Plancher KD

"Report to the Administrator’s Office for a discussion 7:00 am sharp,” reads the email on your phone. The phone log sheet from your administrator is handed to you as you are running to the operating room and reads, “Call back Mr. Smith’s health insurance company because your patient stayed overnight unexpectedly in the hospital, and if the return phone call is not received by 8:40 am the complete hospital stay will be disallowed.” The text message reads, “The head nurse from the emergency department wants to have a discussion with you tomorrow about what transpired in room 23 last night at 1:33 am.” Your physician assistant calls you because a recent history and physical examination from the out-of-state internist has not been cosigned by you, and, therefore, the patient is still in the admitting office; the admitting officer is waiting to go home and won’t accept the physician assistant’s signature.

This simple illustration of a surgeon’s typical morning is hardly hyperbole. Demands and finger-pointing are routine aspects of care, with a concurrent need to attribute blame and create a hostile work environment whether in the office, operating room, or floor of the hospital by anyone who can proudly say to the physician, “Gotcha!” The environment that produces this ethos is toxic and needs to be changed. While all members of a patient care team must be accountable, no member should be antagonistic toward another, and each member must feel a part of a working whole that is led by a competent, caring, and identifiable physician. Yes, the doctor must be the team captain; he or she must take back the reins of care immediately in order to provide the patient with the best possible outcome.

The loss of leadership can be traced back to the rise of regulatory controls put in place by government entities or local hospital administration to contain costs and limit liability. While the target goals of such measures are laudable, the negative impact on the doctor–patient relationship has been palpable and problematic and requires reassessment. The profession itself will be preserved by refocusing on the doctor–patient relationship and returning the physician to the role of team leader. Our patients deserve to feel as though their health care resides in the hands of the physician as the leader of a team that is pursuing a common goal: patient care with minimal distractions.

What, though, makes a great captain or leader? Sociologists have said that in a stable environment a “participatory model” of leadership is appropriate, while in a high-growth or changing environment, like the one in which we presently live, an “authoritative model” can be used to right the ship.^1,2 Many types of leaders exist within both models. Leaders who are “innovators” will design and bring new ideas and original thought but may generate too many ideas that can’t be implemented practically in the hospital setting. Leaders who are “developers” will build and move forward to achieve challenging goals but may be impatient when ideas do not work and may be perceived in many interdisciplinary meetings as unruly. “Bureaucratic” leaders, presently seen in many leadership positions, can be classified as stabilizers and, while they may maintain equilibrium and keep things running smoothly, they often insist on a policy for every situation, resulting in stasis and sometimes even paralysis of the surgical center or hospital system.

I believe that health management and patient care require the simultaneous use of the authoritative and participatory models to encourage innovation, set attainable short- and long-term goals, and maintain the physician as the team leader. To lead effectively under this hybrid model, the physician must be accessible and fair, a teacher and a student, and a risk-taker, but, ultimately, at the end of every day, the physician must be accountable.

The time has come for physician leaders to assemble the troops: administrators, clinical providers, and nonclinical support staff. To paraphrase John Quincy Adams, in your actions inspire others to dream more and become more; then, and only then, are you an excellent leader. A secret to effective leadership is in finding one’s voice and acknowledging strengths and weaknesses. The leader must recruit other leaders who are very different from himself or herself and must listen to them deeply and trust them completely. One of our former first ladies said wisely, “A leader takes people where they want to go. A great leader takes people where they don’t necessarily want to go, but ought to be.” To truly find this leadership model, we as busy surgeons must spend some concentrated time away from our patients and exciting research to sit in the room with our nurses, administrators, and all other members of the health care community and listen to their thoughts and understand their concerns. We must understand policy to assess if it is reasonable and, if it is not, to reject it and propose more effective and appropriate rules for good care. We must remove from leadership positions those that do not have the interest of the patient as their primary concern. We must challenge any policy that does not have the patient’s interest and health as its raison d’etre. We must be proactive and not reactive. We must be ready to stand tall and politely question when dictated to unless evidence-based medical reasons can be presented.

You may ask, therefore, where should we lead? The answer is obvious! We need to be involved in every aspect of this great profession. We need to be the leaders of hospital systems, we need to be in charge of research institutions, and, as always, we need to be the chief of the operating room and the chief within each room as the team leader for the nurse, anesthesiologist, and nonclinical staff in order to safely guide our patients through the stress of a medical crisis or routine intervention. We need to find those of us with other degrees, whether MPH, MBA, MHA, or JD, and place those physicians in positions of business and political leadership as well as in leadership positions in hospitals and private practitioner offices. We need to encourage our medical students, residents, and fellows to continue their rigorous training to include an understanding of health care policy and economics so as to help manage and resolve the crisis at hand.

We must now navigate the sea of change to allow for continuity of care and not throw up our arms in despair. The role of physician as private practitioner or as full-time faculty member has its origins deeply imbedded in the roots of our profession, and this traditional role as caretaker and scientist must continue. But in this century, we need to be leaders in the political and business communities as well. This vision requires a new and fresh momentum. We cannot sit idly by as patient care becomes increasingly managed by nonphysicians. The time has come to use our unique position as doctors to frame the debate, participate in the discussion, and lead our profession and the management of health care toward calmer waters with compassion, science, and responsibility. To do this, we must demand transparency, proceed with respect, and require excellence from everyone around us and make sure it is demanded from all of us.◾

"Report to the Administrator’s Office for a discussion 7:00 am sharp,” reads the email on your phone. The phone log sheet from your administrator is handed to you as you are running to the operating room and reads, “Call back Mr. Smith’s health insurance company because your patient stayed overnight unexpectedly in the hospital, and if the return phone call is not received by 8:40 am the complete hospital stay will be disallowed.” The text message reads, “The head nurse from the emergency department wants to have a discussion with you tomorrow about what transpired in room 23 last night at 1:33 am.” Your physician assistant calls you because a recent history and physical examination from the out-of-state internist has not been cosigned by you, and, therefore, the patient is still in the admitting office; the admitting officer is waiting to go home and won’t accept the physician assistant’s signature.

This simple illustration of a surgeon’s typical morning is hardly hyperbole. Demands and finger-pointing are routine aspects of care, with a concurrent need to attribute blame and create a hostile work environment whether in the office, operating room, or floor of the hospital by anyone who can proudly say to the physician, “Gotcha!” The environment that produces this ethos is toxic and needs to be changed. While all members of a patient care team must be accountable, no member should be antagonistic toward another, and each member must feel a part of a working whole that is led by a competent, caring, and identifiable physician. Yes, the doctor must be the team captain; he or she must take back the reins of care immediately in order to provide the patient with the best possible outcome.

The loss of leadership can be traced back to the rise of regulatory controls put in place by government entities or local hospital administration to contain costs and limit liability. While the target goals of such measures are laudable, the negative impact on the doctor–patient relationship has been palpable and problematic and requires reassessment. The profession itself will be preserved by refocusing on the doctor–patient relationship and returning the physician to the role of team leader. Our patients deserve to feel as though their health care resides in the hands of the physician as the leader of a team that is pursuing a common goal: patient care with minimal distractions.

What, though, makes a great captain or leader? Sociologists have said that in a stable environment a “participatory model” of leadership is appropriate, while in a high-growth or changing environment, like the one in which we presently live, an “authoritative model” can be used to right the ship.^1,2 Many types of leaders exist within both models. Leaders who are “innovators” will design and bring new ideas and original thought but may generate too many ideas that can’t be implemented practically in the hospital setting. Leaders who are “developers” will build and move forward to achieve challenging goals but may be impatient when ideas do not work and may be perceived in many interdisciplinary meetings as unruly. “Bureaucratic” leaders, presently seen in many leadership positions, can be classified as stabilizers and, while they may maintain equilibrium and keep things running smoothly, they often insist on a policy for every situation, resulting in stasis and sometimes even paralysis of the surgical center or hospital system.

I believe that health management and patient care require the simultaneous use of the authoritative and participatory models to encourage innovation, set attainable short- and long-term goals, and maintain the physician as the team leader. To lead effectively under this hybrid model, the physician must be accessible and fair, a teacher and a student, and a risk-taker, but, ultimately, at the end of every day, the physician must be accountable.

The time has come for physician leaders to assemble the troops: administrators, clinical providers, and nonclinical support staff. To paraphrase John Quincy Adams, in your actions inspire others to dream more and become more; then, and only then, are you an excellent leader. A secret to effective leadership is in finding one’s voice and acknowledging strengths and weaknesses. The leader must recruit other leaders who are very different from himself or herself and must listen to them deeply and trust them completely. One of our former first ladies said wisely, “A leader takes people where they want to go. A great leader takes people where they don’t necessarily want to go, but ought to be.” To truly find this leadership model, we as busy surgeons must spend some concentrated time away from our patients and exciting research to sit in the room with our nurses, administrators, and all other members of the health care community and listen to their thoughts and understand their concerns. We must understand policy to assess if it is reasonable and, if it is not, to reject it and propose more effective and appropriate rules for good care. We must remove from leadership positions those that do not have the interest of the patient as their primary concern. We must challenge any policy that does not have the patient’s interest and health as its raison d’etre. We must be proactive and not reactive. We must be ready to stand tall and politely question when dictated to unless evidence-based medical reasons can be presented.

You may ask, therefore, where should we lead? The answer is obvious! We need to be involved in every aspect of this great profession. We need to be the leaders of hospital systems, we need to be in charge of research institutions, and, as always, we need to be the chief of the operating room and the chief within each room as the team leader for the nurse, anesthesiologist, and nonclinical staff in order to safely guide our patients through the stress of a medical crisis or routine intervention. We need to find those of us with other degrees, whether MPH, MBA, MHA, or JD, and place those physicians in positions of business and political leadership as well as in leadership positions in hospitals and private practitioner offices. We need to encourage our medical students, residents, and fellows to continue their rigorous training to include an understanding of health care policy and economics so as to help manage and resolve the crisis at hand.

We must now navigate the sea of change to allow for continuity of care and not throw up our arms in despair. The role of physician as private practitioner or as full-time faculty member has its origins deeply imbedded in the roots of our profession, and this traditional role as caretaker and scientist must continue. But in this century, we need to be leaders in the political and business communities as well. This vision requires a new and fresh momentum. We cannot sit idly by as patient care becomes increasingly managed by nonphysicians. The time has come to use our unique position as doctors to frame the debate, participate in the discussion, and lead our profession and the management of health care toward calmer waters with compassion, science, and responsibility. To do this, we must demand transparency, proceed with respect, and require excellence from everyone around us and make sure it is demanded from all of us.◾

"Report to the Administrator’s Office for a discussion 7:00 am sharp,” reads the email on your phone. The phone log sheet from your administrator is handed to you as you are running to the operating room and reads, “Call back Mr. Smith’s health insurance company because your patient stayed overnight unexpectedly in the hospital, and if the return phone call is not received by 8:40 am the complete hospital stay will be disallowed.” The text message reads, “The head nurse from the emergency department wants to have a discussion with you tomorrow about what transpired in room 23 last night at 1:33 am.” Your physician assistant calls you because a recent history and physical examination from the out-of-state internist has not been cosigned by you, and, therefore, the patient is still in the admitting office; the admitting officer is waiting to go home and won’t accept the physician assistant’s signature.

This simple illustration of a surgeon’s typical morning is hardly hyperbole. Demands and finger-pointing are routine aspects of care, with a concurrent need to attribute blame and create a hostile work environment whether in the office, operating room, or floor of the hospital by anyone who can proudly say to the physician, “Gotcha!” The environment that produces this ethos is toxic and needs to be changed. While all members of a patient care team must be accountable, no member should be antagonistic toward another, and each member must feel a part of a working whole that is led by a competent, caring, and identifiable physician. Yes, the doctor must be the team captain; he or she must take back the reins of care immediately in order to provide the patient with the best possible outcome.

The loss of leadership can be traced back to the rise of regulatory controls put in place by government entities or local hospital administration to contain costs and limit liability. While the target goals of such measures are laudable, the negative impact on the doctor–patient relationship has been palpable and problematic and requires reassessment. The profession itself will be preserved by refocusing on the doctor–patient relationship and returning the physician to the role of team leader. Our patients deserve to feel as though their health care resides in the hands of the physician as the leader of a team that is pursuing a common goal: patient care with minimal distractions.

What, though, makes a great captain or leader? Sociologists have said that in a stable environment a “participatory model” of leadership is appropriate, while in a high-growth or changing environment, like the one in which we presently live, an “authoritative model” can be used to right the ship.^1,2 Many types of leaders exist within both models. Leaders who are “innovators” will design and bring new ideas and original thought but may generate too many ideas that can’t be implemented practically in the hospital setting. Leaders who are “developers” will build and move forward to achieve challenging goals but may be impatient when ideas do not work and may be perceived in many interdisciplinary meetings as unruly. “Bureaucratic” leaders, presently seen in many leadership positions, can be classified as stabilizers and, while they may maintain equilibrium and keep things running smoothly, they often insist on a policy for every situation, resulting in stasis and sometimes even paralysis of the surgical center or hospital system.

I believe that health management and patient care require the simultaneous use of the authoritative and participatory models to encourage innovation, set attainable short- and long-term goals, and maintain the physician as the team leader. To lead effectively under this hybrid model, the physician must be accessible and fair, a teacher and a student, and a risk-taker, but, ultimately, at the end of every day, the physician must be accountable.

The time has come for physician leaders to assemble the troops: administrators, clinical providers, and nonclinical support staff. To paraphrase John Quincy Adams, in your actions inspire others to dream more and become more; then, and only then, are you an excellent leader. A secret to effective leadership is in finding one’s voice and acknowledging strengths and weaknesses. The leader must recruit other leaders who are very different from himself or herself and must listen to them deeply and trust them completely. One of our former first ladies said wisely, “A leader takes people where they want to go. A great leader takes people where they don’t necessarily want to go, but ought to be.” To truly find this leadership model, we as busy surgeons must spend some concentrated time away from our patients and exciting research to sit in the room with our nurses, administrators, and all other members of the health care community and listen to their thoughts and understand their concerns. We must understand policy to assess if it is reasonable and, if it is not, to reject it and propose more effective and appropriate rules for good care. We must remove from leadership positions those that do not have the interest of the patient as their primary concern. We must challenge any policy that does not have the patient’s interest and health as its raison d’etre. We must be proactive and not reactive. We must be ready to stand tall and politely question when dictated to unless evidence-based medical reasons can be presented.

You may ask, therefore, where should we lead? The answer is obvious! We need to be involved in every aspect of this great profession. We need to be the leaders of hospital systems, we need to be in charge of research institutions, and, as always, we need to be the chief of the operating room and the chief within each room as the team leader for the nurse, anesthesiologist, and nonclinical staff in order to safely guide our patients through the stress of a medical crisis or routine intervention. We need to find those of us with other degrees, whether MPH, MBA, MHA, or JD, and place those physicians in positions of business and political leadership as well as in leadership positions in hospitals and private practitioner offices. We need to encourage our medical students, residents, and fellows to continue their rigorous training to include an understanding of health care policy and economics so as to help manage and resolve the crisis at hand.

We must now navigate the sea of change to allow for continuity of care and not throw up our arms in despair. The role of physician as private practitioner or as full-time faculty member has its origins deeply imbedded in the roots of our profession, and this traditional role as caretaker and scientist must continue. But in this century, we need to be leaders in the political and business communities as well. This vision requires a new and fresh momentum. We cannot sit idly by as patient care becomes increasingly managed by nonphysicians. The time has come to use our unique position as doctors to frame the debate, participate in the discussion, and lead our profession and the management of health care toward calmer waters with compassion, science, and responsibility. To do this, we must demand transparency, proceed with respect, and require excellence from everyone around us and make sure it is demanded from all of us.◾

Technology creates change, and change is moving fast and is relentless. Physicians, on the other hand, are generally slow to change. Wisely, we question change—we observe it, we study it, and we try to ensure our patients will benefit from it over time. Maybe as a result of this or as a consequence of our often myopic view of the world, we mistakenly let others lead the way and dictate how we must change and what our practices must absorb. We must turn this around and be the agents of change for our profession so we can appropriately use the available technology and create systems for managing the demands of a society that expects instant answers with fewer doctor resources devoted to the answer. The insurance industry is encouraging a wholesale dismantling of the classic patient visit to be replaced by nonphysician interactions, virtual diagnostics, and electronic medical records. We must not allow this and must ensure that we safeguard our profession by employing traditional skills, utilizing our 5 senses, and incorporating technology as a tool for better diagnosis and treatment but not as a substitute for the same.  

Great doctors are often described as having a sixth sense—an intuition that guides them in diagnosing and treating patients. It is assumed, therefore, that the good doctor will have the benefit of 5 senses: sight, sound, touch, smell, and taste. Sound: What does the patient tell or neglect to tell the doctor? What sounds does a joint produce when it moves? Sight: How does the patient present? Are they weary from pain or chronic disease? Touch: What does the joint feel like? How does it move? What is the patient’s response to stabilization of a joint? Smell: Is there an odor that helps detect the presence of infection or decay? Is the patient coming into contact with a substance causing harm or preventing healing?

A good doctor must employ these senses first to understand the patient’s needs and then to treat the patient. The sixth sense is a gift, one that comes from years of experience, an attention to detail, and a commitment to the craft of medicine. A recent trend toward virtual medicine is a dangerous path that must be walked with care and discretion so that the 6 senses are maintained and nurtured. Technology must be used to enhance and not limit these senses. The patient cannot be reduced to a 2-dimensional version of his/herself so that the doctor’s powers of diagnosis and healing are similarly limited.

Change in the office has occurred with mandates for electronic medical records and work-hour restrictions for residents. Data do not support that either change has resulted in a net benefit to patients. We are mandated to invest scarce capital to support new technology, resulting in increased pressure to recoup investment. Where there is a cap on revenue, the only way to increase net profit is to increase volume and decrease services. Physician time is the variable and can be streamlined by performing video conferences or smartphone consultations. Change may bring higher order, as the English philosopher John Locke said, but it is time for all of us as physicians to step back and question that this type of change is the path we must take. An office with a schedule of 80 patients seen at 5-minute intervals by physician assistants has no place in medicine. The pressure imposed by the insurance industry or hospital administrators to meet quotas has gotten out of hand and the time is now to say with a strong but fair voice a resounding NO!

The office visit with a history and physical examination is the most exciting and effective time to meet, console, and relate to our patients. The use of the 5 senses is critical. We must not let technological advancements (eg, smartphones, the Internet, and electronic medical records) destroy what was created and taught to us all through our training. The reward that is accomplished by placing one’s hand on a patient’s knee to understand its warmth and swelling, the tactile feeling of a fluid wave, or performing carefully with compassion a provocative maneuver that gives by sight a grimace of discomfort can tell so much more than a status update on the phone. We must not allow ourselves to be replaced by ancillary services for so-called efficiency and cost saving. Rather, we must be innovative and sharp. We must find the way to use the wonders of the virtual world without giving up the human consult.

Imagine that you are able to travel to Iguazu Falls, South America, to see one of the wonders of our world. You sit in that life raft moving upstream to feel the heat from the water as it crushes the rocks below, and you feel the mist on your face. You see the majesty and hear the screams and breadth of excitement of those around you, while you listen to the deafening sounds created by this waterfall. Now imagine you are required to report on this same experience through a video or some form of technology that the world has convinced us is the best and far cheaper substitute. This is our electronic medical record. A tool we are forced to use, and while it has a purpose, it is a sterile tool that fails to provide information that will give clues to awaken the sixth sense. It is a checklist that could allow for completion of a task—like how to fix a leaky faucet.

How then do we accomplish walking the fine line of working with nonphysicians and technology and yet delivering pinnacle care? The answer isn’t simple but it must include education and a commitment to the profession. We must make the public aware that we are one of the few professions that dedicate our lives to others by promoting health and advancing research. My colleagues, the pendulum has swung too far; it is time to take back our great profession through education of ourselves and the public. While technology may help the world connect, it has a limited role unless we first use our 6 senses to help our patients. We must not submit to a compassionless and callous approach that is the inevitable outcome of virtual medicine done with speed. We must maintain our dignity and let the public understand how many years of sacrifice has taken place to earn a sixth sense and not allow a third party to take it away. We are the only source of protection for our patients and we need each one of our senses to perform this task.

Advancing research has been a cornerstone for the orthopedic surgeon. Position statements through meta-analyses and systematic reviews of the literature have recently been utilized with increasing frequency. Combining data of potentially flawed studies can often lead to erroneous conclusions and may stray away from best practices. Is this where we want evidence-based medicine to go? The end result is that decisions are made by insurance companies who rely on these flawed studies to force clinical decisions on the physician, as was most recently seen by the investigation of viscosupplementation for knee osteoarthritis.¹

In a 2007 study published in JAMA (The Journal of the American Medical Association), only 62% of residents could appropriately interpret a P value.² How can we expect young clinicians to evaluate, interpret, and apply the multitude of evidence in the literature to everyday practice? We must marry the use of best evidence with our expertise to make the most informed decision while managing the expectations of our patients. In order to achieve that balance, we must rely on our intuition, our sixth sense. There is too much patient individuality and complexity surrounding each individual’s situation for a one-size-fits-all approach and for wholesale reliance on research to address each unique situation.

If Nathan Davis in 1845 was able to convince the New York Medical Society to establish a nationwide professional association to assist in regulating the practice of medicine, then it is time for all of us to stand up and insist on a code of ethics that is unrelenting and uncompromising. Our wise leaders of the American Orthopaedic Association (AOA) who founded the formation of orthopedics in America knew guidelines were needed to “foster advances in the care of patients, improve the teaching of orthopaedic surgery in medical schools and formal orthopaedic training, and to promote orthopaedic surgery as a surgical discipline worldwide.”³ It is now our turn to renew the guidelines and encourage our leaders to help educate ourselves and patients as we work with technology and administrators, nurses and physician assistants to deliver pinnacle care. We must reform medical education and the practice of medicine so that technology is used as a companion but not a substitute for our 6 senses.

The next time a patient comes into the exam room, sit down, look the patient in the eye, listen, touch, console anxiety, make a human connection, and form a lasting relationship. By all means apologize to your patients as you fill out the electronic medical record and insurance forms. Discuss how we are in the same crisis together and ask for their help as they have come to you for yours.

Technology creates change, and change is moving fast and is relentless. Physicians, on the other hand, are generally slow to change. Wisely, we question change—we observe it, we study it, and we try to ensure our patients will benefit from it over time. Maybe as a result of this or as a consequence of our often myopic view of the world, we mistakenly let others lead the way and dictate how we must change and what our practices must absorb. We must turn this around and be the agents of change for our profession so we can appropriately use the available technology and create systems for managing the demands of a society that expects instant answers with fewer doctor resources devoted to the answer. The insurance industry is encouraging a wholesale dismantling of the classic patient visit to be replaced by nonphysician interactions, virtual diagnostics, and electronic medical records. We must not allow this and must ensure that we safeguard our profession by employing traditional skills, utilizing our 5 senses, and incorporating technology as a tool for better diagnosis and treatment but not as a substitute for the same.  

Great doctors are often described as having a sixth sense—an intuition that guides them in diagnosing and treating patients. It is assumed, therefore, that the good doctor will have the benefit of 5 senses: sight, sound, touch, smell, and taste. Sound: What does the patient tell or neglect to tell the doctor? What sounds does a joint produce when it moves? Sight: How does the patient present? Are they weary from pain or chronic disease? Touch: What does the joint feel like? How does it move? What is the patient’s response to stabilization of a joint? Smell: Is there an odor that helps detect the presence of infection or decay? Is the patient coming into contact with a substance causing harm or preventing healing?

A good doctor must employ these senses first to understand the patient’s needs and then to treat the patient. The sixth sense is a gift, one that comes from years of experience, an attention to detail, and a commitment to the craft of medicine. A recent trend toward virtual medicine is a dangerous path that must be walked with care and discretion so that the 6 senses are maintained and nurtured. Technology must be used to enhance and not limit these senses. The patient cannot be reduced to a 2-dimensional version of his/herself so that the doctor’s powers of diagnosis and healing are similarly limited.

Change in the office has occurred with mandates for electronic medical records and work-hour restrictions for residents. Data do not support that either change has resulted in a net benefit to patients. We are mandated to invest scarce capital to support new technology, resulting in increased pressure to recoup investment. Where there is a cap on revenue, the only way to increase net profit is to increase volume and decrease services. Physician time is the variable and can be streamlined by performing video conferences or smartphone consultations. Change may bring higher order, as the English philosopher John Locke said, but it is time for all of us as physicians to step back and question that this type of change is the path we must take. An office with a schedule of 80 patients seen at 5-minute intervals by physician assistants has no place in medicine. The pressure imposed by the insurance industry or hospital administrators to meet quotas has gotten out of hand and the time is now to say with a strong but fair voice a resounding NO!

The office visit with a history and physical examination is the most exciting and effective time to meet, console, and relate to our patients. The use of the 5 senses is critical. We must not let technological advancements (eg, smartphones, the Internet, and electronic medical records) destroy what was created and taught to us all through our training. The reward that is accomplished by placing one’s hand on a patient’s knee to understand its warmth and swelling, the tactile feeling of a fluid wave, or performing carefully with compassion a provocative maneuver that gives by sight a grimace of discomfort can tell so much more than a status update on the phone. We must not allow ourselves to be replaced by ancillary services for so-called efficiency and cost saving. Rather, we must be innovative and sharp. We must find the way to use the wonders of the virtual world without giving up the human consult.

Imagine that you are able to travel to Iguazu Falls, South America, to see one of the wonders of our world. You sit in that life raft moving upstream to feel the heat from the water as it crushes the rocks below, and you feel the mist on your face. You see the majesty and hear the screams and breadth of excitement of those around you, while you listen to the deafening sounds created by this waterfall. Now imagine you are required to report on this same experience through a video or some form of technology that the world has convinced us is the best and far cheaper substitute. This is our electronic medical record. A tool we are forced to use, and while it has a purpose, it is a sterile tool that fails to provide information that will give clues to awaken the sixth sense. It is a checklist that could allow for completion of a task—like how to fix a leaky faucet.

How then do we accomplish walking the fine line of working with nonphysicians and technology and yet delivering pinnacle care? The answer isn’t simple but it must include education and a commitment to the profession. We must make the public aware that we are one of the few professions that dedicate our lives to others by promoting health and advancing research. My colleagues, the pendulum has swung too far; it is time to take back our great profession through education of ourselves and the public. While technology may help the world connect, it has a limited role unless we first use our 6 senses to help our patients. We must not submit to a compassionless and callous approach that is the inevitable outcome of virtual medicine done with speed. We must maintain our dignity and let the public understand how many years of sacrifice has taken place to earn a sixth sense and not allow a third party to take it away. We are the only source of protection for our patients and we need each one of our senses to perform this task.

Advancing research has been a cornerstone for the orthopedic surgeon. Position statements through meta-analyses and systematic reviews of the literature have recently been utilized with increasing frequency. Combining data of potentially flawed studies can often lead to erroneous conclusions and may stray away from best practices. Is this where we want evidence-based medicine to go? The end result is that decisions are made by insurance companies who rely on these flawed studies to force clinical decisions on the physician, as was most recently seen by the investigation of viscosupplementation for knee osteoarthritis.¹

In a 2007 study published in JAMA (The Journal of the American Medical Association), only 62% of residents could appropriately interpret a P value.² How can we expect young clinicians to evaluate, interpret, and apply the multitude of evidence in the literature to everyday practice? We must marry the use of best evidence with our expertise to make the most informed decision while managing the expectations of our patients. In order to achieve that balance, we must rely on our intuition, our sixth sense. There is too much patient individuality and complexity surrounding each individual’s situation for a one-size-fits-all approach and for wholesale reliance on research to address each unique situation.

If Nathan Davis in 1845 was able to convince the New York Medical Society to establish a nationwide professional association to assist in regulating the practice of medicine, then it is time for all of us to stand up and insist on a code of ethics that is unrelenting and uncompromising. Our wise leaders of the American Orthopaedic Association (AOA) who founded the formation of orthopedics in America knew guidelines were needed to “foster advances in the care of patients, improve the teaching of orthopaedic surgery in medical schools and formal orthopaedic training, and to promote orthopaedic surgery as a surgical discipline worldwide.”³ It is now our turn to renew the guidelines and encourage our leaders to help educate ourselves and patients as we work with technology and administrators, nurses and physician assistants to deliver pinnacle care. We must reform medical education and the practice of medicine so that technology is used as a companion but not a substitute for our 6 senses.

The next time a patient comes into the exam room, sit down, look the patient in the eye, listen, touch, console anxiety, make a human connection, and form a lasting relationship. By all means apologize to your patients as you fill out the electronic medical record and insurance forms. Discuss how we are in the same crisis together and ask for their help as they have come to you for yours.

Technology creates change, and change is moving fast and is relentless. Physicians, on the other hand, are generally slow to change. Wisely, we question change—we observe it, we study it, and we try to ensure our patients will benefit from it over time. Maybe as a result of this or as a consequence of our often myopic view of the world, we mistakenly let others lead the way and dictate how we must change and what our practices must absorb. We must turn this around and be the agents of change for our profession so we can appropriately use the available technology and create systems for managing the demands of a society that expects instant answers with fewer doctor resources devoted to the answer. The insurance industry is encouraging a wholesale dismantling of the classic patient visit to be replaced by nonphysician interactions, virtual diagnostics, and electronic medical records. We must not allow this and must ensure that we safeguard our profession by employing traditional skills, utilizing our 5 senses, and incorporating technology as a tool for better diagnosis and treatment but not as a substitute for the same.  

Great doctors are often described as having a sixth sense—an intuition that guides them in diagnosing and treating patients. It is assumed, therefore, that the good doctor will have the benefit of 5 senses: sight, sound, touch, smell, and taste. Sound: What does the patient tell or neglect to tell the doctor? What sounds does a joint produce when it moves? Sight: How does the patient present? Are they weary from pain or chronic disease? Touch: What does the joint feel like? How does it move? What is the patient’s response to stabilization of a joint? Smell: Is there an odor that helps detect the presence of infection or decay? Is the patient coming into contact with a substance causing harm or preventing healing?

A good doctor must employ these senses first to understand the patient’s needs and then to treat the patient. The sixth sense is a gift, one that comes from years of experience, an attention to detail, and a commitment to the craft of medicine. A recent trend toward virtual medicine is a dangerous path that must be walked with care and discretion so that the 6 senses are maintained and nurtured. Technology must be used to enhance and not limit these senses. The patient cannot be reduced to a 2-dimensional version of his/herself so that the doctor’s powers of diagnosis and healing are similarly limited.

Change in the office has occurred with mandates for electronic medical records and work-hour restrictions for residents. Data do not support that either change has resulted in a net benefit to patients. We are mandated to invest scarce capital to support new technology, resulting in increased pressure to recoup investment. Where there is a cap on revenue, the only way to increase net profit is to increase volume and decrease services. Physician time is the variable and can be streamlined by performing video conferences or smartphone consultations. Change may bring higher order, as the English philosopher John Locke said, but it is time for all of us as physicians to step back and question that this type of change is the path we must take. An office with a schedule of 80 patients seen at 5-minute intervals by physician assistants has no place in medicine. The pressure imposed by the insurance industry or hospital administrators to meet quotas has gotten out of hand and the time is now to say with a strong but fair voice a resounding NO!

The office visit with a history and physical examination is the most exciting and effective time to meet, console, and relate to our patients. The use of the 5 senses is critical. We must not let technological advancements (eg, smartphones, the Internet, and electronic medical records) destroy what was created and taught to us all through our training. The reward that is accomplished by placing one’s hand on a patient’s knee to understand its warmth and swelling, the tactile feeling of a fluid wave, or performing carefully with compassion a provocative maneuver that gives by sight a grimace of discomfort can tell so much more than a status update on the phone. We must not allow ourselves to be replaced by ancillary services for so-called efficiency and cost saving. Rather, we must be innovative and sharp. We must find the way to use the wonders of the virtual world without giving up the human consult.

Imagine that you are able to travel to Iguazu Falls, South America, to see one of the wonders of our world. You sit in that life raft moving upstream to feel the heat from the water as it crushes the rocks below, and you feel the mist on your face. You see the majesty and hear the screams and breadth of excitement of those around you, while you listen to the deafening sounds created by this waterfall. Now imagine you are required to report on this same experience through a video or some form of technology that the world has convinced us is the best and far cheaper substitute. This is our electronic medical record. A tool we are forced to use, and while it has a purpose, it is a sterile tool that fails to provide information that will give clues to awaken the sixth sense. It is a checklist that could allow for completion of a task—like how to fix a leaky faucet.

How then do we accomplish walking the fine line of working with nonphysicians and technology and yet delivering pinnacle care? The answer isn’t simple but it must include education and a commitment to the profession. We must make the public aware that we are one of the few professions that dedicate our lives to others by promoting health and advancing research. My colleagues, the pendulum has swung too far; it is time to take back our great profession through education of ourselves and the public. While technology may help the world connect, it has a limited role unless we first use our 6 senses to help our patients. We must not submit to a compassionless and callous approach that is the inevitable outcome of virtual medicine done with speed. We must maintain our dignity and let the public understand how many years of sacrifice has taken place to earn a sixth sense and not allow a third party to take it away. We are the only source of protection for our patients and we need each one of our senses to perform this task.

Advancing research has been a cornerstone for the orthopedic surgeon. Position statements through meta-analyses and systematic reviews of the literature have recently been utilized with increasing frequency. Combining data of potentially flawed studies can often lead to erroneous conclusions and may stray away from best practices. Is this where we want evidence-based medicine to go? The end result is that decisions are made by insurance companies who rely on these flawed studies to force clinical decisions on the physician, as was most recently seen by the investigation of viscosupplementation for knee osteoarthritis.¹

In a 2007 study published in JAMA (The Journal of the American Medical Association), only 62% of residents could appropriately interpret a P value.² How can we expect young clinicians to evaluate, interpret, and apply the multitude of evidence in the literature to everyday practice? We must marry the use of best evidence with our expertise to make the most informed decision while managing the expectations of our patients. In order to achieve that balance, we must rely on our intuition, our sixth sense. There is too much patient individuality and complexity surrounding each individual’s situation for a one-size-fits-all approach and for wholesale reliance on research to address each unique situation.

If Nathan Davis in 1845 was able to convince the New York Medical Society to establish a nationwide professional association to assist in regulating the practice of medicine, then it is time for all of us to stand up and insist on a code of ethics that is unrelenting and uncompromising. Our wise leaders of the American Orthopaedic Association (AOA) who founded the formation of orthopedics in America knew guidelines were needed to “foster advances in the care of patients, improve the teaching of orthopaedic surgery in medical schools and formal orthopaedic training, and to promote orthopaedic surgery as a surgical discipline worldwide.”³ It is now our turn to renew the guidelines and encourage our leaders to help educate ourselves and patients as we work with technology and administrators, nurses and physician assistants to deliver pinnacle care. We must reform medical education and the practice of medicine so that technology is used as a companion but not a substitute for our 6 senses.

The next time a patient comes into the exam room, sit down, look the patient in the eye, listen, touch, console anxiety, make a human connection, and form a lasting relationship. By all means apologize to your patients as you fill out the electronic medical record and insurance forms. Discuss how we are in the same crisis together and ask for their help as they have come to you for yours.

“New opinions are always suspected, and usually opposed, without any other reason but because they are not already common.”

—John Locke, English philosopher

How often are we told by non–physi­cian third parties how to do things, when to do things, and if we are even allowed to treat patients? How often do we foolishly mistreat a colleague within our own profession? This way of thinking and loss of control has caused many of us to retreat instead of taking the advice of great sports-minded athletes that “the best defense is a strong offense.” My hope is that we will become less divided, more united, and more willing to accept individuality of thought and progressive ideas.

The first inaugural Emerging Techniques in Orthopedics, Sports Medicine and Arthroscopic Surgery meeting in December 2011, sponsored by The American Journal of Orthopedics and The Orthopaedic Foundation for Active Lifestyles (www.ofals.org) has come and gone. Many lessons were learned from this exciting educational opportunity. I was honored to chair 50 faculty members who debated each other with strength and civil­ity so that there could be frank and meaningful exploration of many of the most complex issues in knee, shoulder, and hip surgery. This 2 1/2 day conference taught us that we can get to a consensus statement, alter how we treat our patients with the newest thoughts and patient safety, and still treat each other with respect and dignity. I am indebted to this group of men and women, especially Richard Hawkins, MD, and Russell Warren, MD, who, as honored professors, gave not only the perspective of evidence based medicine, but taught us how to achieve better outcomes for our patients.

Last year’s meeting also had a special section led by Jack Bert, MD, on Practice Management. How timely was it to hear and learn how we can continue the practice of medi­cine without third parties trying to change the face of our great field? We learned that too many of us have chosen to end private practice as we know it and join large corpo­rate models/hospitals. Does this truly benefit the consumer? Playing it safe has never let our profession rise to the top. The faculty helped question our decisions and taught us how we can still succeed on our own without the interference of others.

We look forward to this year’s Emerging Techniques in Orthopedics: An International Perspective confer­ence, which takes place December 6-8, 2012. It will prove to be even more exciting with the continued debate format. Invited faculty from France, Spain, Brazil, and Italy will challenge all of us on a global per­spective. Our honored professors will include, John Bergfeld, MD (knee), James Esch, MD (shoulder), and Gilles Walch, MD (international guest).

New sections will tackle the care of pediatric sports injuries, nonopera­tive treatment of osteoarthritis from steroids, glucosamine, platelet rich plasma, and advances in minimal invasive prosthetic shoulder replace­ment– does it make a difference, and the utilization of allografts – speed, cost, does it make sense. Our no holds barred debates on anterior cruciate ligament surgery, shoulder instabil­ity, arthroscopic rotator cuff repair without anchors, techniques of labral repair in hip arthroscopy, and more importantly, complications we have dreaded, seen, and fear with ways to remedy will be featured once again.

It is my hope that this conference will continue to create stimulating discussions. In these confusing and upsetting times, we will learn how facts meets fiction in our profession as we struggle, no different from others, in our society. It is our time to allow for structured chaos, both in the classroom in Las Vegas this December, and even more importantly, back in our practices at home. The crisis of medicine is upon us. If rules are to be made, we need to be there to help make them, and most importantly, be kind to each other. We must learn to ask for fairness from our administrators, nurses, and politicians as we navigate our new lives, while always keeping patients and their well being as the number one credo. This conference of sharing ideas, I believe, is a start. Some new opinions may not be well received, but they give us time to think and what to think about.

I am proud to have been the vehicle to bring all of us together and will do so again this December. Until then, we must each prepare for small challenges, whether it be educating our patients on insurance issues, understanding malpractice, helping for cost containment, or allowing the public to be educated on surgery centers and their utiliza­tion versus hospitals for certain procedures to save health­care cost dollars.

Is there a crisis in medicine? Yes. It is time to get involved and be proud of what we do. I hope we will all come together to help each other, because together we will succeed and maintain decision-making in the hands of the doctors.

Author's Disclosure Statement. Dr. Plancher wishes to disclose that he is Conference Chair of the Emerging Techniques in Orthopedics meetings.

“New opinions are always suspected, and usually opposed, without any other reason but because they are not already common.”

—John Locke, English philosopher

How often are we told by non–physi­cian third parties how to do things, when to do things, and if we are even allowed to treat patients? How often do we foolishly mistreat a colleague within our own profession? This way of thinking and loss of control has caused many of us to retreat instead of taking the advice of great sports-minded athletes that “the best defense is a strong offense.” My hope is that we will become less divided, more united, and more willing to accept individuality of thought and progressive ideas.

The first inaugural Emerging Techniques in Orthopedics, Sports Medicine and Arthroscopic Surgery meeting in December 2011, sponsored by The American Journal of Orthopedics and The Orthopaedic Foundation for Active Lifestyles (www.ofals.org) has come and gone. Many lessons were learned from this exciting educational opportunity. I was honored to chair 50 faculty members who debated each other with strength and civil­ity so that there could be frank and meaningful exploration of many of the most complex issues in knee, shoulder, and hip surgery. This 2 1/2 day conference taught us that we can get to a consensus statement, alter how we treat our patients with the newest thoughts and patient safety, and still treat each other with respect and dignity. I am indebted to this group of men and women, especially Richard Hawkins, MD, and Russell Warren, MD, who, as honored professors, gave not only the perspective of evidence based medicine, but taught us how to achieve better outcomes for our patients.

Last year’s meeting also had a special section led by Jack Bert, MD, on Practice Management. How timely was it to hear and learn how we can continue the practice of medi­cine without third parties trying to change the face of our great field? We learned that too many of us have chosen to end private practice as we know it and join large corpo­rate models/hospitals. Does this truly benefit the consumer? Playing it safe has never let our profession rise to the top. The faculty helped question our decisions and taught us how we can still succeed on our own without the interference of others.

We look forward to this year’s Emerging Techniques in Orthopedics: An International Perspective confer­ence, which takes place December 6-8, 2012. It will prove to be even more exciting with the continued debate format. Invited faculty from France, Spain, Brazil, and Italy will challenge all of us on a global per­spective. Our honored professors will include, John Bergfeld, MD (knee), James Esch, MD (shoulder), and Gilles Walch, MD (international guest).

New sections will tackle the care of pediatric sports injuries, nonopera­tive treatment of osteoarthritis from steroids, glucosamine, platelet rich plasma, and advances in minimal invasive prosthetic shoulder replace­ment– does it make a difference, and the utilization of allografts – speed, cost, does it make sense. Our no holds barred debates on anterior cruciate ligament surgery, shoulder instabil­ity, arthroscopic rotator cuff repair without anchors, techniques of labral repair in hip arthroscopy, and more importantly, complications we have dreaded, seen, and fear with ways to remedy will be featured once again.

It is my hope that this conference will continue to create stimulating discussions. In these confusing and upsetting times, we will learn how facts meets fiction in our profession as we struggle, no different from others, in our society. It is our time to allow for structured chaos, both in the classroom in Las Vegas this December, and even more importantly, back in our practices at home. The crisis of medicine is upon us. If rules are to be made, we need to be there to help make them, and most importantly, be kind to each other. We must learn to ask for fairness from our administrators, nurses, and politicians as we navigate our new lives, while always keeping patients and their well being as the number one credo. This conference of sharing ideas, I believe, is a start. Some new opinions may not be well received, but they give us time to think and what to think about.

I am proud to have been the vehicle to bring all of us together and will do so again this December. Until then, we must each prepare for small challenges, whether it be educating our patients on insurance issues, understanding malpractice, helping for cost containment, or allowing the public to be educated on surgery centers and their utiliza­tion versus hospitals for certain procedures to save health­care cost dollars.

Is there a crisis in medicine? Yes. It is time to get involved and be proud of what we do. I hope we will all come together to help each other, because together we will succeed and maintain decision-making in the hands of the doctors.

Author's Disclosure Statement. Dr. Plancher wishes to disclose that he is Conference Chair of the Emerging Techniques in Orthopedics meetings.

“New opinions are always suspected, and usually opposed, without any other reason but because they are not already common.”

—John Locke, English philosopher

How often are we told by non–physi­cian third parties how to do things, when to do things, and if we are even allowed to treat patients? How often do we foolishly mistreat a colleague within our own profession? This way of thinking and loss of control has caused many of us to retreat instead of taking the advice of great sports-minded athletes that “the best defense is a strong offense.” My hope is that we will become less divided, more united, and more willing to accept individuality of thought and progressive ideas.

The first inaugural Emerging Techniques in Orthopedics, Sports Medicine and Arthroscopic Surgery meeting in December 2011, sponsored by The American Journal of Orthopedics and The Orthopaedic Foundation for Active Lifestyles (www.ofals.org) has come and gone. Many lessons were learned from this exciting educational opportunity. I was honored to chair 50 faculty members who debated each other with strength and civil­ity so that there could be frank and meaningful exploration of many of the most complex issues in knee, shoulder, and hip surgery. This 2 1/2 day conference taught us that we can get to a consensus statement, alter how we treat our patients with the newest thoughts and patient safety, and still treat each other with respect and dignity. I am indebted to this group of men and women, especially Richard Hawkins, MD, and Russell Warren, MD, who, as honored professors, gave not only the perspective of evidence based medicine, but taught us how to achieve better outcomes for our patients.

Last year’s meeting also had a special section led by Jack Bert, MD, on Practice Management. How timely was it to hear and learn how we can continue the practice of medi­cine without third parties trying to change the face of our great field? We learned that too many of us have chosen to end private practice as we know it and join large corpo­rate models/hospitals. Does this truly benefit the consumer? Playing it safe has never let our profession rise to the top. The faculty helped question our decisions and taught us how we can still succeed on our own without the interference of others.

We look forward to this year’s Emerging Techniques in Orthopedics: An International Perspective confer­ence, which takes place December 6-8, 2012. It will prove to be even more exciting with the continued debate format. Invited faculty from France, Spain, Brazil, and Italy will challenge all of us on a global per­spective. Our honored professors will include, John Bergfeld, MD (knee), James Esch, MD (shoulder), and Gilles Walch, MD (international guest).

New sections will tackle the care of pediatric sports injuries, nonopera­tive treatment of osteoarthritis from steroids, glucosamine, platelet rich plasma, and advances in minimal invasive prosthetic shoulder replace­ment– does it make a difference, and the utilization of allografts – speed, cost, does it make sense. Our no holds barred debates on anterior cruciate ligament surgery, shoulder instabil­ity, arthroscopic rotator cuff repair without anchors, techniques of labral repair in hip arthroscopy, and more importantly, complications we have dreaded, seen, and fear with ways to remedy will be featured once again.

It is my hope that this conference will continue to create stimulating discussions. In these confusing and upsetting times, we will learn how facts meets fiction in our profession as we struggle, no different from others, in our society. It is our time to allow for structured chaos, both in the classroom in Las Vegas this December, and even more importantly, back in our practices at home. The crisis of medicine is upon us. If rules are to be made, we need to be there to help make them, and most importantly, be kind to each other. We must learn to ask for fairness from our administrators, nurses, and politicians as we navigate our new lives, while always keeping patients and their well being as the number one credo. This conference of sharing ideas, I believe, is a start. Some new opinions may not be well received, but they give us time to think and what to think about.

I am proud to have been the vehicle to bring all of us together and will do so again this December. Until then, we must each prepare for small challenges, whether it be educating our patients on insurance issues, understanding malpractice, helping for cost containment, or allowing the public to be educated on surgery centers and their utiliza­tion versus hospitals for certain procedures to save health­care cost dollars.

Is there a crisis in medicine? Yes. It is time to get involved and be proud of what we do. I hope we will all come together to help each other, because together we will succeed and maintain decision-making in the hands of the doctors.

Author's Disclosure Statement. Dr. Plancher wishes to disclose that he is Conference Chair of the Emerging Techniques in Orthopedics meetings.