Orthopedics vs Primary Care:
Time for a Cease-Fire
THE PHYSICIAN AND SPORTSMEDICINE - VOL 30 - NO. 4 - APRIL 2002
Want to generate a little excitement at your next conference? Ask family physicians or orthopedists, "What specialty is best suited to act as team physicians?"
As an editor, I've had the opportunity to be a "fly on the wall" when this subject has been debated. I often talk to family physicians who feel they have a more holistic approach and a wider range of skills to meet the vast array of problems encountered by the physically active. As they point out, musculoskeletal injuries, and particularly those that need surgery, are only one, small part of sports medicine.
The orthopedic surgeons most often state that musculoskeletal medicine is the most important aspect of sports medicine, that they are particularly well trained in that field, and that they possess a superior skill set to treat musculoskeletal problems.
Why does this debate even exist? Historically, orthopedic surgeons have had higher profiles, published much of the literature in sports medicine, and, together with athletic trainers, provided most of the care to athletes on teams. Even now, orthopedic surgeons are the most visible healthcare providers in the field. If you tell someone that you're a sports medicine physician, the most common response is, "Are you an orthopedic surgeon?" Primary care, on the other hand, is a latecomer with less history, less focus on musculoskeletal knowledge and skills, and a less developed scientific underpinning to clinical practice.
While historical realities exist, patient demographics and the practice of sports medicine have changed. Many more patients are aware of this field and seek advice and treatment. Also, nonsurgical musculoskeletal problems like knee pain and stress fracture occupy a greater percentage of cases seen. In addition, excellent nonsurgical treatment of disease through rehabilitation has been pioneered by those in physical medicine and rehabilitation, cardiology, physical therapy, and athletic training. Finally, the creation of new professional societies, growth of managed care, and expansion of sports medicine have all affected the discussion.
So where does that leave us? I agree that orthopedic training and experience cannot provide the full range of expertise necessary to be a team physician or provide ongoing care to an athletic population. However, I have not met a group more dedicated to the field. Their training is rigorous and long (minimum 4 years, often 5 to 6 with fellowships), their professional meetings outstanding, and their research contributions substantial.
Primary care, in contrast, is playing catch-up. Not that that is bad. A nonsurgical specialty in sports medicine needs to develop more fully to complement orthopedic surgery much the way the rest of medicine functions (eg, neurology and neurosurgery).
What will that take? Contrary to what some primary care physicians state—that orthopedic surgeons are preventing them from taking their rightful place in the management of cases—nonsurgical sports medicine needs to establish its own credibility. That means quality, rigorous training programs with lots of experience in clinical sports medicine (not just sideline coverage). It means excellent societies with outstanding annual meetings in which research and other shared knowledge move the field forward. And it means learning from and cooperating with—not combating—each other.
Both groups have their share of dogma, and both have their fixed notions and quality issues. The very best way to address the impasse is through the leadership of fellowship training programs. If nonsurgical and orthopedic sports medicine programs cannot involve each other in education, then the message sent from the "top" is clear to all those in training: "We don't work together." That attitude needs to change.
Gordon O. Matheson, MD, PhD
P.S. Oh yeah, no letters please!