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India and other developing countries have a huge number of patients and grossly inadequate health infrastructure, and thus, a minimum standard of care is not assured to every citizen.1 Hence, at the first instance, we need to assure a minimum standard of care which gradually evolves to the best possible care for all. Every patient deserves the “best possible care”, irrespective of patient's inherent pathology, which is governed by the surgeon and his infrastructural resources. The excellence of medical training, knowledge and skills, power of analysis and reasoning, interpersonal skills of communication, empathy, and ethical behavior contribute to the development of excellence in a professional. Infrastructural resources not only involve the professional in terms of his vision and management skills but also are largely based on the interaction of the professional with his environment.
Although professional development is largely a self-directed activity, professional organizations like the Indian Orthopaedic Association (IOA) have a large role to play to elevate the standards of professional excellence. This can be achieved by timely audit of the orthopedic education, setting the standards for patient care, providing inputs to the government on minimum standards of infrastructure and setting the priorities of health policies, providing training opportunities for continuous upgradation of knowledge and skills and certification of expertise, providing direction for research, and innovation of contemporary orthopedic practices, inculcating professionalism and good professional values among orthopedic fraternity.
The education of professionals would mean the education of orthopedic surgeons, other doctors and allied professionals involved in the treatment loop. Educating the patients increases the level of awareness of the patients about orthopedic ailments and makes the patients better partners for their own treatment.
The American Academy of Orthopedic Surgeons (AAOS, 2005) launched the Patient Centered Care (PCC) initiative, the hallmarks of this program being surgeon and patient education, communication, safety, and quality of treatment offered.2
The multiyear project of patient centered care initiative has four goals: (a) to improve the quality of healthcare provided to patients with musculoskeletal ailments; (b) to increase patient satisfaction with the orthopedic care; (c) to increase AAOS member satisfaction with their practices, and improve outcomes, decrease liability risk, and improve practice efficiency; and (d) to place the AAOS in a leadership position among physician groups in the PCC movement. Some areas of concern and the strategies taken to provide solutions are as follows.
Communication: In 1998, the AAOS conducted an extensive national survey to which 807 patients and 700 orthopedic surgeons responded. Patients rated technical skills as important (“hightech”) and valued communication skills equally (“high-touch”). Also, 75% of the orthopedic surgeons believed that they communicated satisfactorily with their patients, but only 21% of the orthopedic patients reported satisfactory communication with their surgeons.3 The AAOS partnered with the Bayer Institute for Health Care Communication (BIHCC) in 2001 to form the AAOS Communication Skills Mentors Program (CSMP). This program provides trainees and practicing orthopedic surgeons with easy-to-learn techniques that sharpen their professional communication skills.4 The importance of education for communication skills has been fully recognized recently, leading to requirements of documented teaching in orthopedic residency programs as well as assessments within the proposed maintenance-of-certification process.5
Patient safety: The Patient Safety Committee of the AAOS compiled the results of a member survey6 to identify trends in orthopedic errors, which would help to direct quality assurance efforts, by sending a questionnaire to 5540 academy fellows; of these, 917 (16.6%) responded, with 483 (53%) reporting an observed medical error in the previous 6 months. The equipment (29%) and communication (24.7%) errors were of the highest frequency. Medication errors (9.7%) and wrong-site surgery (5.6%) represented serious potential patient harm.6
The AAOS Patient Safety Committee has decided to begin in the near future, a new initiative called the “Highly Reliable Operating Room”.7 This program will incorporate communication and PCC. This initiative is directed to strengthen the concept of team and team responsibility by moving away from “name, blame, and shame” of individuals and crew resource management to allow any member of the team to speak up concerning a quality or safety, thus helping to reduce errors occurring because a team member has failed to communicate a recognized error due to hierarchical considerations. This will also focus on team training, team communication and WHO operating room checklist.7 The “Safe Surgery Saves Lives” 0program was launched by second WHO patient safety challenge to reduce the number of surgical deaths across the globe. Surgical deaths and complications are a preventable global public health problem. In England and Wales, the National Patient Safety Agency's national reporting and learning system recorded 129,419 surgery related events in 2007. In the United States, the state of Minnesota (with less than 2% of the US population) reported 21 surgeries in the wrong site during one year (October 2007 to October 2008). The real situation is probably even worse, though, as most safety incidents are not reported.8 The aim of the program is to harness political commitment and clinical will to address important safety issues, including inadequate anesthetic safety practices, avoidable surgical infection, and poor communication among team members.
Objectives for patient safety were compiled into a checklist intended as a tool for use by clinicians to reduce surgical deaths and complications. With the use of such a checklist, the death rate has declined to 0.8% from 1.5% (P=0.003). Inpatient complications have reduced to 7.0% from 11.0% (P<0.001). Hence, implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients, at least 16 years of age, who were undergoing noncardiac surgery in a diverse group of hospitals.9
In the Indian context, “Better Patient Care”, vis-à-vis the association, has broader connotations and can be outlined as below:
Professionalism and patient education: Some initiatives include dissemination of orthopedic information through the IOA website (www.ioaindia.org). A workshop on safe surgery, data documentation and “Management Competencies for Orthopedic Surgeons” is a novel concept that covers many core areas of professionalism, such as communication and leadership.
Elevation of educational standards: A number of initiatives are desirable for undergraduate, postgraduate, and super speciality orthopedic education and continuing orthopedic education for the practicing surgeons, which include training courses, fellowships, mentorship, and certification. The evaluation of prevalent teaching curriculum and practices and correlation with the needs of our population has to be conducted from time to time.
Broader percolation of research and publication methodology and efforts for innovation: Development of research temper, documentation, research, publication, and innovation need to be ingrained in the minds of young orthopedic surgeons from the beginning of their career. In the long term, this would see a strong pool of knowledge, based not on empiricism but on evidence, and importantly, applicable to the Indian scenario. The IOA would be wise to invest in research and publication workshops and modules, evidence-based reviews, and also in encouraging prospective multicentered studies. Let us all say that the buzz words are “Document, Research, Publish!”
One cannot plant a tree without sowing the seed. A reasonable expectation of sowing the seed of “Better Patient Care” is to see the Indian Orthopedic Association flowering and such efforts bearing fruit, to place the association in the frontline of the powerful orthopedic associations of the world.