupational therapists. Much too often orthopaedic surgeons contribute to the cost of care by recommending long periods of therapy for conditions where supervised treatment is not necessary. This pattern is growing at a fast pace. In increasing numbers many patients recovering from minor surgery or mild disabilities seem to have come to the conclusion that supervised and lengthy periods of therapy are essential for their recovery and request them. However, we must be aware that even within this group there are patients who for one reason or another benefit from formal supervised therapy to initiate the rehabilitation process and to continue it for additional time if necessary.

Muscle strengthening exercises is a commonly prescribed modality for a variety of conditions However, if they are initiated during the inflammatory stage, very often the pain is increased and maintained longer than necessary. The resistive exercises should be carried out after the subsidence of acute pain and, in general, when weakness is the real culprit and not the pain.  

Inappropriate actions, no matter who commits them, should be exposed and criticized. In orthopaedics, the abuse of surgery, which is frequently driven by personal greed, the prescription of expensive tests such as MRIs and CT scans when they are not essential for the provision of good care, and the institution of physical and occupational therapy modalities when they are unnecessary, are appropriate representative examples. The growing cost of cost of medical care, a significant issue at this time, must be addressed in earnest since the country is desperately trying to cope with a critical financial situation. It behooves all us, surgeons and therapists, to be part of the solution rather than part of the problem. Medicine should not have profit as its raison d’etre.

Since the cost of health care is reaching unsustainable and unaffordable levels, country-wide draconian measures, such nationalization of Medicine and the Pharmaceutical and Surgical Implant Industry, can become a reality. ^{3, 4} Accustomed as we are to a capitalistic laisssez-faire and democratic system we dread the possibility of such a scenario becoming a reality.

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REFERENCES.

1.         Sarmiento, A. and McCollough, N. The Orthopaedist and                 Rehabilitation. Clin. Orthop.& Rel. Res. 41:111-115, 1965.

Sarmiento A. Bare Bones. Prometheus Publishers, 2005.

D. and Wasumma A. Medicine and the Market.  John Hopkins, 2006.

     4.     Relman A. Doctors as the key to Health Care Reform. New England Journal of medicine.  361, 13:12251227. 2009

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

            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.

by Howard H. Steel, MD

Lord, Thou knowest I am growing older.

Keep me from becoming talkative and possessed with the idea that I must express myself on every subject.

Release me from the craving to straighten out everyone’s affairs.

Keep me from the recital of endless detail.  Give me wings to get to the point.

Seal my lips when I am inclined to tell of my aches and pains.  They are increasing with the years, and my love to speak of them grows sweeter as time goes by.

Teach me the glorious lesson that occasionally I may be wrong.

Make me thoughtful but not nosy, helpful but not bossy.  With my vast store of wisdom and experience, it does seem a pity not to use it all,

but Thou knowest, Lord, that I want a few friends at the end.

 [Published with permission from Dr. Steel.]

Howard Steel, MD is an icon in Orthopaedics and his inspiration goes beyond Orthopaedics.   Clinically he dedicated his career to children at Temple and the Shriners.  Educationally, he taught thousands of residents, medical students and junior faculty about surgery and life.  In 1970, he founded the Eastern Orthopaedic Association and was the Society President for the first two years.  He has hardly missed a meeting since.  Recognizing there is more to life than medicine, Dr. Steel donated funding (30+ years) for a “non-Orthopaedic” lectureship for many of the regional orthopaedic societies, the AOA and other orthopaedic entities.   Howard is funny, fun-loving and bigger than life. 

 
Comments about Dr. Steel by Judith F. Baumhauer, MD MPH, University of Rochester School of Medicine and Dentistry

by Tom Morris

From Plato and Aristotle to the present day, the wisest people who have ever thought about challenge and achievement in our lives and work have left us bits and pieces of powerful advice for attaining true success in anything we do. I’ve put these ideas together in a simple framework of seven universal conditions. Let me lay them out briefly and then we’ll look at each. Whether you apply them in your practice, in your life, or teach them to your patients, they can be very helpful for focusing on what it takes to reach important goals.

The 7 Cs of Success

For the most deeply satisfying and sustainable forms of success, we need to bring into any challenge, opportunity, or relationship:

(1) A clear CONCEPTION of what we want, a vivid vision, a goal clearly imagined.

(2) A strong CONFIDENCE that we can attain that goal.

(3) A focused CONCENTRATION on what it takes to reach the goal.

(4) A stubborn CONSISTENCY in pursuing our vision.

(5) An emotional COMMITMENT to the importance of what we’re doing.

(6) A good CHARACTER to guide us and keep us on a proper course.

(7) A CAPACITY TO ENJOY the process along the way.

There are certainly other concepts often associated with success, but every other one is just a version or application of one of these in specific situations. The 7 Cs give us the most universal, logical, and comprehensive framework for success.

(1) A clear CONCEPTION of what we want, a vivid vision, a goal clearly imagined.

In any facet of our lives, we need to think through as clearly as possible what we want to accomplish. True success starts with an inner vision, however incomplete it might be. The world as we find it is just the raw material for what we can make it. We are meant to be artists with our energies and our lives. And the only way to do that well is to structure our actions around clear goals.

(2) A strong CONFIDENCE that we can attain the goal.

Inner attitude is a key to outer results. Philosopher William James learned from championship athletes that a proper confidence should be operative in all our lives. In any new enterprise, we need upfront faith in what we’re doing. Sometimes we may have to work hard to generate this attitude. But it’s worth the work it takes, because it raises our prospects for success. The best confidence arises out of competence and then augments it.  It’s of course no guarantee of success. But it is among the chief contributors to it.

(3) A focused CONCENTRATION on what it takes to reach the goal.

Big dreams just lead to big disappointments when people don’t learn how to chart their way forward. Success at anything challenging comes from planning your path and then putting that plan into action. Gestalt psychologists teach us that a new mental focus generates new perceptual abilities. Concentrating your thought and energy in a new direction, toward a clear goal, you begin to see things that you might have missed before, that relate to the goal you’ve set. This focus allows you to plan and act, and adjust along the way. Even a flawed plan can start you off and lead you to where you can discover a better one. A focused concentration of thought and action is key.

(4) A stubborn CONSISTENCY in pursuing our vision.

The word ‘consistency’ comes from two Greek roots, a verb meaning “to stand” and a particle meaning “together.” Consistency is all about standing together. Do my actions stand together with my words? Do my reactions and emotions stand together with my deepest beliefs and values? Do the people I work with stand together? This is what consistency is all about. It’s a matter of unifying your energy and efforts in a single direction. Inconsistency defuses power. Consistency moves us toward our goals.

(5) An emotional COMMITMENT to the importance of what we’re doing.

Passion is the core of extraordinary success. It’s a key to overcoming difficulties, seizing opportunities, and getting other people excited about your projects. Too much goal setting in the modern world has been an exercise of the intellect and not also of the heart. Philosophers appreciate the role of rationality in human life. But we know that it’s not just the head, but also the heart, that can guide us on to the tasks right for us, and keep us functioning at the peak of our abilities.

(6) A good CHARACTER to guide us and keep us on a proper course.

Character inspires trust. And trust is necessary for people to work together well. Good character is required for great collaboration. In a world in which innovative partnerships and collaborative synergies are increasingly important, the moral foundation for working well together matters more than ever before. And good character does a lot more than just provide for trust. It has an effect on each individual’s own freedom and insight. Bad character not only corrupts, it blinds. A person whose perspective has been deeply skewed by selfishness or mendacity cannot understand the world in as perceptive a way as someone whose sensibilities are ethically well formed. Good character makes sustainable success more likely.

(7) A CAPACITY TO ENJOY the process along the way.

The more you can enjoy the process of what you’re doing, the better the results tend to be. It’s easier to set creative goals. Confidence will come more naturally. Your concentration can seem effortless. Consistency will not be a battle. The emotional commitment will flow. And issues of character will not be as difficult to manage. A capacity to enjoy the process is entwined with every other facilitator of success in a great many ways.

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These conditions of success are all deeply connected. They constitute a unified framework of tools with which we can work our way toward the most fulfilling forms of achievement. They will help us to make our proper mark in the world. They will move us in the direction of true success. And why should we ever settle for anything less?

 Tom Morris is the author of such books as True Success, The Art of Achievement, If Aristotle Ran General Motors, and If Harry Potter Ran General Electric. He writes weekly for The Huffington Post and can be found philosophizing on Twitter as TomVMorris.  He can be reached at TomVMorris@aol.com or through the Morris Institute.

Dr. Morris was kind enough to guest author this article for OrthopaedicLIST.com.