Orthopaedic surgical techniques have evolved rapidly over recent decades, and enormous improvements in the clinical outcome have been achieved. Orthopaedic surgeons generally believe that they are top specialists in bone and joint problems. However, I am skeptical as to whether doctors in other medical fields or the general population have a similar opinion. I am afraid that these days orthopaedic surgeons might be regarded just as "surgeons operating on bones and joints." This means orthopaedic surgeons are required only when the patients require surgery. Doctors from range of medical fields have become interested in bone and joint problems, including neurosurgeons, rheumatologists, endocrinologists, rehabilitation doctors, family doctors, pediatricians, gynecologists, pain medicine doctors and even traditional Korean medicine practitioners. Our competitors are everywhere in all directions and in all dimensions. However, I do believe that doctors well-trained in the orthopaedic field are the right one to take the best care of every bone and joint problem. This assertion is not for the sake of orthopaedists but for the sake of national health.
There are several reasons for the current undesirable situation. Among them, I would point out that orthopaedic surgeons have become too surgically oriented. Historically, orthopaedics was based on non-surgical managements of children to allow them to grow "straight." With the advances in medical technology, surgery has become possible for the spine and extremities, and must have been a cutting-edge technology at that time. Orthopaedic surgeons have sought for dextrous surgical skill and accumulated surgical experience as their career goals while they have disdain for non-surgical management as a job to be done by those with little surgical talent. From this attitude, we have focused on how to perform surgery rather than how to understand the patient condition or the disease itself. We need to change this attitude to non-surgical managements for several reasons. First, in most bone and joint problems, a well-balanced therapeutic approach between non-surgical and surgical methods would reach the best outcome. Second, it is non-surgical intervention, not surgery that the patients really want. If we do not pay attention to non-surgical intervention, the patients would believe that orthopedic surgeons are just surgeons, not comprehensive care-givers for bone and joint problems. Third, the market for non-surgical intervention is actually much larger than that of surgical treatments.
More importantly, orthopaedic surgery has long been a treatment-oriented discipline. Treatment-oriented surgeons may produce good surgical results. However, without a deep understanding of a disease we cannot provide comprehensive management for it. This is why osteoporosis and arthritis patients tend to visit endocrinologists and rheumatologists rather than orthopaedic surgeons. Genetics is another field that sheds new light on old bone diseases. For example, infantile cortical hyperostosis (Caffey disease), despite its low incidence, has long been well-known to orthopaedic surgeons because most patients present with limb pain. It is a serious-looking but essentially benign disease in its natural course, and would not interest treatment-oriented surgeons at all. However, the parents usually ask us why their children are affected by this disease. The answer was reported in 2005; a specific mutation in the type I collagen gene. However, few orthopaedic surgeons are aware of this new finding, and even the textbook published in 2007 still describes it as "idiopathic."
Decades ago, few researchers in biomedical fields were interested in bone and joint research. Nowadays, bone and joint are one of the most rapidly growing fields in biomedical research, and considerable research products regarding bone and joint have emerged out of diverse medical fields, not just orthopaedic laboratories. Paramount information regarding the etiology and pathogenesis of osteoporosis, disc degeneration, joint destruction, many "idiopathic" bone and joint diseases, and even congenital spine and limb anomalies are coming out from basic research, endocrinology, rheumatology, and genetics laboratories. Therefore, specialists in every orthopaedic field should constantly be updated with this flood of knowledge, and should lead orthopaedic society to catch up with the current progress of knowledge. This should also be stressed in orthopedic education for medical students, orthopedic residents as well as fellows. Without an up to date understanding of bone and joint diseases, we cannot compete with our competitors and cannot provide optimal treatment to our patients.
Another aspect of understanding a disease is when we are confronted with novel therapeutic methods introduced everyday to the market. Surgeons are not exempt from human nature in that they tend to prefer a novel method even though its safety and effectiveness have not been verified. We can cite many examples of promising methods that have been introduced to solve difficult cases or to manage problems at much lower cost, either financial or physical, but finally turned out to be neither safe nor effective. Then, how can our patients be protected from the harmful influence of this incorrect information? We, the treating orthopaedic surgeon, should remain keen to decide whether to adopt a so-called novel, promising method or not. To decide properly, we need to fully understand the disease. It is not enough that one can treat the disease well.
Overall, to provide better care of our patients in the long run, we need to change our education/training system and direct research to better understand a disease rather than just treat it.