Abstract
Orthopaedics like all other branches of medicine is likely make tremendous scientific progress in the new millennium. The extent of this progress will depend on how we have done in last 1000 years. I feel it is important in a discussion of this nature to separate orthopaedic surgery from orthopaedic surgeons. Progress in orthopaedic surgery need not necessarily mean progress of the orthopaedic surgeon or for that matter the medical profession.
As an orthopaedic surgeon we have to deal with many issues such as taking care of all the patients who come our way; balancing our responsibilities to our patients and our families; fighting with the administration in the interest of good patient care and for our own economic well-being; and trying to keep up with advances in orthopaedics in order to stay, both competent as well as competitive. Unlike my generation you must deal with a host of health-care delivery systems, need to have a business acumen that rivals that of a corporate CEO and increasingly you require knowledge of coding that should qualify you as medical-records librarian. Before long you may become convinced unfortunately that medicine is really a business and not a profession. The essence of professionalism in medicine is the willingness of the physician to value the patient’s welfare above his or her own and to provide care when necessary without remuneration or at personal inconvenience. It is unselfish attention to the welfare of others and advancement of our patient interests that earns the public’s respect and trust. These in turn have caused the public to support the autonomy of medical practice, including the privilege of self-regulation. However, this trust has begun to erode. Financial return and economic security are important to all of us. But if and when the commercial ethic in medicine becomes so predominant that it is perceived by the society as greed replacing altruism, we will certainly face loss of autonomy and the ability to self-regulate. I believe that we are nearing that point when society will view medicine as a trade rather than as a profession and we will be treated accordingly.
Looking to the roots of western medicine, Hippocrates (466 to 370 BC) is recognized as the father of modern medicine. However the earliest mention seems to be in the Indian literature, the Rig Veda, the oldest book of Veda period (1500–99 BC) when the use of artificial leg as well as artificial eyes and teeth were recorded. Before the 20th Century, the practice of medicine employed little science and was mostly an art. Yet despite this its practitioners were held in the highest esteem. 100 years ago, a physician had few tools with which to work except those of compassion and caring. However, during this century a technological explosion has led to spectacular advances in medicine and as a consequence physicians are infinitely better equipped to bring good health-care to their patients. Our orthopaedic roots date back to 1743 when Nicholas Andre unveiled his splinted crooked tree. However, it was not until the use of plaster of Paris 100 years later that we moved out of the splint age. Modern fracture management rapidly accelerated during and after World War I with Sir Robert Jones espousing the principles of Hugh Owen Thomas. This was followed by the impact of World War II and subsequent war has led great advance in the management of musculoskeletal trauma.
Operative practice however came into its own with the introduction of modern anesthesia by William Morton a dentist in 1846, sterility by courtesy of Joseph Lister in 1876 and antibiotics from Alexander Fleming in 1945. These advances made the outcome of surgery more predictable and the practice of orthopaedics, in particular expanded exponentially as operative risks decreased substantially. New methodologies involving joint replacement, arthroscopy, spinal instrumentation and reconstruction following trauma were all developed in the latter part of this century. Last 30 years has sen the rapid changes in technology and it may be a good time to pause and think where all are going and take an account of our games and losses.
The Future: Developments in physics and engineering have rewarded our specialty with spectacular advances, but the changes in biotechnology by means of the DNA molecular genetic engineering and stem-cell transformation will be even more profound. This new area of biology has the potential to conquer cancer, grow new blood vessels in cardiac patients, create new organs from the stem-cells and possibly even reset the genetic code that causes our cartilage to age. Very soon we will be able to transplant virtually any tissue without fear of rejection. In the next century, when computer technology merges with biotechnology, we may be able to map the ten billion or so neurons in our brain and replace our minds with a machine.
Changes: Some of these changes in medical science and particularly in orthopaedics is already hear. It is important for orthopaedic surgeons to realise this and to prepare themselves so that they are not left behind.
Most important thing is “orthopaedic education” both at undergraduate and postgraduate level and continuing education. We must re emphasize that orthopaedic surgery means total care of the musculoskeletal system both conservative and operative. Most of us are interested in operative care because it is lucrative, and as Graham Apley use to say “Surgery in Fun” but 80% of our patients need conservative treatment. Scientific basis of our conservative treatment is appealing and is no better than the alternatives medicine providers. No wonders so many of our patients are now moving to “sinseh” and other providers, with dubious repetition.
Emphasizes in our residency is operative treatment and the residents enjoy it. Our continuation education if you may call it “Education” is sponsored one-way or other by multinational is mainly technology oriented to promote a particular product. This is not difficult to understand. These multinational are listed companies and it is not surprising that their motive is to make profit for their shareholders. Unfortunately I feel we are being caught and deviated from our goal of education and professionalism.
Type of education we are getting and type of education we need is quite different. What we need is an orthopaedic specialist with compassion but what we are becoming is a high-grade technician.
More emphasizes must be placed both at undergraduate and postgraduate level to have a better understanding of the biology of healing of the musculoskeletal system. We must emphasize on the conservative treatment and put it on a more scientific basis. We can no longer dismiss the alternatives as being substandard or even dangerous. We must therefore offer appropriate non-operative alternatives to our patients. If we do not adjust to this reality, we will be relegated to secondary status and will be called up only when operative intervention is a last resort. We are not just surgeons but we are physicians also lastly we may have gained in technology but may have lost in compassion. Medicine is both a science and art and even balance is necessary to provide good medical care. I am sure we will progress in the science of medicines but I hope we will not lose the art of medical practice. For future we must keep abreast with the new technological advances but should not forget the patient care is more than a technical achievement. As Ambre Pare said “we the physician treat the patient He cures them”.
The abstracts were prepared by Professor Jegan Krishnan. Correspondence should be addressed to him at the Flinders Medical Centre, Bedford Park 5047, Australia.
