e5(1) C OPYRIGHT Ó 2014
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
AOA Critical Issues On Volunteerism and Orthopaedics AOA Critical Issues Scott D. Weiner, MD, G. Paul DeRosa, MD, Christopher T. Born, MD, Lindley B. Wall, MD, and Bradley K. Weiner, MD Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Sometimes give of your services for nothing. And if the opportunity for serving a stranger in financial straits, give full assistance to all such. For wherever the art of medicine is loved, there is also a love of humanity—Hippocrates As the quotation above suggests, the selfless giving of one’s services and time has been recommended by generations of medical leaders since medicine’s earliest emergence as a paid profession. Whether such recommendations are prescriptive (i.e., what a physician should do if he or she is so inclined) or descriptive (i.e., what a physician is obligated to do, given his or her skills, as part of being a physician) has long been a subject of debate. The philosophical center of the debate is whether health care is a ‘‘right’’—regardless of one’s ability to pay for it or deliver himself or herself to a physician. For if it is indeed a ‘‘right,’’ we are obligated to provide care to all. One man’s right is another man’s moral and ethical obligation. In this spirit, a recent American Orthopaedic Association (AOA) symposium and round table discussion (at the 2012 annual meeting) explored whether volunteerism should be considered a ‘‘core competency’’ and, if so, how we might implement it as we do the other competencies outlined by
the Accreditation Council for Graduate Medical Education (ACGME). It is our opinion that a careful reading of the currently accepted ACGME competencies indicates that volunteerism clearly falls under the ‘‘professionalism’’ umbrella and should be considered part of what we must do (and must teach) to be (and to produce) complete, competent orthopaedic surgeons. In an on-site survey, the audience felt strongly that role modeling by faculty is an important predictor of resident behavior. Although most of the audience felt neutral about incorporating an international elective in a resident curriculum, most felt that there is substantial value in a program offering this experience for faculty and residents. Sixty percent felt that volunteerism as a core competency was a critical issue for the AOA. There are many ways in addition to international travel in which the importance of volunteering in our and our trainees’ careers can be emphasized. Local Volunteerism Although more general forms of volunteering (such as nonmedical community service) are often pursued by orthopaedic surgeons, local volunteerism as an orthopaedic core competency is
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:e5(1-4)
d
http://dx.doi.org/10.2106/JBJS.M.00383
e5(2) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 1 J A N UA RY 1, 2 014 d
d
O N V O LU N T E E R I S M
AND
O RT H O PA E D I C S
d
inextricably tied to the provision of orthopaedic care without pay to those within the community who are underinsured or uninsured. Unfortunately, many opportunities for practicing community surgeons to volunteer by giving freely of their services have been lost because of the need to generate income. It is, quite simply, becoming financially tighter and tighter for orthopaedists, and expected changes in reimbursement will continue to raise the financial pressure. The same holds true for academic orthopaedic surgeons, where the need to justify their salary to the department chair (and the chair to the Dean) not uncommonly takes precedence over service to the community. Consequently, community doctors often refer indigent patients to academic centers for care, academic physicians refer them to resident-run clinics, and residents are often left to manage poorer, sicker patients with little to no oversight by attending physicians. That the care provided to these patients is suboptimal is well recognized and often just accepted as ‘‘the way it is.’’ Inevitably, residents learn (both explicitly and implicitly) that the care of those without financial means is simply not worth the attending physician’s time and effort—and this lesson is carried with them as they begin their own orthopaedic careers, whether those are academic or community-based. Clearly, such behavior is unprofessional, and we believe that discovering ways to break this unfortunate cycle is a critical issue to be faced by all of us in orthopaedics. National and International Volunteerism Currently, there are over 6000 global short-term medical missions undertaken per year. Some are administered by governments, some by faith-based organizations, and some through charitable foundations. There is tremendous need. Although cancer and cardiovascular disease gather the attention of the press, given their life-threatening nature, musculoskeletal disease is the major factor negatively impacting functional quality of life worldwide and this impact is increasing1. Fortunately, musculoskeletal disease and trauma also lend themselves well to short-term medical interventions that are commensurate with the character of most medical missions. Orthopaedic problems can be addressed surgically at central locations in a concentrated fashion over a period of weeks by experts from medically developed regions who travel to underserved locations worldwide to provide the care. Preoperative preparation and postoperative rehabilitation can be managed by local medical, nursing, and surrogate providers before and after the surgical procedures. Ideally, such short-term stays should be tied to education of the local care providers in order to afford a lasting, continuous impact. Ironically, it is often easier for surgeons to volunteer and provide surgical care overseas than in the United States. Legislation that would reduce licensing issues across state lines and some measure of tort reform could remove some of those barriers to ‘‘national volunteering.’’ Organized Disaster Response Volunteerism Within minutes, the earthquake that struck Haiti in January 2010 resulted in thousands of orthopaedic injuries. Over 500 members of the American Academy of Orthopaedic Surgeons
(AAOS) responded in some form, volunteering their services to the U.S. government, nongovernmental organizations (NGOs), and independent hospitals that sent teams to Haiti. Many surgeons arrived on their own as spontaneous unaffiliated volunteers (‘‘SUVs’’) with minimal equipment, no pharmaceuticals, no supply chain, and no sustainment provision for food, water, shelter, transportation, or security. They had no plans and presented no credentials. Many practiced ‘‘medical tourism’’ and acted as health-care providers outside of their areas of expertise. Following analysis of both federal and professional society response efforts, the AAOS and the Orthopaedic Trauma Association (OTA) recognized that there was no coherent, overarching organizational plan by which orthopaedic surgeons could be trained and pre-credentialed as surge responders to an internal or international mass casualty incident. These organizations were unprepared to coordinate civilian surgeon response and had no database of qualified responders. In addition, there was a realization that without preexisting relationships with the U.S. government, the response of established NGOs was unlikely to be highly efficient or effective. Accordingly, a project team was impaneled by the Board of Directors of the AAOS to develop a process to identify a cadre of orthopaedic responder surgeons for the future. The project team consisted of members of the AAOS and OTA along with orthopaedic consultants to the Surgeons General of the Army, Navy, and Air Force. The charge to the team was to review issues of orthopaedic response to international mass casualty events and to design a formal response plan. In addition, certification, credentialing, and training pathways for these surgeon responders were to be developed. These surgeons would undergo mass casualty response education and training and would become pre-credentialed volunteers identifiable in a database cooperatively maintained by the organizations. Criteria for inclusion in either the ‘‘acute phase’’ or ‘‘sustaining phase’’ responder types have since been developed, mandatory educational pathways have been identified, and a society database has been established. A new ‘‘austere environment’’ Disaster Response Course (DRC) modeled on the military’s Combat Extremities Surgical Course (CESC) has been developed by the Society of Military Orthopaedic Surgeons (SOMOS) for the AAOS and OTA. Over 250 civilian volunteer orthopaedic surgeons have taken the course as of April 2013, and over 190 participants have been listed in the AAOS responder database. Enrollees benefit from a full day of didactic instruction on personal preparedness, on working and operating in an austere environment, as well as on ethical and cultural considerations. The risks of doing this kind of work are discussed. These include liability considerations as well as health issues related to disease, fatigue, deconditioning of volunteers, and unfamiliarity with field work. The relationships between responder volunteers and local medical and governmental agencies, NGOs, the U.S. military, and the Department of Health and Human Services (DHHS) are explored and explained. A one-half-day cadaver-based laboratory program on skills appropriate for an austere surgical environment follows the didactic program. Additional courses are scheduled for the future.
e5(3) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 1 J A N UA RY 1, 2 014 d
d
O N V O LU N T E E R I S M
AND
O RT H O PA E D I C S
d
Relationships with the U.S. military and the U.S. government response system are being developed, and ways by which civilian surgeons could become pre-credentialed to work as temporary federalized employees of the U.S. military and/or DHHS are being explored. ‘‘Federalization’’ provides some level of liability, job security, and Workers’ Compensation protection for injuries sustained while performing authorized voluntary services. This protection includes medical care and disability compensation. It should be noted that disability payments are based on federal General Schedule (GS) pay rates. This is unlikely to provide adequate disability compensation for a surgeon’s lost career. Supplementary private disability insurance coverage might be prudent to acquire. Within the military, all medical providers are entered into a common database. As a Department of Defense (DoD) medical provider moves between facilities, his or her credentialing file can be pulled up by the base or hospital commanding officer for approval. The AAOS and OTA have been working with their military liaisons to see whether appropriately credentialed civilian volunteers might also be placed into the military’s system. Barriers to this inclusion include the labor-intensive requirement for initial background checks and yearly updates. In addition, the DoD might not be willing to budget contingency dollars to cover the costs of potential tort defenses. A Multi-Specialty Enhancement Team (MSET) pilot program to increase surge capacity in several surgical specialty areas including orthopaedics is also under development by DHHS. Participants in the AAOS disaster responder program could logically be used to ‘‘backfill’’ federal Disaster Medical Assistance Teams (DMATs) and International Medical Surgical Response Teams (IMSuRTs). A streamlined credentialing process for placement of AAOS-certified surgeons into the MSET program is also being explored. The Haiti earthquake demonstrated that U.S. government agencies and the military had insufficient depth of orthopaedic surge capacity to rapidly and effectively respond to a major incident that triggered massive numbers of musculoskeletal injuries. There will likely be a future need for U.S. civilian physicians and surgeons to be able to work side by side with our medical colleagues in uniform and with other civilians working with federal disaster response agencies. Sechriest et al.2 looked at deployments of U.S. Navy casualty receiving and treatment ships (CRTSs) in response to mass casualty (earthquake) incidents in Indonesia (2004 and 2005) and Haiti (2010). They found that musculoskeletal extremity injuries in age and sexdiverse populations represented the majority of clinical diagnoses managed by these response assets. They concluded that CRTSs were useful in augmenting shore-based facilities for the delivery of medical services. Their data also suggested that medical and surgical staff numbers could be ‘‘. . .ramped up on short notice and as needed. . .,’’ including the use of civilian resources as was done in Haiti. Unfortunately, there is no uniform process to pre-credential these civilian medical professionals for such service. The ideal solution would be to have a common credentialing pathway, valid across all governmental agencies and the military, by which civilian volunteers could be
vetted, trained, and certified in advance for this type of work. Activation and deployment would be on an ‘‘as-needed’’ basis. Ultimately, legislative statutory relief may be required to facilitate this process. Obviously, this should not be limited to orthopaedic surgeons but should be implemented across a number of vital responder-oriented medical specialties such as general and neurological surgery, anesthesiology, pediatrics, emergency medicine, and infectious disease. Specific professional societies could be used to develop focused educational programs (such as the DRC) in conjunction with the government. Teaching and Encouraging Volunteerism The need to dedicate time to income-generating activities is not only felt by those in mid-career who have faced changes in reimbursements requiring them to work longer and harder while making less money than they did ten or fifteen years ago. Increasing numbers of graduating residents and fellows are entering the field with considerable debt, given the escalating costs of undergraduate and graduate education, and the giving of orthopaedic care without remuneration (even if it is in their heart to do so) may well be a secondary consideration to personal financial stability for our next generation of orthopaedists. Recognizing this, we must aim to find novel ways both to deliver care as efficiently as possible and to instill a spirit of volunteerism in our young workforce. Clearly, volunteerism should also be brought to the forefront early in residency training. Educating young surgeons regarding the importance of, and the need for, volunteerism is crucial. It has been shown that early exposure and involvement in volunteerism during training increases the likelihood that surgeons will continue to participate in such activities once they are in practice. Teaching volunteerism is often done by example. With faculty spending less time volunteering, such examples are lost or at least inconsistent. Didactic lectures alone are not sufficient. With proper education, guidance, and mentorship, volunteerism can assume its rightful place as part of ‘‘what we do’’ as professionals who practice orthopaedic surgery. That said, there are currently only a handful of orthopaedic training programs that have integrated an international volunteer rotation into their educational curriculum. For years, residents at Pennsylvania State University (Hershey) have optionally traveled with attending staff to Honduras to provide pediatric orthopaedic care. Many other residency programs have established or are planning to incorporate a rotation in international volunteerism as a requirement. The University of California San Francisco orthopaedic residency program has offered an international rotation in its training since 1998 and formalized it into the program in 2001. The participants in that program were surveyed and two important conclusions could be drawn: (1) those residents who participated in the program were more likely to believe that physicians had an obligation to the medically underserved, and (2) participants were more likely to continue international volunteerism after graduating from residency than those who did not participate3. An international volunteer rotation allows residents to see firsthand the contrast in resource allocation, the deficit in
e5(4) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 1 J A N UA RY 1, 2 014 d
d
O N V O LU N T E E R I S M
AND
O RT H O PA E D I C S
d
educational opportunities, the lack of access, and the inequities in distribution of health care and services. It also provides a wholly unique learning experience—providing autonomy, exposure to different cultures, the opportunity to adaptively and creatively provide care with minimal resources, exposure to pathologies and disease processes in advanced stages, and the chance to establish relationships across borders. Although such an experience has many benefits for both the international community and the individual, and some residencies have made it ‘‘part of the program,’’ there are real hurdles to be overcome. First, the financial support for such a rotation is limited. The time away from the institution is not supported by graduate medical education funding. Exploring philanthropic and other opportunities is often needed. Not all institutions are able to support this endeavor and grant funding can be difficult to obtain. Second, many programs rely on residents to ‘‘man/woman the ship’’—and ‘‘away rotations’’ might leave the home institutions underserved. Third, real risks may exist, and additional insurance coverage may be necessary for liability and health coverage for volunteers. Finally, not all residents are able or willing to participate (e.g., because of discomfort with international travel, time away from family, or loss of vacation). Creative ways to address these issues will need to be developed prior to considering a ‘‘mandate’’ for incorporation into residency training. Offering optional local and international opportunities may be the best solution currently. Assessing ‘‘Volunteerism’’ Although assessing volunteerism as a subcompetency of professionalism is easy in the case of orthopaedic residents—residents can be evaluated in their management of charity cases—doing so in the case of practicing orthopaedic surgeons is fraught with difficulties. Local and legal considerations regarding taking call and nonemergency indigent care are complicated and legally and ethically challenging. That said, the American Board of Orthopaedic Surgery (ABOS) appears to agree that volunteerism is part of what we must do to be complete orthopaedic surgeons and should be part of the certification process itself. Under ‘‘professionalism,’’ the Board specifically asks, ‘‘Does the applicant demonstrate behavior that reflects responsible attitudes, and accepts community responsibility for emergency and/or indigent care.’’ Per the previous ABOS director, ‘‘The ABOS believes that a competent surgeon must accept responsibility in the community where he or she lives.’’ How this is to be assessed and weighted during the oral cer-
tification or maintenance-of-certification process is yet to be established. But as simple, local on-call and indigent care issues become increasingly contentious, the certification process provides one way in which the greater orthopaedic community as a whole might provide leadership and guidance regarding the issues. Conclusions Providing orthopaedic care to local, national, and international patients who are unable to pay or cannot easily access care is not only an ethical responsibility but also a professional one. As such, it is our opinion that we must engage in and teach these activities and must also be accountable for having done so. It is hoped that the 2012 AOA symposium and round table discussion on the topic as well the present paper will serve as a nidus for further discussion and, more importantly, productive action to help those in need. n
Scott D. Weiner, MD Department of Orthopaedics, Summa Health System, 444 North Main Street, Akron, OH 44309 G. Paul DeRosa, MD American Board of Orthopaedic Surgery, 400 Silver Cedar Court, Chapel Hill, NC 27514 Christopher T. Born, MD Alpert Medical School, Brown University, 2 Dudley Street, MOC 200, Providence, RI 02905 Lindley B. Wall, MD Washington University Orthopaedics, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110 Bradley K. Weiner, MD The Methodist Hospital, 6550 Fannin Street, Suite 2500, Houston, TX 77030
References 1. Weinstein SL. 2000-2010: the bone and joint decade. J Bone Joint Surg Am. 2000 Jan;82(1):1-3. 2. Sechriest VF 2nd, Wing V, Walker GJ, Aubuchon M, Lhowe DW. Healthcare delivery aboard US Navy hospital ships following earthquake disasters:
implications for future disaster relief missions. Am J Disaster Med. 2012 Fall;7(4):281-94. 3. Rovinsky D, Brown HP, Coughlin RR, Paiement GD, Bradford DS. Overseas volunteerism in orthopaedic education. J Bone Joint Surg Am. 2000 Mar;82(3):433-6.
Copyright of Journal of Bone & Joint Surgery, American Volume is the property of Journal of Bone & Joint Surgery, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
AOA Critical Issues On Volunteerism and Orthopaedics AOA Critical Issues Scott D. Weiner, MD, G. Paul DeRosa, MD, Christopher T. Born, MD, Lindley B. Wall, MD, and Bradley K. Weiner, MD Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Sometimes give of your services for nothing. And if the opportunity for serving a stranger in financial straits, give full assistance to all such. For wherever the art of medicine is loved, there is also a love of humanity—Hippocrates As the quotation above suggests, the selfless giving of one’s services and time has been recommended by generations of medical leaders since medicine’s earliest emergence as a paid profession. Whether such recommendations are prescriptive (i.e., what a physician should do if he or she is so inclined) or descriptive (i.e., what a physician is obligated to do, given his or her skills, as part of being a physician) has long been a subject of debate. The philosophical center of the debate is whether health care is a ‘‘right’’—regardless of one’s ability to pay for it or deliver himself or herself to a physician. For if it is indeed a ‘‘right,’’ we are obligated to provide care to all. One man’s right is another man’s moral and ethical obligation. In this spirit, a recent American Orthopaedic Association (AOA) symposium and round table discussion (at the 2012 annual meeting) explored whether volunteerism should be considered a ‘‘core competency’’ and, if so, how we might implement it as we do the other competencies outlined by
the Accreditation Council for Graduate Medical Education (ACGME). It is our opinion that a careful reading of the currently accepted ACGME competencies indicates that volunteerism clearly falls under the ‘‘professionalism’’ umbrella and should be considered part of what we must do (and must teach) to be (and to produce) complete, competent orthopaedic surgeons. In an on-site survey, the audience felt strongly that role modeling by faculty is an important predictor of resident behavior. Although most of the audience felt neutral about incorporating an international elective in a resident curriculum, most felt that there is substantial value in a program offering this experience for faculty and residents. Sixty percent felt that volunteerism as a core competency was a critical issue for the AOA. There are many ways in addition to international travel in which the importance of volunteering in our and our trainees’ careers can be emphasized. Local Volunteerism Although more general forms of volunteering (such as nonmedical community service) are often pursued by orthopaedic surgeons, local volunteerism as an orthopaedic core competency is
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:e5(1-4)
d
http://dx.doi.org/10.2106/JBJS.M.00383
e5(2) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 1 J A N UA RY 1, 2 014 d
d
O N V O LU N T E E R I S M
AND
O RT H O PA E D I C S
d
inextricably tied to the provision of orthopaedic care without pay to those within the community who are underinsured or uninsured. Unfortunately, many opportunities for practicing community surgeons to volunteer by giving freely of their services have been lost because of the need to generate income. It is, quite simply, becoming financially tighter and tighter for orthopaedists, and expected changes in reimbursement will continue to raise the financial pressure. The same holds true for academic orthopaedic surgeons, where the need to justify their salary to the department chair (and the chair to the Dean) not uncommonly takes precedence over service to the community. Consequently, community doctors often refer indigent patients to academic centers for care, academic physicians refer them to resident-run clinics, and residents are often left to manage poorer, sicker patients with little to no oversight by attending physicians. That the care provided to these patients is suboptimal is well recognized and often just accepted as ‘‘the way it is.’’ Inevitably, residents learn (both explicitly and implicitly) that the care of those without financial means is simply not worth the attending physician’s time and effort—and this lesson is carried with them as they begin their own orthopaedic careers, whether those are academic or community-based. Clearly, such behavior is unprofessional, and we believe that discovering ways to break this unfortunate cycle is a critical issue to be faced by all of us in orthopaedics. National and International Volunteerism Currently, there are over 6000 global short-term medical missions undertaken per year. Some are administered by governments, some by faith-based organizations, and some through charitable foundations. There is tremendous need. Although cancer and cardiovascular disease gather the attention of the press, given their life-threatening nature, musculoskeletal disease is the major factor negatively impacting functional quality of life worldwide and this impact is increasing1. Fortunately, musculoskeletal disease and trauma also lend themselves well to short-term medical interventions that are commensurate with the character of most medical missions. Orthopaedic problems can be addressed surgically at central locations in a concentrated fashion over a period of weeks by experts from medically developed regions who travel to underserved locations worldwide to provide the care. Preoperative preparation and postoperative rehabilitation can be managed by local medical, nursing, and surrogate providers before and after the surgical procedures. Ideally, such short-term stays should be tied to education of the local care providers in order to afford a lasting, continuous impact. Ironically, it is often easier for surgeons to volunteer and provide surgical care overseas than in the United States. Legislation that would reduce licensing issues across state lines and some measure of tort reform could remove some of those barriers to ‘‘national volunteering.’’ Organized Disaster Response Volunteerism Within minutes, the earthquake that struck Haiti in January 2010 resulted in thousands of orthopaedic injuries. Over 500 members of the American Academy of Orthopaedic Surgeons
(AAOS) responded in some form, volunteering their services to the U.S. government, nongovernmental organizations (NGOs), and independent hospitals that sent teams to Haiti. Many surgeons arrived on their own as spontaneous unaffiliated volunteers (‘‘SUVs’’) with minimal equipment, no pharmaceuticals, no supply chain, and no sustainment provision for food, water, shelter, transportation, or security. They had no plans and presented no credentials. Many practiced ‘‘medical tourism’’ and acted as health-care providers outside of their areas of expertise. Following analysis of both federal and professional society response efforts, the AAOS and the Orthopaedic Trauma Association (OTA) recognized that there was no coherent, overarching organizational plan by which orthopaedic surgeons could be trained and pre-credentialed as surge responders to an internal or international mass casualty incident. These organizations were unprepared to coordinate civilian surgeon response and had no database of qualified responders. In addition, there was a realization that without preexisting relationships with the U.S. government, the response of established NGOs was unlikely to be highly efficient or effective. Accordingly, a project team was impaneled by the Board of Directors of the AAOS to develop a process to identify a cadre of orthopaedic responder surgeons for the future. The project team consisted of members of the AAOS and OTA along with orthopaedic consultants to the Surgeons General of the Army, Navy, and Air Force. The charge to the team was to review issues of orthopaedic response to international mass casualty events and to design a formal response plan. In addition, certification, credentialing, and training pathways for these surgeon responders were to be developed. These surgeons would undergo mass casualty response education and training and would become pre-credentialed volunteers identifiable in a database cooperatively maintained by the organizations. Criteria for inclusion in either the ‘‘acute phase’’ or ‘‘sustaining phase’’ responder types have since been developed, mandatory educational pathways have been identified, and a society database has been established. A new ‘‘austere environment’’ Disaster Response Course (DRC) modeled on the military’s Combat Extremities Surgical Course (CESC) has been developed by the Society of Military Orthopaedic Surgeons (SOMOS) for the AAOS and OTA. Over 250 civilian volunteer orthopaedic surgeons have taken the course as of April 2013, and over 190 participants have been listed in the AAOS responder database. Enrollees benefit from a full day of didactic instruction on personal preparedness, on working and operating in an austere environment, as well as on ethical and cultural considerations. The risks of doing this kind of work are discussed. These include liability considerations as well as health issues related to disease, fatigue, deconditioning of volunteers, and unfamiliarity with field work. The relationships between responder volunteers and local medical and governmental agencies, NGOs, the U.S. military, and the Department of Health and Human Services (DHHS) are explored and explained. A one-half-day cadaver-based laboratory program on skills appropriate for an austere surgical environment follows the didactic program. Additional courses are scheduled for the future.
e5(3) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 1 J A N UA RY 1, 2 014 d
d
O N V O LU N T E E R I S M
AND
O RT H O PA E D I C S
d
Relationships with the U.S. military and the U.S. government response system are being developed, and ways by which civilian surgeons could become pre-credentialed to work as temporary federalized employees of the U.S. military and/or DHHS are being explored. ‘‘Federalization’’ provides some level of liability, job security, and Workers’ Compensation protection for injuries sustained while performing authorized voluntary services. This protection includes medical care and disability compensation. It should be noted that disability payments are based on federal General Schedule (GS) pay rates. This is unlikely to provide adequate disability compensation for a surgeon’s lost career. Supplementary private disability insurance coverage might be prudent to acquire. Within the military, all medical providers are entered into a common database. As a Department of Defense (DoD) medical provider moves between facilities, his or her credentialing file can be pulled up by the base or hospital commanding officer for approval. The AAOS and OTA have been working with their military liaisons to see whether appropriately credentialed civilian volunteers might also be placed into the military’s system. Barriers to this inclusion include the labor-intensive requirement for initial background checks and yearly updates. In addition, the DoD might not be willing to budget contingency dollars to cover the costs of potential tort defenses. A Multi-Specialty Enhancement Team (MSET) pilot program to increase surge capacity in several surgical specialty areas including orthopaedics is also under development by DHHS. Participants in the AAOS disaster responder program could logically be used to ‘‘backfill’’ federal Disaster Medical Assistance Teams (DMATs) and International Medical Surgical Response Teams (IMSuRTs). A streamlined credentialing process for placement of AAOS-certified surgeons into the MSET program is also being explored. The Haiti earthquake demonstrated that U.S. government agencies and the military had insufficient depth of orthopaedic surge capacity to rapidly and effectively respond to a major incident that triggered massive numbers of musculoskeletal injuries. There will likely be a future need for U.S. civilian physicians and surgeons to be able to work side by side with our medical colleagues in uniform and with other civilians working with federal disaster response agencies. Sechriest et al.2 looked at deployments of U.S. Navy casualty receiving and treatment ships (CRTSs) in response to mass casualty (earthquake) incidents in Indonesia (2004 and 2005) and Haiti (2010). They found that musculoskeletal extremity injuries in age and sexdiverse populations represented the majority of clinical diagnoses managed by these response assets. They concluded that CRTSs were useful in augmenting shore-based facilities for the delivery of medical services. Their data also suggested that medical and surgical staff numbers could be ‘‘. . .ramped up on short notice and as needed. . .,’’ including the use of civilian resources as was done in Haiti. Unfortunately, there is no uniform process to pre-credential these civilian medical professionals for such service. The ideal solution would be to have a common credentialing pathway, valid across all governmental agencies and the military, by which civilian volunteers could be
vetted, trained, and certified in advance for this type of work. Activation and deployment would be on an ‘‘as-needed’’ basis. Ultimately, legislative statutory relief may be required to facilitate this process. Obviously, this should not be limited to orthopaedic surgeons but should be implemented across a number of vital responder-oriented medical specialties such as general and neurological surgery, anesthesiology, pediatrics, emergency medicine, and infectious disease. Specific professional societies could be used to develop focused educational programs (such as the DRC) in conjunction with the government. Teaching and Encouraging Volunteerism The need to dedicate time to income-generating activities is not only felt by those in mid-career who have faced changes in reimbursements requiring them to work longer and harder while making less money than they did ten or fifteen years ago. Increasing numbers of graduating residents and fellows are entering the field with considerable debt, given the escalating costs of undergraduate and graduate education, and the giving of orthopaedic care without remuneration (even if it is in their heart to do so) may well be a secondary consideration to personal financial stability for our next generation of orthopaedists. Recognizing this, we must aim to find novel ways both to deliver care as efficiently as possible and to instill a spirit of volunteerism in our young workforce. Clearly, volunteerism should also be brought to the forefront early in residency training. Educating young surgeons regarding the importance of, and the need for, volunteerism is crucial. It has been shown that early exposure and involvement in volunteerism during training increases the likelihood that surgeons will continue to participate in such activities once they are in practice. Teaching volunteerism is often done by example. With faculty spending less time volunteering, such examples are lost or at least inconsistent. Didactic lectures alone are not sufficient. With proper education, guidance, and mentorship, volunteerism can assume its rightful place as part of ‘‘what we do’’ as professionals who practice orthopaedic surgery. That said, there are currently only a handful of orthopaedic training programs that have integrated an international volunteer rotation into their educational curriculum. For years, residents at Pennsylvania State University (Hershey) have optionally traveled with attending staff to Honduras to provide pediatric orthopaedic care. Many other residency programs have established or are planning to incorporate a rotation in international volunteerism as a requirement. The University of California San Francisco orthopaedic residency program has offered an international rotation in its training since 1998 and formalized it into the program in 2001. The participants in that program were surveyed and two important conclusions could be drawn: (1) those residents who participated in the program were more likely to believe that physicians had an obligation to the medically underserved, and (2) participants were more likely to continue international volunteerism after graduating from residency than those who did not participate3. An international volunteer rotation allows residents to see firsthand the contrast in resource allocation, the deficit in
e5(4) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 1 J A N UA RY 1, 2 014 d
d
O N V O LU N T E E R I S M
AND
O RT H O PA E D I C S
d
educational opportunities, the lack of access, and the inequities in distribution of health care and services. It also provides a wholly unique learning experience—providing autonomy, exposure to different cultures, the opportunity to adaptively and creatively provide care with minimal resources, exposure to pathologies and disease processes in advanced stages, and the chance to establish relationships across borders. Although such an experience has many benefits for both the international community and the individual, and some residencies have made it ‘‘part of the program,’’ there are real hurdles to be overcome. First, the financial support for such a rotation is limited. The time away from the institution is not supported by graduate medical education funding. Exploring philanthropic and other opportunities is often needed. Not all institutions are able to support this endeavor and grant funding can be difficult to obtain. Second, many programs rely on residents to ‘‘man/woman the ship’’—and ‘‘away rotations’’ might leave the home institutions underserved. Third, real risks may exist, and additional insurance coverage may be necessary for liability and health coverage for volunteers. Finally, not all residents are able or willing to participate (e.g., because of discomfort with international travel, time away from family, or loss of vacation). Creative ways to address these issues will need to be developed prior to considering a ‘‘mandate’’ for incorporation into residency training. Offering optional local and international opportunities may be the best solution currently. Assessing ‘‘Volunteerism’’ Although assessing volunteerism as a subcompetency of professionalism is easy in the case of orthopaedic residents—residents can be evaluated in their management of charity cases—doing so in the case of practicing orthopaedic surgeons is fraught with difficulties. Local and legal considerations regarding taking call and nonemergency indigent care are complicated and legally and ethically challenging. That said, the American Board of Orthopaedic Surgery (ABOS) appears to agree that volunteerism is part of what we must do to be complete orthopaedic surgeons and should be part of the certification process itself. Under ‘‘professionalism,’’ the Board specifically asks, ‘‘Does the applicant demonstrate behavior that reflects responsible attitudes, and accepts community responsibility for emergency and/or indigent care.’’ Per the previous ABOS director, ‘‘The ABOS believes that a competent surgeon must accept responsibility in the community where he or she lives.’’ How this is to be assessed and weighted during the oral cer-
tification or maintenance-of-certification process is yet to be established. But as simple, local on-call and indigent care issues become increasingly contentious, the certification process provides one way in which the greater orthopaedic community as a whole might provide leadership and guidance regarding the issues. Conclusions Providing orthopaedic care to local, national, and international patients who are unable to pay or cannot easily access care is not only an ethical responsibility but also a professional one. As such, it is our opinion that we must engage in and teach these activities and must also be accountable for having done so. It is hoped that the 2012 AOA symposium and round table discussion on the topic as well the present paper will serve as a nidus for further discussion and, more importantly, productive action to help those in need. n
Scott D. Weiner, MD Department of Orthopaedics, Summa Health System, 444 North Main Street, Akron, OH 44309 G. Paul DeRosa, MD American Board of Orthopaedic Surgery, 400 Silver Cedar Court, Chapel Hill, NC 27514 Christopher T. Born, MD Alpert Medical School, Brown University, 2 Dudley Street, MOC 200, Providence, RI 02905 Lindley B. Wall, MD Washington University Orthopaedics, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110 Bradley K. Weiner, MD The Methodist Hospital, 6550 Fannin Street, Suite 2500, Houston, TX 77030
References 1. Weinstein SL. 2000-2010: the bone and joint decade. J Bone Joint Surg Am. 2000 Jan;82(1):1-3. 2. Sechriest VF 2nd, Wing V, Walker GJ, Aubuchon M, Lhowe DW. Healthcare delivery aboard US Navy hospital ships following earthquake disasters:
implications for future disaster relief missions. Am J Disaster Med. 2012 Fall;7(4):281-94. 3. Rovinsky D, Brown HP, Coughlin RR, Paiement GD, Bradford DS. Overseas volunteerism in orthopaedic education. J Bone Joint Surg Am. 2000 Mar;82(3):433-6.
Copyright of Journal of Bone & Joint Surgery, American Volume is the property of Journal of Bone & Joint Surgery, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
