It’s an enormous honor for me to be standing
before you this morning as your incoming President at a time of
remarkable change, the magnitude of which was emphasized in the
very critical Institute of Medicine report featured on the front
page of this morning’s issue of USA Today1.
In preparing this talk, I’ve been reflecting on the
changes that have affected my career since I attended my first Academy meeting
back in 1975. That meeting was also here in San Francisco. It was
my first year in practice; I had a two-year-old daughter.
Now I have three children; they’re all grown, they’re all
through college, and they’re all contributing to society
in very positive ways.
I remember the meeting in 1975 clearly. I remember being impressed
by the depth and breadth of the science and being very proud to
be a member of the Academy.
Not long ago, I came across the program from 1975. As impressive
as the science was, the strides we’ve made since then are
nothing less than astounding. Consider that, just over twenty-five
years ago, arthroscopy wasn’t on the program at all, total
knee replacement was in its infancy, anterolateral instability of
the knee was just being described, and total shoulder arthroplasty
was experimental and performed only in patients with deficient rotator
cuffs.
In fact, in 1975 we had only three papers related to the shoulder
and elbow. Today, these subspecialties constitute a separate discipline.
This year, we have four sessions, twenty-seven papers, and more
than fifty posters on shoulder and elbow topics alone. It is an
entirely different world. There were no presentations on health-care
reform in 1975. Now, just twenty-six years later, we live in a world
of HMOs and PPOs. And the changes extend far beyond health care.
We live in a world of e-mail, Palm Pilots, and cell phones. It is
common to buy airline tickets and stocks online and to access the
Internet for information on everything from the status of one’s
portfolio to the state of one’s health.
Will things ever settle down?
I don’t think so. The English economist John Stuart
Mill taught us, a century and a half ago, that constant change is
a fact of life. In a changing world we have no choice but to continually
change ourselves2. As General
Electric’s Chairman, Jack Welch, said about organizations
today, "When the rate of change outside exceeds the rate
of change inside, the end is in sight."3 There
are two ways to respond to change: we can react to defend our weaknesses,
or we can lead with our strengths.
Friends and colleagues, the time has come for us to stop reacting to
the agendas set by others. It’s time to start leading with
our strengths. It’s time to step back, look around, and
see what we’re good at. It’s time to set our agenda.
This morning, I want to talk to you about a special task force that
was assembled twenty-four months ago to do just that. The task force,
called The AAOS in 2005, was charged with collecting the evidence
and then determining what we must do to raise the bar in order for
us to be the foremost leader in medicine by 2005.
Specifically, this task force was asked to do three things: to
identify our opportunities, based on the evidence of what our members
need and what we know we do best; to focus on targets and set goals
that are achievable but high; and to push ourselves to new levels
of creativity and innovation.
The task force conducted extensive research, including three retreats
with authorities on organizations such as ours, several focus groups,
a Board workshop, and a survey sent to over 2000 Academy fellows.
The data that were collected pointed to several broad areas of concern—and opportunity—in
practice, in education, in research, and in the very structure of
our organization4-8.
Let’s look first at our core, the heart of the Academy’s
mission: education. Clearly, we are living through a revolution—an
information revolution. The New York Times recently
described what is happening on the Internet as the greatest explosion
of free expression and cultural resources of the last century. Some
have called the information revolution the most important event
in the American economy since the Industrial Revolution6,9-13.
Now, we could see this as a threat. After all, education is the heart
of the Academy’s work. Most of us joined the AAOS to take
advantage of its leadership in cutting-edge educational
programs and resources. But most of us are used to learning through
face-to-face meetings, hands-on training,
personal interaction, and publications. And while these methods
are of enormous value, the Internet and other communication technologies
offer new opportunities for us. But only if we embrace them.
Our younger members know this. They grew up on computers. And
these young members, born after 1960, are not joiners; they don’t
join organizations like this one just because those before them
or those around them did14. They
join to get the best value, the most sustained benefit, the information
and services that they need to perform at the highest level in a
very complex health-care environment. We’re about to start
offering a new online program of sustained benefit. We’re
calling it "Orthopaedic Knowledge Online." This program
is designed to give you access to the latest information whenever
and wherever you want it—in the office, at home, or traveling
with your laptop. With this site, you’ll have instant access
to information developed by recognized authorities in each subspecialty,
and it’s going to be updated quarterly. You’ll
have crisply described indications, contraindications, pearls, and pitfalls.
There will be video demonstrations of operative procedures. There
will be a layered structure so that you can spend less than a minute
getting a specific piece of information or spend hours reviewing
what’s new in the field. And there will be online reminders
when there’s something new in your area of interest.
As far as we know, there’s nothing like this out there
for any other medical specialty. By providing answers to your questions when
you need them in your practice, this type of clinical, problem-focused
information will set the standard for online education, enhancing
the competence of orthopaedic surgeons. These comprehensive, integrated
programs are under construction and will be online sometime next
year.
Another area of importance identified by this task force relates
to the cumulative effect that over eight years of health-care reform has
had on the practice of orthopaedic surgery. Federal reform measures
have created some huge craters in the patient-care landscape. One
example: last year, my hospital’s admissions increased
over 5%. On many days during the year there were no patient
beds to be found anywhere, and the emergency-room and admitting
areas were backed up for hours or on diversion. Yet we barely broke
even and had nothing to reinvest in our infrastructure, much less
in the growth of new clinical programs. Many of you, from all parts
of the country, have had the same experience—the pressure
to effectively maintain high levels of care in your practices and
in your hospitals in the face of declining resources.
What can we do?
The AAOS in 2005 Task Force has taken the initiative with a series
of three innovative programs that constitute our agenda. One is
designed to improve our own specialty, a second has been created
to better understand the care provided to society at large, and
still another is addressed directly to our patients.
The first component of our agenda calls for us to gather data on
the incidence, prevalence, impact, cost, and outcomes—the burden—of
musculoskeletal disease. Already, we have found that musculoskeletal
ailments are the leading cause of visits to physicians in America.
They are also the leading cause of chronic impairment. This year,
musculoskeletal conditions cost Americans a staggering 254 billion dollars15—that’s more than
we spend on clothing and only slightly less than we spend on food
and drink16. And it’s
a forty-billion-dollar increase in just five years15. Our goal is to take the lead by doing
what we do best: accumulating knowledge, positioning ourselves as
the authorities that we are, and using what we learn to advocate
for improved patient care and research.
The second component of our practice initiative requires courage—the
courage for us to look more closely at the impact of our care on
society. In an ambitious study that we’re calling "Improving
Musculoskeletal Care in America," we have collaborated with
Dartmouth Medical School to determine whether or not our patients’ health-care
needs vary by region, gender, ethnicity, age, and other variables17.
A study of thirty-five million Medicare patients revealed, among
other things, that whether or not you have orthopaedic surgery depends
a great deal on who you are and where you live18.
For example, a patient in one city in the central valley of California
is 50% more likely to have a spine operation than a patient in
San Francisco, less than 100 miles away. Why? Patients in this central
valley city are four to five times more likely to have a total joint
replacement than patients in San Francisco. Why?
There are two potential answers. First, findings from a recent study
by Dr. James Wright, of the Hospital for Sick Children in Toronto,
indicate that, when you control for population characteristics and
access to care, the dominant variant is the orthopaedic surgeon’s
enthusiasm for a procedure19.
There is another possible explanation for these variations in care,
however. As was noted in Dr. Wright’s study19, there may be unmet need in both
communities. If that is the case, we need to mount a public-health
initiative to inform primary-care providers of the benefits of our
care. Cardiovascular physicians have done this, with very positive
results. Colleagues, friends—we must gather the evidence
and then address this issue.
We have found that gender and race are also factors in who gets treated.
Black men over sixty-five are 35% more likely to have hip
osteoarthritis20 but are 50% to
75% less likely to have joint replacement surgery than
are white men and women21,22.
We have to change that. Armed with the facts on the burden of disease
and the societal impact of our care, we now have a stronger case
to make for education and advocacy—for our work with Congress,
the Health Care Financing Administration, the National Institutes
of Health, and others, including our own Orthopaedic Research and
Education Foundation.
The third component of the 2005 practice initiative calls for
the development of new methods to strengthen our relationship with patients,
by using the evidence that we have accumulated and combining it
with the new technology. We are testing one such way—a
pilot program that we are calling "Informed Choice." We
have produced an interactive educational program for patients with
herniated discs and spinal stenosis. This program gives patients
specific information about their conditions to help them decide
how to proceed with treatment. The program, which uses Cochran methodology
to rank expected outcomes with evidence for and against each decision15,23-25, gets patients involved
in making their own decisions on the basis of credible information
that they can understand. This year’s goal, consistent
with our focus on osteoarthritis, is to create two new programs
for patients facing decisions about hip and knee replacement surgery.
There is another aspect of "Informed Choice" that
is unique. To participate, patients enter data on a touchpad. An additional
project team established by The AAOS in 2005 Task Force is evaluating
such systems for electronic patient-data entry systems that integrate office,
operating-room, and discharge documents. The goals are to decrease
the hassle factor that we all are experiencing, to improve our ability
to collect meaningful patient-assessment data, and to free up our
time to concentrate on what matters most: patient care.
By using our creativity and by making radical innovations that harness
the latest information technologies, we can make enormous strides
in education and practice. But these gains will be valuable only
to the extent that they allow us to continue to accrue data and
to build knowledge about musculoskeletal disease—about
its causes, prevention, and treatment that is more effective.
That brings me to the third major area of concern identified
by The AAOS in 2005 Task Force: research. Today, the opportunities
in research are huge. At no time in history has there been such
explosive growth in scientific discovery. Basic research in such
areas as computational chemistry, angiogenesis, gene therapy, and
proteomics is opening the way to new treatments that were inconceivable
just a decade ago. The rapidly emerging field of genomics is poised for
a major breakthrough. Soon we should be able to predict susceptibility
to disease and to target prevention to individuals26,27.
Without basic research in our specialty, groundbreaking advances
will be lost opportunities for our patients. And without clinical
research, we have no way to measure how well we are serving them.
Where would we be without penicillin, vaccinations, total joint
surgery, advances in fracture treatment, microsurgery, arthroscopy,
and so much more of which we can be proud? In spite of the evidence
that the burden of musculoskeletal disease is growing rapidly, funding
for the National Institutes of Arthritis and Musculoskeletal and
Skin Diseases is pitifully low—353 million dollars this
year. That is 10% of what we spend on cancer research,
15% of what we spend on heart and lung disease, and less
than half of the research budgets for allergy and infectious disease.
It is roughly equivalent to the funding levels for dental research28. It is no surprise that we are seeing
a significant drop in the numbers of orthopaedic physician-scientists.
Recently, the actual number of first-time M.D. applicants
for National Institutes of Health research plummeted—a greater
than 30% decrease in just three years. At the rate that
we are going, in two more years there will be no first-time
physician applicants29.
In response, The AAOS in 2005 Task Force created a project team
on academic affairs and training. The team was charged with investigating
the special challenges experienced by orthopaedists in academic
health centers and with developing a strategy to improve our standing significantly
over the next several years. It will consider the challenge, made
by a former AAOS President in a recent issue of The Journal
of Bone and Joint Surgery, that the Academy should
take bold and innovative steps—first, to maintain and then,
to expand the number of clinician-scientists within our specialty30. We will take that challenge and we
will make a difference, if we take the lead by doing what we do
best: accumulating the evidence on this critical issue and others,
and then using what we learn to reinvigorate our research and training
programs31.
The overall goal of the Academy’s new efforts in education, practice,
and research is to force ourselves to raise the bar—to increase
the effectiveness of this organization for you and for your patients.
Our strength is our ability to gather the facts and share them effectively—but
it is more than that. Our strength is our willingness to embrace
new technologies and to find radically innovative ways to continually
achieve higher levels of performance—but it is even more
than that. Our greatest strength lies in the depth of our commitment
as orthopaedic surgeons to the health and well-being of
our patients.
Thomas Watson, the legendary founder of IBM, understood how such
a commitment can affect an organization’s success or failure. In
his book A Business and Its Beliefs, he wrote: "I
firmly believe that any organization, in order to survive and achieve
success, must have a sound set of beliefs on which it premises all
its policies and actions. Next, I believe that the most important
single factor in corporate success is faithful adherence to those
beliefs. And finally, I believe that if an organization is to meet
the challenges of a changing world, it must be prepared to change
everything about itself except those beliefs as it moves through
corporate life."32
At the AAOS, we believe in improving patients’ lives
by continually advancing our knowledge of how to prevent and treat musculoskeletal
disease. That is why you are at this meeting—and that belief
is the moral core of this organization and is our greatest strength.
Our ability to improve care is what we can give to make the world
a better place. We must lead with that strength, and we must give
that gift.
To make our contribution as orthopaedic surgeons, we must educate
ourselves and others. Unless we do, our skills will diminish.
We must answer critical questions through research. Unless we
do, there will be no progress.
We must listen to, communicate with, and care for our patients
to the best of our abilities. Unless we do, we cannot fulfill our moral
commitment to society or use our gift of caring for others to the
fullest.
Just look at how far we have come since that meeting in 1975. Then
think how much more we can accomplish in the next five years—and
the next twenty-five. I am looking forward to that meeting in 2025—my
fiftieth! On that day, you and I will look back and marvel at what
we have accomplished since the turn of the century, building on
our strengths. And the generation of leaders that we nurture today will
be showing us their plans for 2050.
I plan to be there. I hope that you will be there too.