I have chosen to speak about something that everyone in this audience has felt—fear. In some situations, it can preserve us; in others, it can destroy us. Fear is the starting point of my speech. However, as the title suggests, I plan to move well past it. By acknowledging and even embracing our fears, we can use that energy to our own advantage. In Chinese characters, the word crisis is represented by danger on one side and by opportunity on the other. Throughout history, it has always been the same: one door closes as another opens. The American Orthopaedic Association has a new mission and a new direction, and I intend to see that our efforts are not thwarted by what is within or what is without. Despite its many detractors, the future looks very bright, as I will describe later, but some of us may be a little too mired in the present to see it.
During times of vast, sweeping change, humans respond in a variety of different ways. However, when the change is relatively sudden, the most pervasive initial response is fear. Fear is a four-letter word in every sense. Edmund Burke said: "No passion so effectually robs the mind of all its powers of acting and reasoning as fear." Fear or anxiety can have disastrous long-term and short-term results. It causes a narrowing of one's perspective on time so that only the present matters. It also often results in an inability to attend to more than one task at a time or to complete any task effectively. It interrupts and distorts organized thought processes. The central feature that characterizes fear is a feeling that one will not be able to master future events. Sound familiar?
There is no doubt that fear has become a pervasive emotion in the medical field. In fact, it would be unnatural not to be fearful in an environment that is changing so rapidly, with such major shifts in power and roles. If we recognize our fear and admit that it is there, we can do something about it. It also then becomes possible to do something about the core problems that are causing it. In an excellent book entitled Managing Your Mind, Dr. Gillian Butler and Dr. Tony Hope wrote: "It is tempting to pretend that our fears and problems are not always with us. It is tempting to close our eyes to them, half hoping that they will, of their own accord, go away. But the problem with problems is that they rarely go away in silence. They usually need to be tackled and solved." It is my strong belief that it is time for us to recognize our problems, to do what we can to begin solving them, and to move forward into a new millennium with renewed strength and purpose. We must remember that it is the tough times that bring us together and unite us. We should not let it be otherwise.
The saying "the only thing we have to fear is fear itself"15 has lost a lot of its impact because it has been so overused. When Franklin Delano Roosevelt made the statement in his inaugural address in 1933, his confidence and calm assurance were able to see an entire nation through one of the worst times in its history, the Great Depression. A more complete quotation reads: "So, first of all, let me assert my firm belief that the only thing we have to fear is fear itself—nameless, unreasoning, unjustified terror which paralyzes needed efforts to convert retreat into advance."15
In an insecure environment, such as the one that we are now facing in medicine and the one that our nation was facing in 1933, there is a great deal of disorientation and disillusionment. There tends to be a reversion to a survival mode, in which selfish concerns override cooperative efforts. Lack of job satisfaction and low morale have led many physicians to look toward financial gain as a means of gratification. I call this the "Show-Me-The-Money" attitude. Those of you who saw the film Jerry Maguire will recognize the source of this quote. I am convinced that one of the worst by-products of insecurity is greed. Cyril Connolly said: "Greed, like the love of comfort, is a kind of fear." When individuals feel that their resources and security are threatened, greed runs rampant.
Edward Dahlberg went further on this theme when he stated: "There is a strange and mighty race of people called the Americans who are rapidly becoming the coldest in the world because of this cruel, man eating idol, lucre …" The word lucre actually comes from the Latin word lucrum, which means avarice. The biblical translation of the expression filthy lucre was actually derived from aishron kerdos, or shameful gain. Financial gain is indeed shameful when it comes from compromising the health care that we provide to our patients.
The only way to prevent greed, fear, panic, and despair during times of sweeping change is through strong, assertive, confident leadership as demonstrated by Franklin Delano Roosevelt during the Great Depression. Our organization has the power, resources, and leadership potential to see our profession through this harrowing time and to offer our own type of New Deal in medicine by instituting various programs that offer guidance and inspiration.
President Roosevelt had an advisory committee known as the Brain Trust. Within our organization, we have our own Brain Trusts that work consistently toward the development of courses of action that will improve the way in which the American Orthopaedic Association operates and that will offer hope and guidance to those individuals, both physicians and patients, who come into contact with us. We are making great strides toward improving educational opportunities. We are also seeking to encourage leadership opportunities, organizational collaboration, and, most importantly, the overall improvement of patient care. Finally, we intend to widely expand the use of technology in order to improve the national and global dissemination of vital information.
We empower our orthopaedic colleagues in much the same way that Franklin Delano Roosevelt empowered our nation by inspiring high morale, defined as "the state of the spirits of a person or group as exhibited by confidence, cheerfulness, discipline, and willingness to perform assigned tasks."1 In an environment in which the very core of our existence becomes threatened, morale is undoubtedly a heroic quality. As managed care and big business compromise our efforts to increase the quality of care that we offer to our patients, decrease funding for basic research, and threaten our educational institutions, we must work even harder to maximize our resources and to present a united front.
The most effective way to overcome fear and to forge ahead is to put aside selfish concerns by helping others. We are all healers and teachers. We should concentrate our unselfish efforts with our patients on a daily basis in the present and should protect our future by encouraging and championing education. As we all know, medical education is suffering immeasurably from the impact of managed health care. In a recent article, Dr. Gert H. Brieger of Johns Hopkins stated it perfectly when he said: "Our medical schools, like our universities, are precious national treasures that cannot be traded in the market." He went on to state the following points, which I would like to reiterate here. His first point was: "Medical education is a public service and a public trust, as indeed are all activities related to medicine. Education of any kind, including medical, is a slow process that demands hard work on the part of both students and teachers. Its profits are reaped in terms of knowledge and understanding not dollars or market shares." Finally, he stated: "Medical education is not only a slow process it is also an inefficient one in the clinical setting. Such inefficiency is costly and poorly tolerated in a market-driven setting."
We must keep in mind that this is not the first time in history that the state of medical education has been less than desirable. In the early part of this century, students at most medical schools were taught by a group of physicians who were motivated in great part by economic considerations. Some of these schools were actually private ventures established by one or more physicians who charged tuition for their personal gain. In addition, some schools had no laboratories for teaching the sciences and some allowed students to graduate within a year or two after they had completed their high-school education2.
In 1910, Abraham Flexner, a non-physician educator who was funded by the Carnegie Foundation, evaluated the 155 medical schools in the United States and Canada and identified the poor quality of the existing form of medical education11. He proposed that the quality of medical education could be improved by (1) limiting the number of medical schools to those at universities in order to promote quality education founded on scientific methods and laboratory experiments and (2) eliminating the economic motivation for faculty by paying them a full salary in order to take away the "distractions of a successful practice." Sweeping changes led to a decrease in the number of medical schools and the establishment of the types of departments that we are familiar with today.
More important to us than the report that Flexner wrote in 1910 is the paper that he wrote in 1925, in which he reported on the outcomes of the academic experiment12. The budgets of the medical schools had increased by 300 to 900 per cent during those fifteen years, whereas inflation had increased by only 175 per cent. He further reported that most universities were able to fund the increased costs through endowments and the interest generated by these endowments. However, since 1925, overhead costs have increased dramatically; the costs of support staff have increased; and government funding, which reached an all-time high in the 1970s, has all but disappeared.
In other words, medical education is expensive and continues to become even more so. One of the most important contributions that we can make to the future is to develop strategies for the continued funding of medical education. This will most likely include strategies for endowment fund-raising, departmental restructuring, and clinical and academic coordination within the medical schools. Part of my mission as President will be to foster educational programs within this organization and to encourage new membership and participation by the next generation of orthopaedic specialists.
At the start of our careers, most of us had what is known as beginner's mind. The Zen Master, Suzuki, stated: "In the beginner's mind there is no thought, `I have attained something.' … When we have no thought of achievement, no thought of self, we are true beginners. … The beginner's mind is the mind of compassion. When our mind is compassionate, it is boundless … we are always true to ourselves." These days, we all recognize the brain drain in the field of medicine. If those of us at the top of our profession are now questioning our incentives, what must those at the beginning of their careers be thinking? How is it possible to maintain an open beginner's mind in a competitive, fast-paced, over-burdened quasi-educational-clinical environment? It is vital that we instill feelings of pride and unity in the next generation so that standards of excellence, upheld by this organization since its inception, will be carried onward into the new millennium.
We have a responsibility as leaders to set an example by mastering our fear and forging ahead. Mark Twain said: "Courage is resistance to fear, mastery of fear—not absence of fear."23 The American Orthopaedic Association is changing with the times. We are setting the stage for the future by preparing a mission that encourages new visions. The new Mission Statement for the American Orthopaedic Association reads as follows: To build our second century of leadership and excellence in musculoskeletal care worldwide, the American Orthopaedic Association will: (1) develop, recognize, and engage leaders; (2) monitor, assess, and support highest quality care; (3) foster education pertinent to all caregivers and patients; (4) initiate and sustain collaboration among all interested organizations to serve our communities, shape orthopaedic policy, and achieve our shared missions; and (5) encourage and support scientific investigation.
The first item on this list is the development of leaders. Going back to the example of Franklin Delano Roosevelt, part of a leader's role in mastering fear is having a willingness to face the hard issues and, furthermore, having the courage to develop both short-term and long-term strategies to overcome them. This requires a great deal of confidence. In the words of John Kenneth Galbraith: "All of the great leaders have had one characteristic in common: it was the willingness to confront unequivocally the major anxiety of their people in their time. This … is the essence of leadership."
The second and third items on this list are, to me, the most important. During these difficult times, we must continue to provide the best quality of care to our patients and must never let our own problems interfere with how we treat each individual person with whom we come into contact. Our patients are also fearful of the quality of care that they will receive. We must take the time to reassure each patient through our attitude, our willingness to offer comfort and insight, and our ability to give them the information that they need in order to lead healthier lives.
This is where the third item—to foster education—comes in. I have already spoken about the education of the next generation of caregivers, but what about the education that our patients need in order to maintain wellness? Now, more than at any other time, we have the ability to keep a majority of our patients healthy. Preventive medicine has become as much a part of our practice as healing disease. Although it may be partially due to market demands, no one can detract from the benefits of the renewed interest in this topic in recent years. Achieving access to preventive services for all Americans is one of the three major goals of Healthy People 2000, one of the national health-promotion and disease-prevention objectives of the United States Department of Health and Human Services in Washington, D.C.14,20. However, if this information is not available, it does not do anyone any good.
Collaboration in shaping orthopaedic policy and the support of scientific investigation are the last two items of our new mission statement. In the words of Helen Keller: "Alone we can do so little, together we can do so much." It is essential that we form a community of orthopaedic specialists all over the globe and unite as an entity to provide the best care possible to our patients. In the wise words of Dr. James Urbaniak, who stood in my position just four years ago: "The American Orthopaedic Association can, and must, continue to promote an interchange of ideas and to facilitate joint action with The American Academy of Orthopaedic Surgeons and other major orthopaedic associations. This interaction among the leaders of the organizations should be natural and without hesitancy or apprehension." As leaders, this is our charge, our responsibility. To come back to my theme, we can set an example as leaders by fostering a magnanimous outlook defined by "a loftiness of spirit and generosity of mind enabling one to sustain danger and trouble with tranquillity, firmness, and courage."1 It is through generosity of mind and spirit, also known as magnanimity, that we put down pettiness, cowardice, and selfishness and foster community among our specialty, with our patients, and with those who work and train beside us. I once saw a depiction of a group of individuals seated in a circle around a very large pot of soup. The only utensil that they had was one very long spoon. In order to eat, they had to feed one another from the large kettle. Everyone in the circle was starving to death. No matter how bad it may seem, we have choices, and the choice we need to make is to cooperate.
We are all aware of the critical state of research funding. Scientific research is the fulcrum upon which our profession rests. It is the support about which the lever of the future rests. To push this element aside is to cast aside our future. In the same creative way as for education, we must develop strategies for funding research and research institutions. We must foster a spirit of discovery and an environment that inspires that spirit. Fear and anxiety do not foster the spirit of discovery, which Mark Twain described in this moving passage: "Discovery! To know that you are walking where none others have walked; that you are beholding what human eye has not seen before; that you are breathing virgin atmosphere. To give birth to an idea, to discover a great thought—an intellectual nugget, right under the dust of a field that many a brain-plough had gone over before. To be the first—that is the idea."22 We have to ask ourselves if we not only can fund but also can invigorate research so as to motivate this spirit of discovery.
Leadership is about motivation. It is about motivating others to believe in themselves by maintaining unwavering confidence and optimism in the face of every challenge. It is about overcoming personal fear and prejudice to secure a future for others and ultimately for yourself. In the words of Ernest Hemingway, courage is "grace under pressure."19
This is a natural segue into the next portion of my speech, which concerns the topic of leadership in the new millennium. I want to start this section with something of a digression into Renaissance history. In approximately 1446, Johannes Gutenberg, a metallurgist and winegrower, invented moveable type and thus ushered in the mass production of the written word. His process was widely copied and, by 1500, presses throughout western Europe had published almost 40,000 books6. We now realize that Gutenberg stood at a crucial dividing point in history. Before him was the scribal culture and after him, mass communication.
Gutenberg made the printing press with use of an old wine press and moveable type; the moveable type was held together by wooden frames. Gutenburg's famous forty-two-line Bible is believed to have been completed by 1455. Let us move ahead in history by 500 years. In 1945, the Atlantic Monthly published a landmark article entitled "As We May Think," which described the conceptual framework of a hypertext document6. It is this type of document, remarkably described more than fifty years ago, that now makes up the body of the World Wide Web. The World Wide Web is one of the vast array of resources available on the Internet. Much like the printing press, the World Wide Web is dramatically changing the way in which we are able to promulgate and access information on a global scale.
The word is getting out regarding the Internet and its usefulness within the medical community. The actual word Internet did not appear in the medical literature until 1992. Biomedical use of the Internet is increasing exponentially. In 1992, there were only eight citations of the word Internet in the Medline database. By 1995, there were 217 citations of the terms Internet, World Wide Web, or WWW8. As of February 1998, there were 1780 such citations. We are in the midst of an information revolution just as significant as that brought about by the appearance of the printing press some 550 years ago.
The Internet is a complex network of computers linked to one another throughout the world. The use of the Internet does not depend on the type of computer to which it is connected. This type of functionality is commonly termed cross-platform functionality. In other words, every type of computer platform is supported. This functionality has largely contributed to the success of the Internet. The Internet is a conglomeration of computer networks that is not controlled by any central governing body. This concept was initially derived from the government's desire to have a communication system that would be difficult, if not impossible, to disrupt. The Internet was demilitarized in 1983 and became a commercial enterprise in 1995. The growth of the Internet has been explosive. In 1971, it was a network that consisted of four nodes; today, there are well over 100,000 nodes. The Internet increases almost 20 per cent each month, and more users are joining daily25. As I mentioned earlier, one of the most useful functionalities of the Internet is the World Wide Web. It was developed by scientists at the European Center of Nuclear Research, or CERN25. It is accessed through what are known as browsers, the most common of which are Netscape and Microsoft's Internet Explorer.
Medicine has always been about information and its best use. Although we would like to feel that we are at a comfortable distance from this information revolution, the fact of the matter is that many of us are missing the excellent opportunities that this amazing technology affords us. It is extraordinarily contradictory that many of us, despite having the most sophisticated and accomplished expertise regarding the instruments in our operating rooms and clinics, have the least insight and strongest phobias about computers, the Internet, and other information tools.
In order to provide leadership in the new millennium, we all have to face down our fear of the digital age. It has arrived, and we had better take advantage of all that it has to offer or risk being taken advantage of by those who are already there ahead of us. Social and political forces demand that we modify and enhance the way in which we see and use information. Because we have not taken a high profile in the digital age, health-care information has largely become concerned with economics, marketing, and outcomes. The advancement and development of medical expertise has largely been ignored. What many of us have considered entertainment has now become a serious resource for the community at large. When patients use the Internet for second opinions and insight into their medical conditions without our participation as leaders, this information could damage them and our relationships with them. If we want to have a global voice, we must convey our messages through a global medium. That medium is the Internet and, more specifically, the World Wide Web.
Other uses of the Internet that fit well with our new mission statement include not only education but also collaboration and the support of scientific investigation. In the clinical area, system developers are exploiting the hypertext and multimedia capabilities of the Web to develop new graphical methods for data display and real-time patient monitoring. Distributed display of radiographic images is now possible. With technology such as this, it is now possible for the patient's clinical record to evolve into a true multimedia information source that will be available to all caregivers.
These concepts bring forth the question of security on the Internet and how best to maintain patient and physician confidentiality. The technology has evolved to such a great extent that it is almost safer and more secure to maintain a patient's file on-line than it is to maintain a hard copy in a file room. Of course, confidentiality issues extend beyond just the patient record and into e-mail and databases. What has actually driven the technology forward on the issue of security is increased commerce over the Internet17. The implementation of secure financial transactions and the protection of data have gained increasing importance. Sites such as www.amazon.com, which offers secure financial transactions for ordering books and does an amazing volume of business, was one of the first pioneers in secure transactions. Obviously, security will be a major issue in determining the feasibility of World Wide Web-based clinical information systems. The emerging standards for secure channels and document encryption on the World Wide Web should help to provide adequate protection for sensitive clinical information.
How does all of this affect those of us who want to maintain the high standards of the American Orthopaedic Association? It means that we, too, must jump on the information bandwagon. I would like to propose a project that, over the next two years, would focus on the development and implementation of a World Wide Web site that would enable this organization to make great strides in achieving its mission to increase awareness of orthopaedics throughout the next millennium. Our current Web site offers very little information for those interested in our organization and in the discipline of orthopaedics. It is in desperate need of a makeover. I am currently working with the Informatics Committee to develop and implement a Web site that is worthy of the standards of excellence of this organization. We hope to support the following: (1) physician and patient education with use of on-line materials available both within our site as well as through links to other important sites; (2) scientific investigation and clinical trials; (3) a collaborative atmosphere among all those who are involved in musculoskeletal care; (4) a global forum for discussion and interactivity on orthopaedic policy, with open discussions about critical issues; and (5) an increased awareness of our organization and its offerings, including our meetings, programs for residents, fellowships, visiting professorships, specialized awards, and especially the International Center for Orthopaedic Education.
We want to present our organization digitally with use of a simple yet elegant interface that is easy to negotiate yet complex enough to allow us to achieve all of our goals. We will be working with experts in the field of World Wide Web design to achieve this goal. In order to include everyone within the organization in this project, we will be accepting your ongoing feedback. Your feedback will not only be welcomed, it will be necessary to guide this project.
In other words, all of you will have to overcome your fear of those boxes on your desks and go digital! Join me in a new year of discovery that will lead to many, many more. I know that most of you have some working knowledge of information systems. Most of us have used computers and the Internet primarily as a research tool in the retrieval of articles on Medline or to send e-mail to our colleagues or even to our kids and relatives. I want to emphasize that we do not need to know the complex inner workings of the World Wide Web any more than we need to know how to build our own computed tomography scanners. In either case, what we need to know is how to use this technology to the best of our ability in order to enhance the health and well-being of our patients and ourselves.
The World Wide Web is an important, evolving information technology that will definitely have a significant impact on the medical field by dramatically improving the ease with which we distribute and access information via the Internet. The World Wide Web represents an amazing first step toward a global information network that will radically alter the way in which we retrieve and use information in the practice of medicine. As network technology continues to evolve, we will be able to consult with one another on a routine basis through technologies such as videoconferencing and virtual-reality imaging.
When we become discouraged about the direction in which our profession is heading, we must not forget the amazing technological advances that are occurring all around us. It is a wondrous time to be in the world and a privilege to be part of a global medical community. I admit that we can always find reasons to dread the future, but I would like to challenge each one of you to endeavor to see all the wonder that exists around us. We can help to relieve our anxiety by finding new ways to communicate with our patients and provide them with the care that they need, to educate the next generation of caregivers, and to promote research and collaboration.
This may all seem like science fiction to some of you, but it is very real and it will change the way every one of us lives and practices medicine. At this point, I think it is fitting to quote the great science-fiction writer Isaac Asimov, who said: "It is change, continuing change, inevitable change, that is the dominant factor in society today. No sensible decision can be made any longer without taking into account not only the world as it is, but the world as it will be … This, in turn, means that our statesmen, our businessmen, our everyman must take on a science fictional way of thinking."
Change can be a frightening thing. I chose to entitle this speech "Beyond Fear" for several reasons, but the most important part of getting past our fear at this particular point in history is to forge a new path. It is easy to become hopeless and to turn away from challenge, but that is not our destiny as healers and educators. It is our destiny to maintain order and to provide leadership during times of chaos and change. We must embrace the good as well as face the hardships and overcome them. This is only the beginning. Today, at this moment, we can take the knowledge that we have, augment it, and move beyond our fear into a new age. The environment in which we work and live is evolving very rapidly. We have a mission as healers and educators to participate in this evolution and to see to it that our perceptions of ourselves, if they change at all, change for the better as we continue to seek new ways to improve the lives of everyone with whom we come into contact.
Earlier, I likened the dawn of the information age to that of the Renaissance, which was aptly named by a Florentine artist, Giorgio Vasari, after the word rinascita, or rebirth18. It is our calling to preserve and enhance life. We must embrace the changes that are occurring all around us and encourage others to do so as well. We are entering a new age with new challenges, new risks, and new opportunities.
I want to end my speech on an upbeat note and remind you all that the word courage comes from the French word coeur, which means heart. So, courage is literally to have heart or great heartedness. Courage is having a big enough heart to seek to understand before demanding to be understood. If all of us in this room have the heart to face our own challenges as well as the ability to encourage and inspire others to face theirs, then we have truly moved beyond our fears and forged a new path for the future.
†The Hospital for Special Surgery, 535 East 70th Street, New York, N.Y. 10021.