DOCTORS ARE EARNEST AND INTELLIGENT, ARE BLESSED WITH an excellent memory, and are dedicated to making people feel better. For the most part.

Alas, there also exists a being I call the LK-SS (Limited Knowledge-Suspect Scruples) doctor. This is the kind of doctor you have to watch out for.

It seems incredible that after four years of medical school and four to six more years of orthopedic training, an orthopedist or physiatrist (rehabilitation specialist) could still be deficient in his or her knowledge of the knee. And yet it's true. Over the last four decades, the world of orthopedics has become huge.

When I was in training in the early 1980s, some of my teachers had had no formal training in orthopedic surgery (i.e., the surgery of bones and joints). They had trained as general surgeons and somewhere along the line had taken an interest in orthopedics. Up until the 1960s the sum total of orthopedic knowledge was small enough that any general surgeon could indulge in orthopedic surgery. General surgeons, for example, routinely set fractured bones.

Then the field became more sophisticated. A different approach was developed for every type of fracture in each bone. Moreover, for each of these fractures, controversies developed. The world of fractures became a field unto itself that could no longer be considered a small surgical aside. Techniques were also perfected for spinal deformities, arthritis, sports trauma, and pediatric conditions. Such operations were too numerous for a general surgeon to simply handle in his spare time. By the 1980s, surgeons who had taken specialty training in orthopedic surgery were addressing most of the orthopedic conditions treated in the United States.

Incredibly, orthopedics became yet more complicated. Each part of the body became a specialty unto itself. Consider the scientific literature: There are at least two English-language journals dealing only with knees, many journals dealing only with sports injuries, and entire journals devoted to only the hand, shoulder, spine, foot, joint replacements, fractures, or children's orthopedics.

People were amazed in the 1970s when an entire book was devoted to the knee. Now even the knee is nearly too broad a subject. I have written a medical textbook dealing exclusively with the kneecap-and it's the third textbook on the subject!

A medical-school curriculum calls for, at the very most, one or two weeks of orthopedic training sandwiched in between "more important" subjects. With occasional exceptions, medical students know next to nothing about orthopedics when they graduate.

An orthopedist in training is already an M.D. and is called a resident. He or she learns the basics pertaining to each part of the body and how to perform the most common procedures. All orthopedists learn to recognize and treat fractures. However, the world of orthopedics is too vast for an orthopedist out of general training to know all there is to know about hands, feet, knees, shoulders, etc. So orthopedists often now do fellowships, and learn from one or two doctors whatever it is that those doctors specialize in. Thus, there are hand fellowships, spine fellowships, and so forth. There are very few knee fellowships. This is because for historical reasons the world of knee surgery has been split into two parts. Right from its onset, in the early to mid-1970s, knee-replacement surgery fell into the orbit of hip-replacement surgery, which had already existed for approximately a decade. Surgeons proficient in hip replacement surgery initially performed most of the knee replacements. On the other hand, knee arthroscopies and ligament reconstructions were first performed in the early 1980s by the sports orthopedists. Therefore, there exist joint-replacement surgeons and fellowships for knee arthritis and sports surgeons and fellowships for just about every other knee problem. We have an entire generation of orthopedists knowledgeable in only one aspect of the knee (sports surgery versus joint-replacement surgery), not to mention orthopedists in general who have never had a specific interest in knees to begin with.

If you have an obvious, common problem, any orthopedist will be able to give you good advice. (Whether he chooses to do so is another subject, as we will discuss below.) But the more subtle problems will go undiagnosed. Consequently, the doctor may resort to unnecessary expensive testing, "let's go in and see" surgery, and lengthy, unproductive sessions of unfocused physical therapy.

This is a delicate subject. As a practicing orthopedic surgeon, I am talking about my colleagues, people I work with and have helped train, people I see at every meeting who I hope will come to my courses and buy my textbooks. But let's face it. A number of orthopedists and physiatrists are not straightforward. They are a minority, but not a small one. Your odds of getting a dishonest opinion range from 10 to 50 percent, depending on the setting. Some of the less honest doctors are new to their practice and will do anything to get started in a competitive market; others are chairmen of departments who abuse their prestige. They work in small hospitals; they operate out of large university centers. They are friendly, smooth-talking, and persuasive. They work side-by-side with excellent, knowledgeable, trustworthy doctors from whom they are outwardly indistinguishable. (Read chapter 15 to tell them apart.)

There are shades of dishonesty. Sometimes the doctors are blatantly dishonest, as when they state that something is fine when they know it isn't (or vice versa). But there are more subtle forms of dishonesty: failing to correct a patient's misinformation and misunderstanding. For example, you might undergo a sophisticated test, such as an MRI, and the report will read "grade II tear" of the cartilage. You think, Torn cartilage; I need surgery. Not so. A grade II tear is really not a tear at all and requires no surgery. But the LK-SS surgeon will not tell you this and will happily allow you to sign the surgical consent form. To the LK-SS surgery is irresistible. What better scenario (for a surgeon) than a patient expecting it? The patient is unlikely to know that he or she would have done equally well with more conservative measures.

Here is another scenario: A person has a severe arthritic flare-up in his or her knee and consults a specialist. The pain is so bad that he or she will do anything, which includes agreeing to surgery. Every orthopedist knows that the flare-up will eventually quiet down, especially if it is one of the first painful attacks. But the LK-SS surgeon will gladly offer to eliminate the problem with a knee replacement (soon, before the pain wears off ). Don't scoff. This is not an uncommon scenario.

It is also deceitful to send patients for physical therapy that is not tailored to their specific condition. While some conditions can improve with twenty minutes of heat packs and cycling on an exercise bicycle, many require a more personal approach. But by sending you for plain, impersonal, bare-boned physical therapy that won't help you, the surgeon can tell you that you "failed physical therapy" and that you therefore need surgery.

Which brings us to the "perfect crime": The surgeon picks a high-tech, outpatient procedure that is associated with a low complication rate and a speedy recovery. The procedure is performed on a patient who would eventually do well, anyway. (One has to hurry up before the patient gets better on his or her own.) When the patient does get better, the surgeon is credited with the recovery, and many more patients are referred to him. Everybody wins—except the people paying the bills, but who cares?

Even educated people get tricked into surgery. I can imagine going to the dentist with a toothache and having the dentist send me for an expensive test. If the test came back saying I had some kind of dental rot, it wouldn't dawn on me that perhaps every test on every patient shows dental rot and that my trusty dentist was using that test to sell me an unnecessary procedure. So I sympathize fully with people who've been sold a knee arthroscopy. Therefore, the existence of this book. Physiatrists and chiropractors are not immune to the LK-SS phenomenon, either: Whereas surgeons exploit gullible patients with respect to surgery, LK-SS physiatrists and chiropractors relish endless therapy sessions.

Interestingly, if you have a personal-injury case, your attorney may unwittingly play a role in your getting inappropriate advice and treatment. The chances are overwhelming that your lawyer doesn't know the subtleties of MRI reports. When he sees "cartilage tear," he will think, just like you, that the tear is the result of an injury. From a business point of view, he will not be displeased that you need surgery; it makes for a stronger legal case. Likewise, it makes for a stronger case if you are receiving ongoing physical therapy, as it demonstrates persistent symptoms and a need for prolonged care.

Faced with both a patient and a lawyer who expect surgery and prolonged physical therapy, the LK-SS surgeon and physiatrist find it irresistible to schedule an operation and lengthy therapy, though not necessarily in that order.

In the following chapters we will review what you can do to protect yourself against misinformation and painfully suboptimal treatment.