A few years ago I was invited to visit a trauma center where my assigned guide said to me that every patient with a fracture that reached his institution was treated surgically. He proudly added that the hospital had even closed the plaster room.
Suspecting that he might be exaggerating, I asked if all Colles fractures got the knife? He said “yes”, but almost apologetically added that “sometimes little old ladies had their Colles fractures treated with a splint”.
Still hoping to hear of a real exception, I mentioned the fractured clavicle. “Oh yes, we nail them all”. “Why”, I asked, “when you know that most of them do well if handled with a sling?”
He stared at me with disbelief and said, “Doctor Sarmiento, you don’t seem to understand. Things have changed; people no longer accept the lump that those fractures leave behind.”
Oh my God, I thought, where the Dickens have I been? Was I asleep while the fastest and most amazing Darwinian evolution of human behavior was taking place?
Not long afterwards, I found myself making a presentation to our 65 residents at the University of Southern California on the effects of the environment on fracture healing. Sitting in the back of the room was one of our smartest residents, very skillfully trying to hide the newspaper he was reading.
At the end of the session I approached him and remarked that I thought the reading of the newspaper while the professor was lecturing was not only disrespectful but also provided a bad example to other residents. More importantly, I said, I could not understand why he had chosen to close his ears to a lecture dealing with a subject of importance to his education.
Without the slightest hesitation he replied: “Doctor Sarmiento, frankly, I don’t care to know how fractures heal; I simply want to know how to fix them.”
For a few seconds I thought I was in front of a freak. Then I realized that he was the courageous spokesman for his generation.
He was the same resident we had recruited a few years earlier because when he applied for residency, his CV had shown a great deal of interest in basic research. He had been involved in such investigative endeavors since his high school days and through college and medical school.
However, by the middle of the fourth year of his residency he had not conducted any research. When I expressed my disappointment, he responded with similar candor, “Doctor Sarmiento, never, never again do I want to see the inside of a laboratory; I did all that research because some one told me that the best way to fool a residency program director and get a position was by showing research experience.”
You belong to the generation that seems to have accepted without any questions the gospel that says that any permanent angulation of any fracture, even if unrecognizable by the naked eye; any shortening of a limb, even if it does not produce a limp; any incongruity in the articular cartilage, regardless of its degree, are evils. Unacceptable evils. That these findings are not to be considered simple, inconsequential deviation from the normal, but complications. Complications that have to be corrected, otherwise, arthritis will soon develop, a limp will result and the deformity will become a source of litigation.
I don’t blame him or you for preferring surgery over non- surgical approaches to fracture care. Surgery is more fun; is more prestigious and pays better. A lot better!
This pattern of behavior is not limited to our specialty. It dominates the whole spectrum of medicine.
Recently I published in the Journal of Bone and Joint Surgery (Journal of Bone and Joint Surgery 2002 , Sarmiento 84 (7): 1254) a short article, which I titled “Are We Losing Objectivity?” In it I remarked that when I visited my mother on her 97th birthday, I was asked by a concerned relative to use my influence to convince my mother that she needed to walk more. Apparently she was walking little.
When I said to my dear elderly mother that she needed to walk more, she pithily replied, “What for?” I was left speechless. She was right, What for?
Such an experience prompted me to think more carefully about my behavior and that of others while dealing with medical conditions.
We brace paraplegics and deceive them by doing so, for we know that complete paraplegics cannot walk, no matter what type of braces you prescribe or for how long they try to use them.
I also made reference to an experience I had while serving as visiting professor at a major institution. A child, probably in her mid teen years, was presented for discussion. She had been wheel chair ridden most of her life, as a result of severe poliomyelitis early in life.
She really looked like a pretzel. The severe scoliosis and the dislocated hips made her a pathetic creature. She was frightened at the sight or the many doctors staring at her.
Several of the physicians in the audience recommended various types of surgery to correct the spinal curvature; others felt that her dislocated hips needed attention first.
When I was asked to comment I made it clear that I did not have the necessary expertise to intelligently comment on the case. Pressed to voice an opinion I said, ” Buy her a new wheel chair and a television set; give her love and affection and let nature take its course.”
In my editorial-like article, I mentioned the instance when a woman, 90 years of age, was brought into my office. The family wanted a second opinion, since she had been scheduled for surgery the following week. She was to have a bone grafting procedure.
She was barely able to get out of the chair even with assistance. Pain was not a problem. The problem for which she was to have surgery was the presence of a nonunion of the femur at the mid-level of the prosthesis. The prosthesis and a good column of cement bridged the gap.
In other words the nonunion was stable. The surgeon was going to subject this elderly woman to a major surgical procedure in order to treat a bony defect recognizable only on x-rays.
Why this attitude on the part of the surgeon? Was it lack of common sense or just greed? I suspect it was greed.
In the field of fracture care the lack of objectivity is evident every day.
For nearly half a century, we were told that the ideal method of treatment for fractures was rigid immobilization and interfragmentary compression. That such a method would create the best and most physiological osteogenic environment.
Where was the evidence to support that view? It never existed. From the very outset we knew that immobilization was unphysiological and that the callus that eventually heals the fracture is of an inferior quality. Nevertheless, such a philosophy dominated the entire orthopaedic world. An epidemic of plating ensued.
Now fifty years later we are told that rigid immobilization is not necessary, and that a little bit of motion is good for fracture healing. We have been saying that for over thirty years! Hippocrates said it twenty-five hundred years ago.
You and your generation have been led to believe that surgery is the best way to treat all fractures. You hear those spoken or unspoken words every day of your lives. And your mentors set the example.
Many residents in our country finish the residency years never having learned how to reduce a Colles fracture, manipulate a fractured forearm, a tibia or malleolar fracture. Let alone see the outcome of conservative treatments.
The many conferences you hear; the bio-skill courses to which you are invited, all expenses paid; the listening to lectures given by vendors, camouflaged as surgeons, sent you messages that make you salivate. These invitations and conferences have become are an integral part of your life.
Wake-up fellows; industry controls your and my continuing education to a degree you probably have not even bothered to consider. The practice of medicine is structured to a great extent in order to satisfy the marketing needs of industry!
Think about if for a minute after you leave this room and I assure you that you will agree with me.
Why is the Orthopaedic Trauma Association, after so many years of avoiding any mention of closed treatment of fractures, allotting time for discussion of the nonsurgical care of fractures?
I suspect it is because it has come to the realization that the pendulum has swung too far in one direction, and that a better balance in the education of the orthopaedist needs to be sought. That the exaggerated emphasis in surgical technology has resulted in a neglect of the basic foundations of our profession; that the end product we are delivering is not a physician/scientist but a technician. A cosmetic surgeon of the skeleton.
Soon you will be entering the real world of the practice of medicine. I am sure you have already heard of the terrible times your chosen profession is experiencing. I am sure they have told you that the problems of medicine get worse every day, that reimbursement is a disaster, and that the physician has lost control of his destiny. That lay people are telling us when we can admit a patient into the hospital, how long to keep him there, what implants we can and cannot use.
You hear older orthopaedists say that they would never recommend medicine as a career to their children. And the list goes on and on…
I must admit that many of the examples are true and disturbing. But those problems are not that serious. They will be resolved sooner or later. Society will take care of them and one day we will see a resolution.
The real problem facing medicine is the loss of professionalism: a problem, which only we can solve. A problem, which we will never resolve, as long as we consider financial gain the primary goal of our profession.
Medicine is a microcosm of society and its course is being dictated by a society that has adopted a behavior dominated by an obsession with material things. No longer is man judged by his character but by his possessions. “A man who knows the price of everything but the value of nothing”.
Medicine has chosen to accept a business code of ethics in preference to its traditional one. A code that was based on the premise that the physician, owner of expertise not shared by others, places the needs of those he serves before his own. That is becoming history!
Nothing exemplifies the change better than our tacit acceptance of the modern logo of medicine: two serpents wrapped around a shaft. The shaft with the two serpents, however, is, according to Greek Mythology, the symbol of Hermes, the God of commerce and thieves. The Caduceus of Aesculapius, the one representative of medicine has only one snake.
Augusto Sarmiento, M.D.