Eeric Truumees, MD, FAAOS

AAOS Now

Published 12/31/2019
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Eeric Truumees, MD, FAAOS

Physician Perspectives and Overall Professional Culture

As a communications vehicle of the Academy, AAOS Now seeks to offer news that is relevant to orthopaedic surgeons, as well as provide the Academy’s perspective on various issues, often important advocacy issues. That different parties have different interests and perspectives is normal, reasonable, and not a reflection of “bad” intention. Yet, the inability to see another perspective can devolve rational debate into noisy, nonconstructive invective, masquerading as dialogue. Over the past several months, we have covered topics and received letters about articles that I would not initially have considered controversial.

An example is our June 2019 cover story about John Keating, MD, FAAOS, and his nonprofit, Surgeons for Strays titled, “Animal Rescue: Orthopaedic Surgeon Helps Stray Animals in Need of Surgical Care.” I never anticipated the harsh criticism he would receive from the veterinarian community. Should I have? From my perspective, Dr. Keating was working with a veterinarian on animals that were not likely to receive paid treatment from a veterinary bone specialist. Yet, as I read some of the letters, the veterinarians’ perspectives were that he had violated their scope of practice. I do not condone any of the abuse he received, and none of Dr. Keating’s actions was undertaken for any reason other than a love of animals. On the other hand, I know that certain scope-of-practice issues incense allopathic orthopaedic surgeons, too.

The issue led me to consider the impact of perspective on issues both surrounding and internal to orthopaedic surgery. First, does orthopaedic surgery have a common perspective and personality? If so, is that a good thing? Do personality traits, such as greater selflessness, improve or diminish the chances for this cohesion? Will attracting a more diverse group of people into orthopaedics strengthen the field or challenge solidarity, particularly in areas of advocacy? Finally, to what degree will attracting a more diverse group to orthopaedics require identifying and recruiting people from diverse backgrounds who are most likely to be interested in orthopaedics versus changing the culture of orthopaedic surgery to attract a wider group?

Perspective

To answer the last question about attracting underrepresented individuals to orthopaedic surgery, the best answers probably come from asking those individuals themselves. Interestingly, the article about Dr. Keating’s nonprofit came on the heels of a popular TED Talk by Barbara Natterson-Horowitz, MD, a cardiology professor at the University of California Los Angeles, who discussed her experiences working with veterinarians at the Los Angeles Zoo in imaging and treating cardiac issues in animals. Ultimately, she makes the case that each profession would do well learning more from the other, and she cited a conference series established to bring physicians and veterinarians together. Dr. Natterson-Horowitz suggested that a barrier to this was snobbery on the part of physicians but noted that veterinary school admissions are more competitive than medical school admissions.

Recently, in my hospital, the physician lunchroom was abuzz with stories of hospital systems firing physicians in favor of lower-cost advanced practice nurses. A recent story detailed a suburban Chicago health system that terminated 15 physicians staffing seven urgent care centers. The article went on to point out other cases, including two dozen pediatricians losing their jobs in favor of a “business model that relies more heavily on nurse practitioners” and the case of an anesthesiology group being replaced by a lower-cost professionals that utilizes certified registered nurse anesthetists more extensively. Although some doctors in the room were furious, others—presumably those who felt their job descriptions prevented this type of displacement—were more bemused.

What has been the most interesting to me is the debate around “Medicare for All.” As with surprise medical billing and other legislation, the devil is in the details. Yet, as currently outlined, the plans proffered by presidential hopefuls Senators Elizabeth Warren (D-Mass.) and Bernie Sanders (I-Vt.) include marked cuts in physician compensation. Various articles have pegged this cut ranging from 13 percent to 40 percent. Senator Warren specifically lists orthopaedic surgery as an “overvalued specialty.” Although overall physician response has been negative, from an advocacy perspective, the range is truly remarkable. A Medscape article recently detailed the range of these responses on Twitter, where the debate seemed to range from practical issues (many of which I detailed in my recent Editor’s Message on orthopaedic surgeon pay, published in the September 2019 and November 2019 issues of AAOS Now) to questions of social justice and access to care.

Most of these points, on both sides of the debate, are valid, depending on your perspective. My question became: How does the “house of medicine,” or specifically orthopaedic surgery, present a united front in addressing these divergent conclusions in an incredibly complex healthcare marketplace?

Personality and selflessness

Do these differences arise from the varying individual personalities of the physicians involved? Are some simply more selfless and others greedy? Or are some more practical, whereas others “lead from the heart”? Can these differences be reconciled? Clearly, there is a continuum. Selfless behavior is prosocial in that it serves the greater good. Whether sacrificing for your practice, neighbors, or country, servant leaders and selfless individuals are the backbone of any strong, sustainable group effort.

On the other hand, others have shown that excessive selflessness and pathological altruism “lead to suicide martyrdom, animal hoarding, helicopter parenting, and other social ills.” More typically, though, failure to balance practical considerations with generosity has other effects, including increased risk of burnout and attrition. A 2017 article published in Harvard Business Review suggested, “When you’re dealing with people who have a history of selfishness, don’t reinforce their behavior by being too generous.” In health care, this does not apply to our patients, but, clearly, there are other stakeholders who are more than happy to accept our generosity and fail to pay it forward.

To me, it’s clear that, to win the argument, we often pretend that there is only a single motivation behind a complex decision-making process. This is almost always a gross oversimplification. For example, a study of Chinese physicians found that both monetary rewards and increased community recognition of knowledge stimulated otherwise selfless or prosocial behavior. Another study concluded, “Although financial incentives can be effective, they often fail to motivate complex actions and may oversimplify physicians’ motivations. … Professionals are also driven by autonomy, mastery, and a sense of purpose, and if a system incentivizes actions that undermine these values, it can ‘sap’ physicians of their internal drive.”

An individual’s personality can, with varying degrees of success, be characterized in terms of personality inventories such as Myers-Briggs and the Five-factor models. The Five-factor Inventory describes individuals across a spectrum of five traits: agreeableness, neuroticism, conscientiousness, openness, and extraversion. For the purposes of this discussion, agreeableness describes an individual’s altruism and trust: “Disagreeable individuals find it easier to promote their own interests, [but] those who are more agreeable tend to enjoy better relationships with others.” The Myers-Briggs Inventory follows in describing individual personalities based on thinking, feeling, sensing, and perceiving. Here, significant gender differences have been identified.

Professional culture

Our professional groups contain individuals with wide-ranging personalities. However, for each field, there is a “professional identity” that incorporates certain shared characteristics. As noted in our article about the new clinical practice guideline for the Evaluation of Psychosocial Factors Influencing Recovery from Adult Orthopaedic Trauma, “Military service members exhibit a unique psychosocial profile.” Similarly, doctors, including orthopaedic surgeons, can be seen as “a breed apart.” Perhaps unsurprisingly, surgeons tend to exhibit lower agreeableness than other medical specialties. On the other hand, we “tend to be more conscientious compared [to] other specialties, psychiatry for example.”

Several studies have found that personality traits affect career choice. A meta-analysis of 12 studies looking at the relationship between personality type and choice of field of study found significant differences. For example, medical students had higher levels of agreeableness than law and business students and also exhibited higher levels of conscientiousness than arts and humanities students. However, one study of Indian medical students found that altruism was not common but could be influenced by peers, parents, and training culture.

Understanding the confluence of individual and group personalities is critical to attracting individuals to the field, adopting new policies, and devising the best ways of communicating. Similarly, “Underappreciated values specific to professional groups can cause tension and undermine efforts to promote shared goals and institution-wide initiatives.”

As with the decision-making described in this issue’s point/counterpoint article on clavicle fracture treatment on page 6, individuals value return to activity, cost, and the risk of pseudarthrosis very differently. This is no different when considering questions of autonomy, reimbursement, education, etc. For many individuals, the relative value ascribed to different aspects of practice will change over time.

Conclusion

When orthopaedic surgeons reach consensus decisions, whether for their practice or the Academy as a whole, consideration of alterative perspectives is key. This process is typically best fostered by having a diverse set of voices at the table. In those discussions, “good” intentions can win out over those that appear more self-serving on the surface. Ultimately, sustainable solutions typically lie in the realistic, balanced part of the selflessness spectrum. However, healthy debate, including incorporating other less frequently heard opinions, will strengthen results by considering a wider range of alternatives. Incorporation of such viewpoints will increase the group’s appeal to a wider base of potential participants.

Eeric Truumees, MD, FAAOS, is the chair of the AAOS Now Editorial Board; editor-in-chief of AAOS Now; and an orthopaedic spine surgeon in Austin, Texas, where he is also professor of orthopaedics at the Dell Medical School, University of Texas.

References

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