What is Rationalization?
Rationalization, as defined by George Ritzer, is the means by which individual businesses or broader industries employ the four focal components: efficiency, calculability, predictability, and control. Efficiency is employing the optimum and quickest mode to achieve a task. Calculability is prioritizing the quantitative aspects of products and services, equating quantity to quality, with the objective being quantifiable rather than subjective. Predictability is the uniformity in the products and services offered to consumers over a long-term duration. Control refers to employees becoming standardized and the replacement of human technology by non-human technology. McDonaldization is the phenomenon of when other industries adopt the characteristics of rationalized fast-food restaurants.
History of Orthopedics
Splinting: From Ancient to Modern Society
The practice of orthopedics dates back to ancient civilizations. Fossil evidence indicates that orthopedic pathologies, such as fractures and traumatic amputations, existed in primitive periods and were treated by splinting and rehabilitation practices. Early evidence of splinting, using a rigid or flexible material to immobilize a fractured or dislocated bone, was seen amongst the Shoshone Indians around 700-2000 BCE. They constructed a splint of fresh rawhide that was inundated in water. The splinting practice continued in medieval times, specifically with palm-branch ribs and cane halves as primary materials. The Aztecs used resin paste to hold together wood splints with large leaves. Fast forwarding to the advent of gunpowder in warfare, European armor makers had to modify their existing armor fabricating dexterities. With their familiarity with metalwork, exterior anatomy, and technicalities of joint alignment, brace fabrication was an evident alternative for these specialists. By the 1500s, turnbuckle and screw-driven metal splints treated joint contractures.
In 1592, Hieronymus Fabricius, a surgeon who developed an illustrated miscellany of armor-based splints in treating contractures of all anatomical parts, wrote the first recorded splinting manual, solidifying predictability and uniformity within the design process. The manual was the framework for French and English surgeons who worked alongside appliance makers to design and build custom braces and splints from the mid-1700s to the mid-1800s. The late-1800s splinting advances focused on treating targeted body sections split by upper and lower extremity problems. By the 1900s in America, rehabilitation post-treatment was starting to be acknowledged, and orthopedics, as a specialty area, was gradually assuming sovereignty from general surgery.
Today, splints are often made of fiberglass and thermoplastics, which are more durable and sustainable compared to the past, when splinting materials were prone to damage and wear. In addition, modern splints have more flexible material, so they can easily mold to apply on the body and have better circulation and airflow to mitigate swelling and facilitate healing. Modern splinting provides greater efficiency as it is a more optimal method now than ever, resulting in short-term recovery with less associated risk. Modern splinting also provides greater predictability, ensuring a sounder patient well-being outcome as opposed to past splinting, which had limited ventilation, comfort, and longevity, leading to less promising outcomes.
An Aid to Orthopedic Procedures: The Birth of Anesthesia
Before the mid-1800s, orthopedic surgeons had limited pain-relieving mechanisms for procedures other than opium and alcohol, which were highly potent. In 1844, the quest for modern anesthesia started through public demonstration when Gardner Colton, a medical student at what is now Columbia University, showcased the intoxicating mark of nitrous oxide. Horace Wells, a dentist and audience constituent at the demonstration, noticed that while intoxicated, public participants who had inhaled nitrous oxide were immune to pain from their injuries.
The first recorded use of anesthesia was on October 16, 1846, by Boston dentist William T.G. Morton, who used sulfuric ether, as an alternative to nitrous oxide, to anesthetize Glenn Abbott, a patient who had surgery to extract a vascular tumor from his neck.
During World War I and II, because of battleground bloodshed, there was a sudden upsurge in surgical procedures, resulting in an increased demand for anesthesia. This shift increased public acquaintance with the use. By World War II, numerous orthopedic physicians were drafted to provide anesthesia, including during the treatment course of fractures caused by bullets, bombs, shrapnel, and other blunt trauma. Anesthesia use in treating orthopedic wounds and conditions was integral to the orthopedic surgical efficiency process.
Today's general anesthesia fuses intravenous medicines, inhalable gases, and volatile fluorinated liquids. Virtually every extensive and long-operated orthopedic surgery today requires general or regional anesthesia, which induces a patient to be unconscious. With patients undergoing quicker surgeries, orthopedic doctors can see more patients leading to more profit via calculability. The micro degree of regional anesthesia or general anesthesia altogether results in predictable, less-risk outcomes.
Hip Arthoplasty
Hip arthroplasty is a surgical process in which the diseased parts or the entire hip joint are removed and substituted by artificial parts or a hip prosthesis. Nowadays, hip arthroplasty is dubbed the "operation of the century," but it came after decades and decades of complications and letdowns.
German physician and surgeon Themistocles Glück made the first recorded attempt at hip replacement surgery in 1891, about 130 years ago. He wanted to support his patients diagnosed with tuberculosis which weakened their bodies and caused deterioration of their hip ball-and-socket joints. So Glück created an implantable hip prosthesis of ivory, which was secured with nickel-plated screws.
Sir John Charnley, an orthopedic surgeon at the Manchester Royal Infirmary, is regarded as the father of contemporary total hip arthroplasty. In the late 1950s, Charnley constructed a prosthesis consisting of an implant with acrylic bone cement. This cemented hip replacement became widespread due to the concept of low friction arthroplasty, which had a 77-81% survivance rate. Charnley's design was a low-friction solution enhancing patient motion post-surgery more efficiently than past implant methods. Overall, Charnley's contributions laid the groundwork for today's modern implant designs and surgical techniques, allowing for early discharge.
The Surfacing of Professional Organizations
Founded in 1887 with 36 charter members, the American Orthopedic Association (AOA) was the first national orthopedic association in the United States and is the second oldest national medical association, preceded only by the establishment of the American Medical Association (AMA). The AOAs original purpose was to advance the field of orthopedics and differentiate orthopedics into a specialty. Membership in AOA has been for individuals who have demonstrated significant achievements. Annual meetings began in 1897 and continued every year except 1945 because of World War II. In 1931, the AOA formed two committees that ultimately transformed the entire system of the American orthopedic community. The first committee established a permanent organization that would be more broadly based than the AOA and would not have the AOA's membership restrictions. This marked the dawn of the American Academy of Orthopaedic Surgeons (AAOS), founded in 1933. The second committee investigated the establishment of an orthopedic specialty board.
In January 1933, the AOA advised the concrete arrangement of an Orthopedic Accreditation Board composed of representatives from the AOA, AAOS, and AMA orthopedic departments. In February 1934, Articles of Incorporation were created, setting forth the American Board of Orthopaedic Surgery (ABOS) goals. Soon after, the ABOS formed an Examinations Committee, an Eligibility Committee, and a Residency Training Committee responsible for assessing hospitals and medical schools and training young surgeons to become orthopedic surgeons.
In 1936, the ABOS issued formal necessities for accreditation. This requirement stipulated that a candidate must be a graduate of a medical school endorsed by the AMA Council of Medical Education and Hospitals, must be of high ethical and proficient standing, must be duly permitted to practice medicine in the state or province of their residence, must be a constituent of the AMA or other organization approved by the AMA Council on Medical Education and Hospitals, must have three years of concentrated education in orthopedic surgery approved by and permitted to the ABOS after 1938, and must have had two years additional experience in the actual practice of orthopedic surgery, and also have an understanding of the fundamental medical sciences linked to orthopedic surgery. There it was, the first formal educational standards specified for orthopedic surgery in the United States, ensuring predictability for future practitioners.
Irrationalities in Restructuring Orthopedic Practices
Irrationalities were discussed earlier in the general context, but now this section will precisely describe the trend in orthopedics. Though corporations follow a profit-driven approach by following the McDonaldization model, it is often at the expense of a care-driven approach. Different parties can have countering opinions on whether the change drives rationality or irrationality, though they simultaneously happen. For example, patients are likely to focus on the irrational aspects of the growing industry. At the same time, practitioners, management, and administration not undergoing the consulting and treatment process will embrace the monetary benefits and focus on the rational aspects. The focal areas of irrationality that arise from the McDonaldization of orthopedic surgery are the depersonalization of patient care, cost-cutting treatment measures, and dehumanization of employees.
The first area of irrationality with the trend towards McDonaldization is the increased lack of personal connection between the patients and providers. Communication is paramount to involve patients in decision-making, enlist their sense of responsibility for their care, create a sense of trust, and aid in information recall in patients, patient adherence, and patient satisfaction. While increased control in the orthopedic industry has led to greater predictability for patient treatment and quicker recovery times, this sense of face-to-face interaction has diminished. For example, the rapid growth of telemedicine allows orthopedic surgeons to convey health-related information in real-time without needing an in-person visit or via electronic communication. Though there is a colossal convenience factor in TeleVisit, there are negatives, including impediments in physical examination, such as manual motor testing, sensory examination, reflex testing, and more, as virtual meetings are no adequate substitute.
Another growing factor is the shift from inpatient to outpatient care in orthopedics. Dr. Subir Jossan, MD, Chief Transformation Officer at MedVanta, stated: "The shift to outpatient care began almost two decades ago and has accelerated significantly in the last four to five years," citing technological advances as the cause, including anesthesia postoperative pain control. Less inpatient care means fewer overnight stays at hospitals under the guidance of orthopedic surgeons and nurses. Without oversight and close, intimate proximity, not only the patient-provider relationship is compromised, but also, in extreme cases, the patient's safety by being isolated and miscommunication occurring.
A second area of irrationality is the potential decrease in the quality of treatment via disenchantment, often through prioritizing profits over emotional satisfaction and physical well-being aligning with calculability. US physician markets are dramatically restructuring as longstanding small, solo orthopedic physician practices are being replaced by large multi-specialty practices often owned or employed by hospital systems. Notably, larger systems pursue efficiency and predictability as they are prone to using cost-cutting measures and "quick fixes" that solve the patient quickly but increase the risk of follow-up surgeries such as arthroplasties. Under the private practice model, the relationship is just between the doctor and patient, while, in larger, corporate-owned practices, a third party is introduced. The third party is the health system, predominantly led by administrators with no clinical expertise that significantly impacts a physician's medical judgments daily. The organization may demand what tests to conduct and which brand of implants to use in orthopedic surgery and even push for more surgeries regardless of whether they are indeed needed by the patient..
A final area of irrationality is the dehumanization of employees at the business level and the general decrease in the employer-employee relationship. As mirrored in other specialties, family orthopedic practices often offer more flexible hours and paid time off than large orthopedic practices managed by hospitals, which can be especially critical to employees with families. Independent practices also offer intimacy within the smaller vicinity.
These irrationalities are associated with the growing orthopedic industries inevitably following the McDonaldization model. Unless specific legislations enforce, the irrationalities will aggregate as the byproduct of rationalization.
Current State and Future of Orthopedic Surgery: A Matter of Control
Artificial intelligence and robotic assistance shape modern orthopedic surgery and pave the way for future development. One of the most challenging facets of traditional joint replacement surgery is positioning the individual pieces of the artificial joint in a perfect alignment so they will interlock together and work properly. The robotic arm allows surgeons to execute the most complex operations with more control, accuracy, and flexibility than conventional techniques.
There are two leading classes of robotic surgery systems: haptic and autonomous. Haptic systems require continuous input from the surgeon for the procedure to proceed. Contrarily, autonomous robotic systems require the surgeon to start up the machine, but once activated, the robot directs the surgery without the surgeon's assistance.
The Robotic Arm Interactive Orthopedic System, RIO, is a commercially accessible, haptic robotic system that demands the dynamic support of the surgeon to conduct a unicompartmental knee arthroplasty. It initially CT scans to produce a three-dimensional automated model of the patient's knee. The surgeon uses this model preoperatively to plan the sizing and arrangement of the components and then reference the skeletal surfaces of the femur and tibia, allowing the model to integrate with the natural anatomy of the knee. After moving the knee via a spectrum of motions, the specialists reassess the flexion-extension gaps and finalize the surgical timetable based on component placement, creating a precise cutting site for the robot. During the resection of bone, the surgeon examines the 3D model of the knee while manipulating the burr. The robotic arm delivers aural and haptic responses, limiting the force-controlled tip of the rotating burr to resect bone only within the environs of the pre-defined cutting area. An added safety segment automatically shuts down the burr if the surgeon goes outside the pre-determined zone. This feature also engages if the computer senses that the surgeon is resecting excess bone.
Unlike haptic systems, autonomous systems complete the entirety of surgeries without surgical assistance. Rather, the surgeon manages an emergency shut-off control while the robot operates unaided. Currently, autonomous systems are still under examination for use in orthopedic surgery. A documented exemplar is the ROBODOC, which has now descended from endorsement within the arthroplasty society. Originating as a prototype by IBM in the mid-1980s, this system was presented for patient use in 1992. As discussed earlier, the earliest trials involved robotic assistance for total hip arthroplasties. Statistically significant fit, fill, and alignment headways were confirmed compared to traditional techniques. This system was prevalent, specifically in Germany during the 1990s, but experienced a descent in use amidst safety concerns.
Financial deterrents are restraining the widespread use of robotics in orthopedic surgery. The immediate cost of acquiring and possessing an automated system is often out of the question for many practices, especially independent ones. Furthermore, these systems need ongoing calibration of hardware and software upgrades, leading to added expenses. Practices must reckon with their financial position, accounting for operative volume and potential returns, when considering the usage of robotics. Many smaller hospitals or lower-volume practices lack the specialized surgical competence to explain using these costly systems.
Minimally invasive surgery, a key element of robot-assisted orthopedic surgery, means smaller incisions resulting in less scarring on the body and reduced risk of infection. In addition, the recovery time is generally faster, and patients are often discharged on the same day, depending on the procedure, leading to higher efficiency. The robotic arm additionally provides a high level of predictability with reproducible results eliminating variations in surgical outcomes. With this technology, medical practices will have a greater chance of pursuing calculability, focusing on quantifiable objectives on the number of successful treatments with increased efficiency rather than the patients' experience in the treatment. These various examples of robot-assisted aid in replacing humans using manual aid is a ideal representation of control, of workers consistently performing the same.
Conclusion
Ultimately, Ritzer's principle of rationalization is exerting heavy influence on the orthopedic industry for the better and the worse. The increased control via robot-assisted surgery and efficiency of predictability via overseeing professional organizations have improved patients' overall well-being, leading to efficient, non-lengthy surgical stays. Orthopedic surgeons can now perform arthroplasties and joint replacements with minimal interference, incision, risk of follow-up surgery, and infection. However, the increased control, efficiency, and predictability have made practices more calculable in their approach, demonstrated by the shift from family-owned small orthopedic practices to more prominent, hospital-owned practices. Though the shift to more significant business favored by insurance companies may displace individual orthopedic surgeons who are proprietors and managers within a generation timeframe, it opens the pathway to new occupations in which orthopedic surgeons do not have to manage administrative work. Altogether, the most subtle changes in technology and the overarching industry can directly impact many factors surrounding the patient and the business.
Credits:
Created with images by Issara - "Team of doctor doing surgery inside modern operating room with orange effect. Asian orthopedic surgeon in blue surgical gown suit under surgical lamp.Fracture fixation was done in car accident patient" • makibestphoto - "The medical team visits the car accident patients who are lying on the nursing bed and arm cast with wrapping nurse bandages splint to the arm." • gumpapa - "concentrated professional surgical doctor team operating surgery a patient in the operating room at hospital. tumor cancer. surgical biopsy specimens. healthcare and medical concept."