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Less is more
  1. C Niek van Dijk
  1. Correspondence to Professor C Niek van Dijk, Academic Medical Center Amsterdam, Amsterdam 1105AZ, The Netherlands; C.NiekvanDijk{at}

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This year is my valedictorian, at least in Holland. That is to say, having reached a youthful 65 years, my Academic Faculty is retiring me. In Holland, I should mention, this is the tradition for university heads of department. There will be a series of lectures, and dinners, and congratulations. All of which is proving enjoyable, but also rather puzzling.

First, because I feel myself at the height of my powers. By comparison, politicians of this tender age would only now aspire to become a President, say, or a Prime Minister. And second because, like many of you, I seem to have been leading a frenetic life, a continual round of consultations and operations and lectures, with a deal of travelling in between. It seems to me, looking back, that I have hardly had time to pause and raise my head, and look around at the world. This is what I find so puzzling; the fact that we generally do not have the time to look around, but the sheer exhilaration of it, when we do.

I will anyway venture to share some of my valedictory thoughts, and to engage with you, using this space as a forum. Please do share your responses by email, good or bad or just bored.

One of the things I have realised, and have already hinted, is that our profession is attempting too many operations, attempting to cure things ‘with the scalpel’ that would cure themselves, quite adequately, if we just learnt to restrain ourselves and left them alone. ‘Less is more!’ should be our catchphrase.

Is this a matter of culture and circumstance, of something that differs between countries? And if so, which is the better culture and which the worse?

I am fortunate to be a regular visitor to the USA, which is a magnificent country. Some things about it are immediately clear to any visitor. Americans are confident about their courts, and see them as an immediate means for citizens to redress their wrongs, and thereby to keep everybody ‘up to the mark’ (and even your own government). This is splendid, and it does not happen in Europe, or happen in the same way.

However, it has its drawbacks. Lawyers can become too ambitious (remember, the successful parasite is the parasite that does not draw attention to itself) and your insurance costs are high (getting higher), because practitioners have to look over their shoulders, and insure against mistakes. In Europe, in contrast, medicine is increasingly a state monopoly, where the state taxes its citizens, and then provides them with medicine (it also tends to discriminate against private providers). This can also be splendid, in its way, in that professionals do not get dragged into court for non-negligent mistakes, (or only to a minor extent). They are protected by their paymasters, and only risk an occasional reprimand. Does this mean that incompetent doctors can survive in Europe, when they would be exposed and denounced in America? Hmmm, your opinions please.

It certainly does mean that treatment can be reduced (and even rationed) by the State, especially when it is expensive, and the State finds itself short of money. In England that is certainly the case. Patients there must wait for many categories of treatment—there is often a ‘waiting-list’ for operations—and they wait far longer than if they would just gone out and paid, using their own funds or insurance. This is a fundamental difference.

How does this affect orthopaedics, apart from the obvious point—I have this anecdotally—that rotator-cuffs often get better in England without treatment, because their owners are stuck in a queue? Is this just amusing, or does it support a more conservative approach? I wonder. Let me know what you think, so we can start a conversation.

Our readers will be aware of two different categories of article, specific to JISAKOS, which I announced in the first editorial. Some articles contribute to our State of the Art Review. This is a wide-ranging overview, which describes where we are now, so that we can better decide where we would like to be in the foreseeable future. In this issue, for instance, there is a review of failed cartilage repair, which delivers an important lesson, that we should look for malalignment or instability as a cause of failure.1 Yes indeed, a basic orthopaedic principle!

In contrast, our Classic Articles re-examine the past for clues; they look at past disputes and past techniques, and consider how things have changed. This is invariably interesting, and often insightful. In this issue, The Classic features Arciero's article, which set the standard for arthroscopic Bankart repair, and which has been put into modern perspective by Luo et al.2

I am now delighted to introduce a third and equally novel category; our Current Concepts Review. These articles will be more tightly focused, and each will examine an intervention, or a diagnostic procedure for a certain condition. Since they are specialised, and comparative, they can afford to make recommendations. Effectively they will be saying; this is the problem, these are the current solutions and this is the best one (at least in our opinion). In this issue, we examine the prevention of ankle sprains and conclude with a clear message; that athletes in contact sports or other high-risk sports should apply a tape or brace to obviate a future injury.3 Remember, there is no such thing as a ‘simple ankle sprain’ and simple prevention before is better than a complicated cure after.4

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  • Competing interests None declared.

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