SOME ETHICAL POINTS IN ORTHOPAEDIC PRACTICE ( Part II )

Research and publications rthopaedic surgeon should always stay on the current by learning what is new and by keeping his standard high. This can only be achieved by reading, writing and by performing research projects, research is the life blood of our wonderful specialty. We are currently witnessing profound and far-reaching progress in the technology and biosciences with breakthroughs in human genetic, organ transplantation and the highly sophisticated means for internal fixation. We should go hand in hand with the recent advances, which should be harnessed and guided for the welfare and happiness of mankind and not to be left to go astray for decremental uses. At this juncture it suffices to state that biomedical area which has intimate relations to human life and well being, should receive careful analysis under the broad teaching of medicine and religion in order to ascertain their legality. The cost of each study should be weighed against the anticipated benefits to be derived from it. It is not only appropriate but also an obligation of clinicians who develop new interventions or diagnostic assessments to perform proper clinical research to objectively demonstrate the efficacy and safety of any new procedure. The World Medical Association developed specific guidelines for performing a research with several basic principles. O Among these are: • Health and well-being of human subject must be the first consideration. • Patients and families must be fully informed of all risks as well as benefits of research and so indicated in a proper informed consent. The protocol must be scientifically based. There must be no other way to obtain the information except through use of human subject. Results must be reported accurately. Statements should not just accept because they are said or written by an authority. We have to be aware of those authors who have a special financial interest in the product under review. Continuous education which is the heart and soul of orthopaedic surgery is very vital for the physician, the patient and the public. It is absolutely essential for our practice and economic well-being. The products of orthopaedic research are truly golden eggs and we should forever nourish and cherish these magnanimous geese. Good reasons for performing a study and for publishing its results are to provide information to improve patient care and to record data from a well known study in an accurate fashion, so that the present and future generations of readers will be able to build up upon solid research. Regrettably many


Introduction
odes of Medical ethics have been recognized for thousands of years as essential requirements to shape up the proper and dignified conduct of medical practitioners. From the Hippocrates Oath to the Geneva and Helsinki declarations, the basic Percepts of Medical Conduct have not changed 1 . Orthopaedic surgeons must understand the fundamental of orthopaedic surgery. Adequate knowledge is assumed to mean that the behavior associated with that knowledge would be carried out properly 2 . Educational need in all aspect of Orthopaedic is the primary concern, so we must commit ourselves to a lifetime of learning. We should stay warm and willing to answer questions, but appropriate responses to questions and scenarios do not necessarily translate into appropriate behaviors 2 . Vie have inherited a troubled profession and specialty confronted with problems that are not of our making 3 . The patients are in need for a surgeon who treat his moral and emotion in addition to treating joints, bones and incision. The career needs physician rather than a technician, healing takes more than a surgical skill. The heart muscle or valve may heal but scars from emotionally difficult recovery unsupported by the surgeon, may never heal 4 .
We have to have a good relationship with our patients who will create an environment in which cure take place for the patients, the family and the physician. We must also take on the responsibility of improving the quality of our own practice and monitoring the quality of care. It appears that organized orthopaedic surgery need to clarify its position not only in the minds of the rest medical profession but in the minds of the people who are, will be, or should be our patients 5 . We should always remind ourselves of the ethical reasoning which is of particular importance in orthopaedic career. The patient's best interest should stay with us as one of our fundamentals and the welfare of our patients will always be our higher consideration. We have to do everything in power to uphold the confidence that we have gained from our patients. A mutual trust is mandatory, without trust the success of the healing 4 process would be seriously diminished. There is and always has been one constant in medicine and orthopaedic, that constant is honest caring for our patients 6 . The young may be intelligent but can not be wise; wisdom is not inborn, it is acquired by experience and experience is often painful 7 . The required personality for orthopaedic career Because of the specification of orthopaedic career, special characters are always needed. Orthopaedic surgeon must be sincere and devoted believer in the honesty of his career, he should try his best to keep it in the best possible shape. He must always perfect himself in his specialty or subspecialty which he practices. He should save no effort to acquire all possible details and aspects of his profession and excels in them to the best of his abilities. His belief in his specialty should be manifested in behavior and attitude at the professional as well as the personal level. He should be truthful when lie speaks, writes or gives testimony, should be humble, modest, free from arrogance and self-glorification. Because of the prolonged time usually required for healing, he needs to be kind, patient, comforting and friendly. His word should be soothing, and his effort towards his patient complaints should be prompt and caring. Extending his knowledge and experience to his colleague and medical students is a duty. He should provide medical care to those who need it regardless of race, ethnicity, color or religion. He should have a specific recognized qualification and good practice under supervision for several years in a recognized center before he takes up the responsibility alone. He should work diligently to avoid emotional involvement with his patients. His piety must restrain him from inappropriate physical or emotional feelings during patient's care. Professional secrecy is mandatory and a seal should be placed on the confidentiality on all information lie acquires; any breach of these would be detrimental to the practice and the proper doctor-patient relationship. Finally we should not forget the notable names in Orthopaedic history, those who made the very rough terrain smooth for us to walk on without frequent falls. Their outstanding contributions to science and humanity should not be forgotten. Thanks would not be complete without acknowledgement to their original work. The public that we serve points an accusing finger and say, in effect you did not give us the kind care and help your fathers and your grandfathers gave their patients 5 . Isaac Newton said: "If I have seen further, it is by standing on the shoulders of giants".

Doctor-patient relationship
The fundamental act of professional medical care is the assumption of responsibilities for patient's welfare, an unwritten contract assured by few words, handshake, and eye contact, devoting mutual understanding or acknowledgement by the physician 8 . So we have to provide service even at a physical loss and despite physical discomfort or inconvenience. Whenever we interact with a patient, we must put aside our personal agenda, and interact with the patient for the benefit of the patient, it is not always easy to do this, but it is always necessary 9 . A strong doctor-patient relationship is essential to successful treatment; the doctor must gain his patients trust and respect, which can be achieved by telling the patient an accurate and truthful picture about his or her condition as well as realistic expectations about the result of management 6 . Unfortunately the study of Wenger and Lieberman showed that there was a poor understanding of proper ethical conduct with regard to physician-patient relationship 2 . Since orthopaedic care, frequently extended over a prolonged time and may involve surgery, casting or bracing, a longstanding bond is mandatory, with the patient and the family to establish the good ground work for years of treatment and follow up that line ahead, we have to be sympathetic with our patients, but it is much better to obtain a proper scientific goal than to allow one's motion to overrule sound medical judgment, so that a happy result can be achieved. The first golden moments when we meet the patient may make the difference between acceptance and total rejection. It is important to emphasize that we are not assuming God's role, but merely managing a medical condition, to the best of our scientific ability. The family and the patient must realize this fact and should also understand that the effort must be a team one, which requires their help and patience, if the outcome is this, and then the result will be much more successful for all concerned. The family and the patient should also realize that the nature does not have a specific time clock and can not be hurried, if they are not patient and cooperative at this time, this certainly indicates that they are totally unable to face the bad results of treatment. There is abundance of evidence that attitude affects healing, anxiety and depression have a negative effect on healing. A patient who feels supported and cared for by the physician and the family will be certainly in the best position for healing. The physician who is able to hold a patient's hand, to touch a shoulder, to hug a grateful or sad patient creates a healing environment 4 . When a patient has operation, the family is wounded, with even the simplest and shortest operation. A caring physician who is able to listen to a family's concern will help that family to heal and the family can help the patient to heal 4 . We have to be friend with our patient and their family, we have to prove for them that we are honest, but our relation should always stay at a professional level, probably the best insurance against malpractice is a good doctor-patient relationship. A good doctor-patient relationship can never be achieved with a pernicious practice. We have to look at the patient as a person and not just as an anatomical problem to be fixed. It was in the twelfth century when the philosopher and physician Maimonides prayed "May I never forget that the patient is a fellow creature in pain. May I never consider him merely a vessel of disease" 6 . Sir Francis Fraser's famous observation that the patient come not in search of treatment but of peace of mind 10 . If the patient chose us for sacred purpose we let that happen too 11 . The easy, fast and cheep ways should be considered in the first line of achieving diagnosis and precise treatment, sometimes orthopaedic surgeon gets exposed to multiple pressure from the insurance company, the patient himself or the creator of the accident in that case he should be frank and strong enough to tell the truth as it is irrespective of the severity of the pressure or the different convincing offers. The patient's psychological acumen should be studied carefully so that compensation neurosis can be discovered easily. Religious belief must be taken into serious consideration as in cadaveric transplant, blood transfusion, or even shaving certain parts of the body, there is always strange or special belief for each particular religion, which we need to learn from the patient himself. So that we do not hurt his beliefs, which may be reflected badly on the doctor-patient relationship. It is always necessary to avoid procrastination and to acquire the power of admitting failure and to tell the patient the truth as it is and then to advice him what to do next. A good doctor-patient relationship is mandatory in medical practice and it is of prime importance in orthopaedic career. So we should weld the links of this golden chain to immobilize it. Mankin 12 believes that we were put on earth to help others to recover from their illness, curing a few, making a better world for some, controlling suffering for others and for a few helping them to a reasonable and dignified end. That is for all of us the best of times and is a great feeling and wonderful way to spend our life.

The economic aspect of medical care
Orthopaedists should remember always to place the patient's interest ahead of their own interest including the financial aspect, unfortunately the financial conflicts are inherited in medicine, some of our previous colleagues weakened medicine by wanting too much and now it is reflected badly on our profession and threatens its future. Greed can certainly destroy one's source of wealth; medicine is certainly a profession rather than a business. One of the worst by product of insecurity is greed; greed like love of comfort is a kind of fear 13 . Economic well being is not the patient's pocket or the insurance company, rather as a physician's underlying source of wealth relates more to 'the professional ethic than the business ethic of medicine 3 . Particularly in orthopaedic practice there is always a good chance of collecting money in a short period of time, by simply changing the line of treatment, e.g. from gypsona cast to an internal fixation, but this is certainly against the professional ethic and surely it is a malpractice. Financial gain is indeed shameful when it comes from compromising the health care that we provide to our patient 13 . So we have to put aside the self concern by helping the sufferers. We should try to do our utmost best work not to disappoint any patient simply because he can not cover the expenses. The patient needs us not only for what we can do, but for what they feel we can do. The patient should be protected from the undue conflict of interest, the physician is obliged to provide or recommend treatment when he believes that the treatment will materially benefit his patient, it is unethical to knowingly provide unnecessary care or to be wasteful in providing the needed care because of a hidden financial or personal benefit. Patient should never be kept at an unfair disadvantage under any condition. The financial incentive should always be based on quality rather than the quantity of service. Sadly medicine has not been immune to the materialization and greed, there is increasing interest to change the art of medicine into business, the hospital and the patient care pass from control by physician to control by giants from insurance and industry, a situation that we should stand against. We have to prove to everybody on this earth by our humanistic and ethical handling of our patient that medicine is an honest profession and can never be considered as a business for making money at the expenses of the miserable sufferers. The fundamental objective of commerce in providing medical care is achieving an excess of revenue over cost 14 . We need to focus together on counteracting the pernicious behavior of the industries and institutions that threaten the golden quality of care which we need to keep on for our dear patients. Medical ethics prohibit solicitation and cheep advertising and any other form of commercialism. It has become painfully obvious that still some Orthopaedic surgeons are still performing operations basically for their own financial or scientific interest and what is more painful that operations sometimes performed to satisfy the producer company.

Professional respects towards our colleagues
It is of vital importance to keep a high standard of relation with our colleagues which is based on respect and harmonious cooperation in all aspects. Because there is various methods used to treat identical pathology, a lot of opinions may appear for solving one identical clinical problem, so respect and caution for our previous colleagues is indicated. Suggestions and advice should be considered. Some surgeons unfortunately are unwilling to face their own complications, but at the same time they are very eager to search for the complications of their colleagues. The author feels that this tendency should be reversed and it is much better to look seriously for our own complications rather than to be proud of our good results or to look with widely opened eyes for complications of our colleagues. We have to remember that alone we can do so little but together we can do so much. Unfortunately sometimes colleagues malignantly attack each other, certainly this is unethical attitude and we have to maintain a degree of professional respect towards one another under any condition. it is important not to criticize prior treatment or even the delay of it, since this only add to the sense of ill feeling, guilt and defeat already present. We have to stand shoulder to shoulder in support of our career at every turn. We should never recommend treatment for condition that needs no treatment just because if we don't do, someone else will, and the real motive behind it is usually financial.
Let's avoid making bitter remarks or demeaning comments about our colleagues in public or in front of patients. We have to criticize constructively when we believe that the best possible care has not been provided. We must emphasize advice and education rather than punishment as a remedy for a defeat in quality care 5 . All human being are bound to make mistakes and lucky is the one whose mistakes can be counted, we have to keep ourselves busy in analyzing and then solving our mistakes, rather than concentrating on the mistakes of our colleagues, but we have in the same time to learn from their mistakes rather than learning from our mistakes because we are not going to live to make all the possible mistakes in our career. Disaster may arise from an incompetent colleague practice, unfortunately this is not rare, and it is reflected badly on the miserable patient and our career reputation alike. It is certainly not an easy problem to solve, probably the best answer is to repair the defect created by the incompetent colleague, to keep the patient totally unaware of the guilt and then to proceed with education and advice to the competent colleague, in a direct or indirect way. We should make him fully convinced that he is not competent, but if he continues doing surgical crime, I think the final answer is to keep him out of our highly respected specialty through the court. It is a duty of the wise an experienced senior colleague to support and help the young and inexperienced by education and advice in a very wise manner. Perkins 7 said that: The Young may be intelligent but can not be wise, wisdom is not inborn, it is acquired by experience and experience is often painful.