This is a period of enhanced efforts by a variety of forces to shape the behavior of orthopaedic surgeons. The changing transparency of information surrounding physician performance and judgment, the role of the supplier, the push for cost effectiveness, and the stronger patient voice are all influential. Neither the profession as a whole nor orthopaedic surgeons alone have heeded the warning that “professions must act boldly to prevent their members from forming relationships with suppliers that exploit the client/professional relationship—thereby risking government intervention or further erosion of the profession’s legitimacy” [2
]. Much of the contested terrain between surgeons and hospitals has been centered on the belief by surgeons that hospitals only care about costs and have little interest in supporting physician practices in ways that meet their goals. As hospitals have employed a variety of tactics to influence physician choice, including prioritization of their relationships with physicians, presentation of good product data, and incentives for physicians [18
], they are hampered in their efforts by the lack of evidence.
This paper has identified two opposing strategies about suppliers that are worthy of further discussion: (1) bringing suppliers into a much more meaningful role to support physician accountability and (2) substantially reducing physician dependency. The former is an area where physicians could lend a louder voice in redefining the supplier’s role in patient care and how their presence impacts the accountability of both physicians and the hospital. Ways to integrate suppliers into the supply chain to improve quality and processes have not been adequately explored. Accomplishing this will require a substantial change on the part of both the hospital and physician, characterized by the creation of a culture of coproduction.
Despite questions of undue influence, suppliers bring value to the surgeon and the hospital. Utilization of the surgeon to develop new products is only logical as the surgeon is most well-versed in product limitations. A first step in transforming this complex relationship is disaggregating the service, advisory, and sales component.
The surgeon-supplier relationship is not well-understood by those outside of the profession, is unstudied, and is generally viewed in a derogatory light. Anecdotal evidence suggests that dependence on the supplier representative in the operating room is variable. The recent ethical challenges to surgeon-supplier relationships discussed briefly above do not appear to have contributed to a clear definition of appropriate supplier involvement to maximize accountable practice.
Today’s supply chain managers are in the position of answering to the hospital in terms of risk reduction, cost effectiveness, and cost savings while also answering to physicians in terms of product availability for clinical care. The difficulty they often face is a lack of infrastructure that supports achieving all of these desired outcomes. This is an important opportunity for a physician-led effort to assure that the physician voice lends credibility and a focus on clinical care to this conversation.
Much of the discussion in this paper has been about the potential for the improved strategic management of orthopaedic surgery as an organized entity to redefine professionalism for 21st century practice. Areas requiring attention by the profession include the establishment and monitoring of standards for physician-supplier relationships and surgeon assumption of leadership roles in hospitals pertaining to product selection, supplier choice, and the orchestration of choice based on cost and clinical effectiveness. A key ingredient that is generally lacking for physicians to enter these leadership roles is the required knowledge to guide the business aspects and complexity of relationships as detailed above. Lacking in most graduate medical education (GME) residency programs is introduction to basic business concepts and terms, the different priorities of management, and experience in being a part of hospital committees while in clinical training. Equally lacking in most hospital management programs is an understanding of physician priorities and the essence of clinical medicine that often does not fit well into an economic cost model. Physicians who do enter leadership roles may have additional training in business (MBA) or may just have interest in cost and management issues along with their clinical care and pursue these opportunities. Inclusion of basic business concepts, some level of administrative experience, and focus on potential conflicts of interest with industry during GME is an important consideration to assist physicians to understand and be influential with issues surrounding their autonomy, accountability, cost, and industry relationships and to lead strategic management of their profession. Finally, following Horton [9
], it is important for surgeons to continue taking a leadership role in seeking funding for higher-level outcomes-based studies, comparative analysis, and advocating for large population-based data bases such as a national joint registry.
The terms “shared decision making” and “coproduction” have been utilized in this paper to represent the myriad of roles, relationships, and factors associated with contemporary implant surgical practice. Orthopaedic surgeons, supplier representatives, hospital personnel, and others come together to orchestrate the surgical episode of care. These synergies, and how each contributes to outcomes and affects accountability, are not well-understood. In the face of increased quality and transparency of information, there is a mounting demand for accountability relating to both cost and clinical outcomes. This demand, frequently made by outside agencies dominated by nonphysicians, challenges the idea of the surgeon as an autonomous practitioner and extends his/her accountability. This is an area of opportunity for physicians to lend their voice and clinical expertise and be leaders in comparative effectiveness and in helping to bridge the gap between clinical and cost effectiveness. The suggestion here is that neither term—autonomy or accountability—fully reflects the reality of modern surgical practice or the reality of physician professionalism. Increasingly, invocation of autonomy fails to legitimize surgeon choice and behavior. The challenge before orthopaedic surgeons, as a profession, is to redefine the idea of professionalism, autonomy, and accountability for 21st century practice of orthopaedic surgery.