The Family Revisited

I am honored and humbled to stand before you today as your 84th President. Last year in Las Vegas, as the Academy’s incoming First Vice-President, I spoke to you about the importance of unity within our profession. It is significant that 32 years ago, Dr. Charles Rockwood gave his incoming AAOS Presidential address on the very same topic. Dr. Rockwood, my chairman and fellowship director at the University of Texas in San Antonio, not only steered me toward shoulder surgery but also has become a lifelong mentor and friend. I am so fortunate to have trained with the faculty at the University of Texas. It was a special time that changed my life and career. In his 1984 address, titled “Keep the Family Together,” Dr. Rockwood identified six challenges to maintaining unity within the orthopaedic family. These challenges were communication and trust, fellowship certification, the resident and young orthopaedic surgeon, research funding, socioeconomic and legislative engagement, and education. All of these have been addressed in many ways since 1984. We have achieved a great deal, and our Academy’s many parts are well integrated and strong. However, there is much left to be done if we are to remain unified within our profession, which I believe is more critical today than ever before. I would like to touch on each of Dr. Rockwood’s six challenges to highlight the progress we have made, focus on work we need to do, and provide some current and potential strategies to meet these challenges. Communication and Trust Communication and trust, which make up the first challenge, go hand in hand, and we have made great strides with them since Dr. Rockwood’s address. By 1984, specialization in the field of surgery in general was well on its way, which caused great concern in some quarters. Dr. James Handy, a past president of the American College of Surgeons, wrote an editorial in 1982 in which he bemoaned what he called the fragmentation of surgery. In my humble opinion, any fragmentation that occurred was caused more by the failure of surgical leaders to embrace specialization than by the change itself. Fortunately, orthopaedic leaders of the time recognized that specialization was good for patients. They not only embraced it but also nurtured it, encouraged it, owned it. In 1984, for example, five specialty societies had affiliation agreements with the Academy. Today, there are 23 separate groups on our Board of Specialty Societies (BOS). Our Board of Councilors (BOC) consists of more than 100 members elected by state and regional orthopaedic societies. The board also includes representatives from Puerto Rico, the US military, and Canada. The BOC represents the grassroots of the profession, the frontline of orthopaedic care. It meets every fall and at the National Orthopaedic Leadership Conference in Washington, DC, in conjunction with visits to key lawmakers on Capitol Hill. The BOC has a robust committee structure and has a huge impact on Academy policy. In fact, our parallel advocacy organization, the American Association of Orthopaedic Surgeons, and the Orthopaedic Political Action Committee (PAC), were largely initiated by the BOC. Virtually every Academy activity involves the BOS and BOC. They are our connective tissue. Coming together as we do multiple times per year to work on education, quality, advocacy, and other issues binds us as colleagues and friends. Trust naturally follows. I treasure the experiences I have had—and the friends I have made—working in the trenches over the years with fellow members of the BOS and BOC. Fellowship Certification Fellowship certification, the second challenge, was not as important in 1984 as it is today. Dr. Rockwood had the foresight to recognize that, as specialization grew, so would the number of fellowships. At that time, 700 residents graduated annually from 185 residency programs. There were approximately 185 orthopaedic fellowships in various disciplines. Today, the number of residents who graduate every year is up slightly, to 794. The number of programs is down a bit, to 157. But the number of fellowship positions and programs has exploded, with approximately 943 positions in 480 programs. When the osteopathic programs are included, the numbers are even larger. Accreditation of these fellowships is spotty. Because accreditation by the Accreditation Council for Graduate Medical Education (ACGME) is required in order to sit for the American Board of Orthopaedic Surgery (ABOS) Subspecialty Certificate examination in Surgery of the Hand and Sports Medicine, close to 100% of fellowships in these two specialties are ACGME accredited. Trauma has an accreditation pathway, as well. But in fields outside Hand, Sports, and Trauma, more than 50% of fellowship programs have no accreditation pathway whatsoever. There is a variety of reasons, largely related to difficulties in compliance with ACGME rules and regulations. However, the existence of so many unaccredited fellowships may be difficult to justify in the future in this age of increasing oversight from the public, the government, and third-party payers. The Academy, therefore, established a Board of Directors project team in 2015 to examine an alternate accreditation pathway. Further work on this topic will proceed in conjunction with multiple stakeholders, including orthopaedic specialty societies, the American Orthopaedic Association (AOA), the ABOS, and the ACGME. Residents and Young Orthopaedic Surgeons Dr. Rockwood’s third challenge was recognizing and meeting the needs of the young orthopaedic surgeon. He recommended reevaluating the concept of a candidate membership category and called on the membership committee to investigate the possibility of a shorter time between training and admission to the Academy, which was then 4 to 5 years. Today, we have not only a candidate membership category but also resident members. Moreover, orthopaedic surgeons are eligible to apply for Academy membership as soon as they are ABOS certified. Another way that the Academy is engaging young orthopaedic surgeons is through our new Resident Assembly. The Assembly’s inaugural session last year drew nearly 200 resident attendees from more than 125 programs. We expect an even bigger turnout when the group meets here this afternoon. I am thrilled by this strong showing of interest in the Academy by our youngest members. In the future, we must continue to nurture and develop this important supporting organization. As we all know, the residents are our future. Research Funding Dr. Rockwood’s fourth challenge was to increase support for musculoskeletal research. We have a great deal of work to do in this area, in particular. It’s quite a story. Indulge me a bit while I cite some figures. In 1983, about $19 million was raised for musculoskeletal research, mostly from the National Institutes of Health (NIH), but also from the profession and local grants. In the years since, support of musculoskeletal research has grown a great deal. We now have a separate National Institute for Arthritis and Musculoskeletal and Skin Diseases (NIAMS). The Department of Defense (DOD) funds research on extremity war injuries. Our own profession’s contributions have grown through the Orthopaedic Research and Education Foundation (OREF). We have made a good case to Congress through efforts such as Research Capitol Hill Days and our Unified Research Agenda. Over the past 20 years, NIH funds for NIAMS have grown substantially. In 2015, NIH funding for musculoskeletal research was nearly $337 million. OREF grant awards totaled $2.5 million, and musculoskeletal grant funding from the DOD totaled $30 million. But here’s the rub: In the context of actual disease and suffering by Americans, musculoskeletal research remains woefully underfunded. In the years 2009 through 2013, musculoskeletal conditions impaired and affected one of every two American adults. In 2011, for example, musculoskeletal conditions drove 18% of all healthcare visits and 16.3% of healthcare costs. Yet research funding in the field has totaled less than 2% of the total NIH budget every year since 2000, declining even more in recent years, when the overall budget of the NIH was either level or cut in constant dollars. That, ladies and gentlemen, is a profound mismatch. We need to make the case to Congress and to society at large for more support of musculoskeletal research. And I think we as individuals need to step up our game, as well, with greater support for the OREF. Nobody will support our research efforts if we do not support them ourselves. Socioeconomic and Legislative Engagement The fifth unity challenge to the Academy was to become involved in socioeconomic and legislative issues. To my mind, this means advocacy for our patients and, by extension, our profession. In 1984, medicine consumed a staggering 10% of the Gross Domestic Product. Experts predicted more changes in medicine in the next 2 to 3 years than had occurred in the last hundred. Boy, was that an understatement. Orthopaedics alone now consumes 6% of our GDP and one third of all medical expenditures. The government and private payers are adopting increasingly intrusive alternate payment models that they say are based on quality. In this new environment, we must drive the national discussion from a patient-centric position. Your Academy is well recognized by both the government and other payers as an authority that defines quality with evidence-based criteria. We must get even better in the quality arena, never losing sight of the fact that evidence-based guidelines must acknowledge the role of experience-based clinical judgment in making good treatment decisions. After all, medicine is still an art as well as a science. The Academy has also been very active in the legislative and regulatory arenas. In fact, the Association was created expressly for the purpose of advocacy. Our political action committee, the Orthopaedic PAC, has become one of the top 10 association PACs and top medical PACs in Washington. Our Washington office drives our regulatory and legislative agendas expertly, and we are fortunate to have them. Despite many successes, such as last year’s final resolution of the years-long sustainable growth rate pay dispute, we still have much on our plate in terms of advocacy. The Academy must maintain partnerships with our orthopaedic specialty societies, especially those who have their own advocacy arms. We must also increase the participation of our members in our PAC. We have a 31% participation rate, with an average contribution of $500. If half of our members contributed to our PAC at the Capital Club level of $1,000, we would dwarf other medical PACs and substantially amplify our message. The trial lawyers and the hospital association each have over 90% participation of their members at substantially higher contribution levels. There is a reason why no healthcare reform package, including the Affordable Care Act, had a single word in it about malpractice reform. Knowing how good this field has been to us, it’s hard for me to believe more of us can’t dig a little deeper to help support the Academy’s mission on behalf of our patients as well as our profession. Please consider contributing to the Orthopaedic PAC at whatever level you can. Education Education was the sixth, and final, Rockwood challenge. While education is one of our core competencies, it’s safe to say we’re in a historically trying time in education. In 1984, there was no such thing as digital content. Videos were few and far between. There was almost no competition for your educational dollar. Now educational content that isn’t digital in some way is hard to find. Superb high-definition video content is just one click away on the Internet. Competition is fierce and comes from all directions. To maintain our strong educational brand and remain the primary source for unbiased musculoskeletal education of the highest quality, the Academy has invested heavily in both time and money to update our website, convert existing educational products into a digital format, shift our educational product development from a product-based process to a portfolio-based one, and create digital, scalable platforms for the creation, management, and delivery of learning content. In addition, we, along with key specialty societies, have invested in a truly spectacular, state-of-the-art Orthopaedic Learning Center (OLC), with video-streaming capabilities and opportunities for concurrent courses. If you’re ever at our headquarters in Rosemont, just outside Chicago, don’t miss a tour of the OLC, where at any given time, you’ll find multiple classes, including 24 workstations, interactive video to show live demonstrations of surgical techniques, and ceiling-high screens with three times the resolution we had before. The Academy also recognizes the critical importance of our specialty societies to the success of our educational activities. We have redoubled our efforts to partner with them for content creation, course development, and delivery. Finally, we have many international society partners who value and use the high-quality programs and courses from the Academy to support deeper knowledge in orthopaedics around the globe. The Academy education brand is global, indeed. Unity As you can see, the Academy has made great strides in addressing the challenges outlined by Dr. Rockwood in 1984. It is truly remarkable that the Academy still successfully admits 96% of eligible orthopaedic surgeons and retains 98% of those. Other societies would kill for that record. However, the road ahead is far from easy. Our membership has never been more diverse—by specialty, scope of practice, income, practice environment, gender, age, race, or ethnicity. Membership diversity has many positives, but trying to deliver value to such a diverse group is not easy. We face increasing external pressure from multiple fronts: government, private insurers, hospitals, and the public. And finally, we are likely to continue to be asked to do more with less. We must keep in mind that even though orthopaedic surgeons represent just 3% of all doctors, we use the most resources—and, by the way, are compensated better than any other specialty in medicine. We will have to face these challenges with a large bullseye on our back. In my opinion, we will be most successful if we remember two things: The patient is king (or queen), and there is strength in numbers. As I mentioned, we are only 3% of all physicians; we are strongest with one voice. We, as physicians, know that we are the patient advocates. We must always put the patient’s interest first in any situation. This notion is prominent in the AAOS Standards of Professionalism but shouldn’t need to be. It is obvious, self-evident. In these days of bundled payments, accountable care organizations, and other alternate-payment initiatives, some will inevitably lose sight of who are advocates for the patient. I am reminded of a recent visit to Capitol Hill with Academy colleagues to discuss the Comprehensive Care for Joint Arthroplasty proposal—a Centers for Medicare & Medicaid Services (CMS) bundled-payment initiative for knee and hip replacement. We were meeting with the health policy advisor for a very prominent member of Congress. The advisor was an economist who had worked in Washington since 1975. I said that the program would likely be more successful if CMS allowed someone besides the hospital to control the payment bundle, adding that some doctors’ groups, for example, would be well positioned to do so. I was incredulous when I heard this career Washington bureaucrat reply that “Everyone wants to control the bundle—hospitals, nursing homes, rehab facilities, and doctors—but someone needs to look out for the patient’s best interest.” I bit my tongue—which, as some of you know, is not my greatest strength—and said as respectfully as I could that we agreed and that this was the purpose of our visit. I reminded him that we physicians take the Hippocratic Oath, that we have had the privilege of looking out for the patient for hundreds, if not thousands, of years, and that we would continue to do so for a thousand more. What we were there to discuss was simply the finances. We must remind all of those who have lost sight of our role—both outside and within medicine—that we are the patient’s advocate, period. End of story. If we embrace that role and never forget it, I believe we will win in the end. As Churchill once said, a pessimist sees the difficulty in every opportunity; an optimist, the opportunity in every difficulty. I am an optimist, and I hope you all will join me in embracing the opportunities that await us. Our patients are depending on us. Thank you for your attention and for giving me the privilege of serving as your 84th President.