Principles of Practice - May 1987


Every man has a philosophy of life in thought, in word, or in deed, worked out in himself unconsciously. 10


As I near the completion of my residency training and contemplate the private practice of orthopaedic surgery, I will attempt to define my principles of practice. Knowing that much of medical training has deliberately been made stressful, defensive, and negative to fulfill the rite de passage and in light of the entrepreneurial environment fostered in my residency, I find it necessary to clearly define my personal feelings of what constitutes the practice of good medicine.


My primary responsibility is to my patients who I will care for with kindness, understanding, dignity, and respect, no matter if they are men, women, or children, of whatever race, creed, color, or financial circumstance. What occurs between us will be confidential and my patients have the right to be fully informed of any and all available diagnoses, treatments, possible risks, and expectations of cost of their care. I will treat people and patients not consumers, clients, voters, beneficiaries, or constituents, and my patients will be my equal, no matter their status or position in society. I will communicate with my patients sincerely, honestly, and in terms that are familiar to them.



It is much better to know that one is not perfect, (then one feels much better).8 I realize that I will make mistakes, and I will manage them. I will quickly recognize a complication, promptly seek appropriate assistance, extract a general lesson from the clinical experience, and attempt to never make the same error. I humbly recognize my limitations and my need for the knowledge, support, and inspiration of others.


Ethics/ Professionalism:

Medical ethics ... a code of fundamental morality and justice between medicine and the people.1 Medical ethics and professionalism are my responsibility not my obligation. These ideals are something that I wish to nurture and maintain, not to which I am compelled to obey the law or peer pressure. Ethical principles of practice will demand a higher standard than by law, which requires only the minimum.14 I will not let medical ethics and my own professionalism become abstractions.


The master word is discipline.  Learning does not terminate with the cessation of formal training. I will strive to be an educator of my patients, my colleagues, and myself. I will honor my profession, seeking to improve it both by scholarly inquiry and thoughtful consultation. I will review each and every case for possible improvement in the diagnosis, treatment, surgical procedure, or technique. I will accurately follow my patients as long as necessary to reassess my surgical procedures in a scientific manner, and alter my practice of medicine accordingly.


Ideally, part of choosing a specific therapy is an exercise in science.3 If possible, I intend to foster my "divergent thinking"; 14 to remain curious, sensitive, persistent, and to tolerate ambiguity while maintaining the capacity for intense concentration. I contend that some questions have many answers while other questions have none. Uncertainty and anxiety are therefore inevitable but acceptable emotions.


I believe that there is a growing conflict between the economics and the ethics of medicine which challenges medicine as a genuine profession. When a physician becomes the investor, the corporate employee, or the entrepreneur and his performance is measured by productivity and profit rather than excellence of care, there is a serious conflict between his economic self-interest and his moral obligation to protect the patient's best self interest.


I have witnessed such a process and take away from my residency some very vivid memories of the distortion of academic values, the altering of clinical data, and the whole-hearted acceptance of blatant self interests as a desirable and protected quality necessary for advancement in the academic community. It is clearly the reason that I have become so disenchanted with academic orthopaedic surgery. I can only hope that I do not follow such an economic and distorted creed.


The failure to cultivate the power of peaceful concentration is the greatest single cause of mental breakdown.10


Much of my training has required a certain disregard for personal needs and, I'm sure, an alteration of some of my beliefs and values. Although I have found it more and more difficult to find those who I consider to be true mentors -those wise, experienced, and trusted advisors -I hope to be a "pathfinder" and not a "follower" of opinions and values of my teachers. To adopt a particular system of thought, action, or values is to lose one's individuality. I recognize the importance of my family in my life. This has strongly influenced where and how I have chosen to practice orthopaedics. Having been raised the son of a research oriented Mayo Clinic physician, I am acutely aware of the possible conflicts between my work and my time spent with my family. My goal is to strike the medium between practicing the best medicine that I know how to and being the best father and husband that I can possibly be while admitting to my hypertrophied work ethic -a characteristic of those in medicine whether in private practice or in academia.


1.    Bethune, H.N. ; Sword and Scalpel, p. 95, p. 280.

2.    Bosk, C.L. ; Superior Surgical residents -Who are they? Res. Staff Phys. 30: 1984, p. 73-76.

3.    Cooper, R.R. ; MOS Presidential Address, San Francisco, 1987.

4.    Coury, J.J. ; Physicians' Fundamental Responsibility. JAMA 256:8, 1986, p. 1005-6.

5.    Enneking, W.F. ; The Quality of Orthopedic Education. MOS Bulletin, April, 1987.

6.    Fairbanks, A. ; Five Smooth Stones. 7.    Janes, J.M. ; De Populo, p. 61.

8.    Jung, C.G. ; Analytical Psychology, p. 108.

9.    Oath for New Physicians -written by the graduating class of 1982, University of Minnesota.

10.    Osler, W. ; A Way of Life. Oxford U. Press, 1958, p. 237, p. 246.

11.    Pellegrino, E.D. ; Medical Ethics. JAMA 256:15, 1986, p. 2122-2124.

12.    Pfifferling, J.; Anidote to Effects of the M.D. Training System. Prep. For Practice, p. 4-5.

13.    Sullivan, A.W.; Personal communication, 1986.

14.    Wilson, F.C.; Creativity of Medicine -A Faculty Perspective. Perspective in Biology and Medicine, vol 29, 1986, p. 310-315.