Dear colleagues,
Dear members of the DGOU,
It is an exceptional honour for me to represent the German Society for Orthopaedics and Trauma Surgery as its President in 2020. I wish to thank you for your trust and your support in allowing me to take up this position.
What are the questions and tasks we need to address in 2020 and the subsequent years? I feel that there are four main aspects:
- Which structures in clinic and practice do we need in Orthopaedics and Trauma Surgery under the given health policy framework conditions to ensure good care quality for our patients?
- How do we make our subject attractive to the next generation and how can we ensure excellent ad-vanced training?
- What structures do orthopaedics and trauma surgery need in research to be able to answer the many questions that remain open in a translational manner?
- What can the professional society do and what should it do to implement these aspects?
To answer the first question, let me briefly summarise the framework conditions that are currently in place. In both clinic and practice, we work in an environment determined by economics that is character-ised by ever-increasing regulation (keyword: Working Hours Act), a delay in structural investment (key-word: digitisation) and an innovative capacity that is no longer there (keyword: medical device regulation). On the other hand, the justified patient desire for greater quality of life and quality of care is also increas-ing in an ageing society. Personalised and individualised treatment methods with a high degree of differ-entiation and specialisation are what society is demanding.
In an international comparison of orthopaedics and trauma surgery, we are still in a good position: almost every one of us would prefer to be treated at home than in another healthcare system. However, we cannot ignore the fact that the analysis of the current data from the German Endoprosthesis Register (see 2019 EPRD annual report), for example, show that we have significantly higher complication and revision rates for certain procedures compared to other countries. Among other reasons, this is because we offer care that is close to the patient’s home for many surgical procedures in our specialism, particularly planned operations. The extensive hospital landscape ensures good basic care across a wide range of specialisms, which is right and important for emergency traumatological care in particular. On the other hand, not every planned operation needs to be carried out in every hospital and by every surgeon with a specialist qualifi-cation, whether it’s an endoprosthesis or trauma surgery.
I am therefore of the opinion that our specialism needs more of a central point, with a clear definition of which clinical pictures and which injury patterns need to be treated in which clinic. Ultimately, the profes-sional associations have set out where which patients need to be treated and by whom in the case of inju-ries covered by professional association insurance. I am convinced that even larger clinics (orthopaedics and trauma surgery centres) should in an ideal world no longer be divided into orthopaedics and trauma surgery but rather need internal clinic structures focused on topography and anatomy (e.g. a department of shoulder/elbow surgery, a department of spinal surgery, a department of pelvic/hip surgery etc.). Only those who always work on the spine or on the pelvis and hips will be able to achieve excellent quality in their results. Case numbers, experience and knowledge of complication management all pay off when it comes to care quality. This applies to treating fractures caused by accidents and to planned orthopaedic surgery.
Of course structures of this type are human resource and cost-intensive, but this is the only way for com-plex surgery (including replacement of endoprostheses, septic surgery and pelvic/spinal fractures) well in an interdisciplinary setup. In order to achieve this, a clearly defined centre supplement is needed in the mean-oriented DRG system. Even the clinics that offer 24/7 emergency surgery can only maintain well-trained teams and the corresponding infrastructure if they are given the corresponding financial resources to do this.
As a professional society, we need to use dialogue with politicians setting out clear data and facts to en-sure that the existing broad spectrum emergency care in Germany is further expanded and is not de-stroyed by the closure of hospitals. On the other hand, we also have to make the case for the formation of “in-depth”, specialised centres providing complex care being established and paid for separately. In order to achieve these objectives, we need reliable figures from our registers (including the trauma register and EPRD) and from research into care that has not yet been sufficiently intensive.
If we want to address these aspects from the perspective of the professional society, we will need a de-gree of internal restructuring. We need to join forces and bring together the considerable skills of all of us in the various areas. It doesn’t make any sense to maintain parallel structures in the various areas of sev-eral societies. A declared aim of the DGOU must therefore be to make itself equivalent to the patient-oriented structures in everyday clinic work in terms of both topography and procedures. The existing working groups, committees and departments, some of which overlap, must be merged. This is the only way to make our powerful voice heard in the area being represented when we express our concerns to politicians.
A good example of a development of this kind is the realignment of orthopaedic rheumatology, an issue which has now been anchored in the Further Education Regulation. If we combine all of our conservative skills (including skills in technical orthopaedics, pain therapy, manual medicine), then with this additional title included for specialists in orthopaedics and trauma surgery we will remain the specialists in the con-servative treatment of the musculoskeletal system. But we need to take up and live out this bargaining chip of the strength we have of being able to provide both conservative and surgical treatment, particular-ly where this sets us apart from other disciplines. While conservative treatment principles continue not to be reimbursed sufficiently well in the DRG system and in medical practices, it will be difficult to broaden further advanced training in “orthopaedic rheumatology”. There is a need for action here, and DGOU will address this in 2020.
Conservative treatment skill is, however, also a key aspect that leads me on to the second question posed at the start about the attractiveness of our specialism to the next generation. If teaching at university clin-ics and teaching hospitals has sparked an interest in orthopaedics and trauma surgery, you still don't know whether you're going to be a talented surgeon. Orthopaedics and trauma surgery is fundamentally attrac-tive thanks to the wide range of conservative development opportunities in our specialism. However, we also need to reflect the wide-ranging nature of the specialism in our advanced training structures. Only small numbers of clinics are able to do this if we consider the matter realistically. We therefore need ad-vanced training associations, particularly with medical practices, which are able to offer meet the neces-sary technical and structural requirements. However, as we all know, advanced training “costs money”. Neither the health insurance budget nor the DRG budget includes these costs. As a professional society, we therefore need to work towards ensuring that an advanced training supplement is defined and paid in future. Anyone offering and providing structured advanced training must be paid for doing so. Those who are not contributing to the ensuring care for the population of the future do not need any funds allocated to them. Offering qualified advanced training needs to be worth it.
With the structures mentioned above in the subject, advanced training as a specialist covering a wide range of skills and then possible and also necessary specialisation with the additional titles in surgery and conservative treatment, our specialism is definitely very attractive. We need to make sure the working conditions are also attractive. This is easier said than done. The framework conditions in the DRG system, which is increasingly being trimmed down on the basis of efficiency, and the existing Working Hours Act resulting in an increase in the amount of work done per time unit are difficult. Training as an all-rounder in orthopaedics and trauma surgery is no longer possible in the structures we have, and is also not expedient because of the degree of specialisation needed to ensure excellent care. Organising attractive advanced training is one of the most difficult parts of our specialism. It’s feasible, but only if we work together (key-word: advanced training association).
This is even more relevant when we look at scientific issues in our specialism. Scientific work is definitely not something for everyone in our specialism, and is not feasible or expedient in every location. However, where the fundamental structures for scientific work are in place (which is particularly true in university clinics), a dual approach of “clinic and research” makes a lot of sense. An appreciative research culture is an essential requirement if this is going to be a possibility. Research needs to be valued as highly as good clini-cal patient care.
In orthopaedics and trauma surgery, we are well advised not to look into every issue at each university location. We need to use the core competencies or areas of scientific focus in the respective faculty or university. If a university has a strong biomechanical or engineering focus, it makes no sense to look at immunological issues focusing on the bone cells. Modern-day scientific issues can in any case only be re-solved in an interdisciplinary environment. It is therefore also sensible to network research locations with one another and form research networks. Through start-up funding and fellowship programmes, the DGOU can contribute to increasing the scientific visibility of orthopaedics and traumatology within medical specialisms.
Finally, to conclude my greeting I want to make reference to the DKOU 2020, the highlight of every presi-dency. Prof. Dr. Michael Raschke as President of the DGU, Dr Burkhard as Conference President of the BVOU and I have very intentionally chosen the motto “united in diversity” for the conference. Through this motto, we wanted to express that on the one hand orthopaedics and trauma surgery have now been brought together while on the other hand the strength in our field also lies in maintaining the wide range of skills. We do of course want to take this diversity into account in the conference programme. The aim is also to use the conference as a platform to further strengthen our international relationships. Global top-ics such as the digitisation of medicine and the ecological footprint we are leaving behind with our day-to-day actions in both clinic and practice will be the focus. These topics are particularly relevant to our guest nation, India, the largest democratic country on earth, which is becoming increasingly important in the global arena in the IT sector in particular. Our annual conference is, however, not only about the scientific programme but also about the opportunity to make social contacts outside of one’s usual environment. This is what makes the conference so interesting and unique. You are all warmly invited to the DKOU in October 2020 in Berlin.
I very much look forward to the tasks in hand and the many challenges we face. We can only overcome them by working together and trusting one another on the board and in the committees of our profes-sional society. We’re going to rise to the challenges.
Yours
Prof. Dr. Dieter C. Wirtz
DGOU-President 2020
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