There was time when Orthopedic Surgery was an all-encompassing branch. Then the neurosurgeons started practicing spine surgery. Not that it was not their domain too, but they were doing all spinal fixations and corrections, fusions and decompressions and what have you. It didn’t stop at that. They wanted to take it away from the Orthopedist altogether. The matter reached the Medical Council of India, and the MCI ultimately issued a directive that the orthopedic surgeons could also perform spine surgeries!
Next came the turn of the orthopedists doing hand surgeries. The plastic surgeons insisted that the hand was a part of plastic surgery and the orthopedic surgeons had no business dabbling in it. This was fought tooth and nail as plastic surgeons were doing micro surgery, be it vascular or nerves, and hence felt better qualified to do re-implantation surgery. The Orthopedists contention was that they were more qualified to handle the bones, and as micro vascular surgery was being done by them just as remarkably as the plastic surgeons, they were not going to part with the hand, and they did not.
The latest fracas is now between the Orthopedic surgeon and the Rheumatologist. I wonder why this fight for the rights and domain always seem to land in the lap of the Orthopedist. Well whatever, this time the Orthopedic surgeons in India were wiser and they v very early formed a Rheumatology section of the Indian Orthopedic Association. They even hold regular conferences and CMEs to keep updated. The Orthopedists now practicing Rheumatology are not any less knowledgeable or updated then the physician Rheumatologists, myself included.
However, the bigger question is whether there will be, or already is, a line of demarcation of practice between the “super specialist “Rheumatologist and the Orthopedist practicing Rheumatology. Can the two be at par in the times to come? If not, should the Orthopedists yield ground to the Rheumatologist altogether? My answer to both these questions is NO. With the tremendous advancements in pharmaco-therapeutics and the introduction of newer drugs for the treatment of Rheumatoid arthritis, Rheumatology has developed into a super specialty. Few among the Orthopedists practicing rheumatology have been able to keep abreast with these developments, let alone incorporate them in their practice. However, almost in pace with the expanding medical treatment of Rheumatology, the surgical aspect of its management is also undergoing a sea change. Just as early and all out attack is now the dictum for the medical management of rheumatoid arthritis so also early surgery for deformity prevention and treatment is now the paradigm for the Orthopedists. As the surgical aspect of the treatment of the Arthritis will forever remain the domain of the orthopedic surgeon, this too is slipping out of the hands of the general Orthopedist into the grip of the specialized hand surgeon, be it the Orthopaedic surgeon or Plastic surgeon. No issues about this.
What is contentious is what is to be the role of the orthopedist and the Rheumatologist in the medical management of the disease. Although the Rheumatologist and the Orthopedist who has taken rheumatology as his field of interest would each hold onto it without parting, and there may be no way or need to resolve this issue, for the average general Orthopedist there has to be a line of demarcation. He would not be able to, or maybe even willing to dabble beyond that line. Thus, if this line is not exacted or clearly defined by powers that be on either side, the average general orthopedist will do so himself, eventually. How can I say this? Because I am one such orthopedist and I feel I can very well speak for them all.
I treat the rheumatoid patient aggressively on what I would call the first line of drug therapy, that is not beyond and including anti TNF agents. Beyond this I would like to refer the patient to a Rheumatologist. I believe as an Orthopaedic surgeon I am more qualified on the use of steroids, both local and systemic. What would be my end stage for assessment of the patient’s relief and benefit? That of a typical Orthopaedic surgeon absence of pain and deformity.