President Friedlaender, fellow members of the American Orthopaedic Association, colleagues, and distinguished guests: It is a tremendous honor and privilege for me to address you as the incoming president of the American Orthopaedic Association. The list of the 123 giants of our profession who have served in this role before me is truly awe-inspiring. I respect each of these individuals immensely for their contributions to our profession and I especially cherish and am eternally grateful to the handful from whom I have had the great fortune of receiving mentorship. I feel honored to have the opportunity to add my thoughts and comments to theirs, yet decidedly inadequate to live up to their legacies. Thus, it is with equal measures of excitement and trepidation that I speak this morning. As a means of introducing you to what I have termed creative leadership, as well as a base from which to construct the practical meaning of that term, I will share two brief stories:
It is March 1865. In Glasgow, Scotland, Joseph Lister prepares to treat a patient with an open tibial fracture. In the Royal Glasgow Infirmary where Lister worked at the time, almost half of surgery patients died from infection. In some hospitals in Europe, as many as 80% died. While surgeons regretted this high death rate, they trained themselves to accept this unpleasant aspect of their work. After all, they thought, nothing could be done about these infections, because they arose spontaneously. Lister, however, was not convinced of the inevitability of infection. He turned against conventional wisdom and had, for some time, been searching for a way of preventing infection—an antisepsis method.
Lister began this day by washing his hands and wearing clean clothes. Lister’s practices were scoffed at by most of his colleagues, who considered it a status symbol to wear clothes covered in blood from previous operations. Lister had learned that carbolic acid (phenol) was being used as an effective disinfectant in sewers and could safely be used on human flesh. On this day, he sterilized the air about the wound with a fine spray of carbolic acid, and soaked the surgical instruments, the bandages, and the surgeon’s hands in the same solution. His operation was a success; the patient’s fracture healed without infection and he returned to function and work. By 1867, Lister had treated eleven cases of open fractures with this technique, and published his results. Lister had only one death (from secondary hemorrhage, not infection)—a mortality rate of only 9%!
We travel back in time more than 100 years for the second story—to January 1756. Percivall Pott, one of the pre-eminent surgeons in London, sustained an open fracture of the tibia when thrown from his horse. Pott would not allow himself to be moved, fearing that rough treatment of the leg would increase the danger. Instead, he sent to Westminster for two chairmen, purchased a door from a nearby house, instructed the chairmen to nail their poles to the door, and had himself carried on the door across London Bridge to his home—a distance of 4 miles! At the ensuing consultation of surgeons, the case was thought so desperate as to require immediate amputation. Pott, convinced that no one could be a proper judge of his own case, submitted to their opinions.
As the amputation equipment was being made ready, another surgeon, Mr. Edward Nourse, entered the room and recommended the limb be saved. A heated discussion followed, the result of which was that Nourse treated the limb, which healed after a thirty-day period of infection. Pott kept his leg, but the surgeon, Mr. Nourse, was denied admission to the Royal College of Surgeons for some years, on account of his “reckless and unconventional” treatment of Pott’s fracture.
What can we learn from these vignettes? What common themes are pertinent to this address? Both men in these stories exhibited what I have termed creative leadership. This form of leadership is uniquely required of leaders faced with uncertainty or with adverse situations or circumstances. Leading in good times does not require much creativity—good news occurs almost every day. All a leader must do is support—and occasionally grow—the existing unit and good news keeps flowing. Leading in uncertain times, with constrained resources, or in the face of adversity or criticism is decidedly different. Creative leadership is particularly applicable when a leader is faced with a situation where the current philosophies, behaviors, and practices appear to be under siege.
Leaders in such situations have a choice—they can criticize the forces challenging them and strive to preserve their status quo, or they can attempt to look for new ways to accomplish their goals, creating their own good news in ways that might not have been anticipated from “traditional” or historic practices.
The essence, then, of creative leadership can perhaps be expressed in a few dichotomous questions: Is one a creator or a critic? Is one on offense or defense? Is one proactive or reactive? Does one see opportunity or opposition?
Joseph Lister faced an environment—an accepted status quo—in which it was essentially a coin toss whether a surgical patient would live or would die of infection. He could have—like his fellow surgeons—accepted this as simply a part of the practice of surgery. He chose instead to search for a new and better method, to attempt to innovate—and he was soundly criticized by his colleagues for doing so. One can easily imagine surgeons of the time terming Lister an “oddball,” a “nutcase,” or even a “sissy” for his clean surgical clothes and extra steps for cleanliness at surgery—yet he stood firm. Even when Lister had published his results, he was still criticized, and it took over a dozen years for his techniques to become adopted in Europe.
Edward Nourse, in my view, exhibited an even greater degree of creative leadership. While Lister could practice antisepsis in the privacy of his OR suite, Nourse’s situation required him to stand directly before his critics—face-to-face with the most eminent surgeons in London—and make his case for saving Pott’s leg. He had to look these men in the eye and plead for a method of treatment that flew in the face of current practice—and then begin his treatment with them still in the room, perhaps even heckling him. Yet he did so even though he knew he would be ridiculed. Nourse chose to be a creator directly in the face of his critics, exposing himself to enormous professional risk. This is the essence of creative leadership.
Why is it that, like the surgeons of London attending Pott’s case, we criticize in the face of adversity? Why do we work so hard to preserve the status quo—often long after it is clear there are benefits to change? I believe the answer lies both in human instinct and expedience. It is a basic human instinct to seek security and safety, to protect ourselves and our people from danger and to assure the survival of our way of life. In essence, it is human nature to take comfort in the status quo and in those critics who claim to protect us from change; critics, however, largely disrupt progress through a combination of pessimism and fear. If one believes the rhetoric coming from critics, it is easy to miss opportunities.
It can also be tactically effective to be a critic. To fashion oneself as one who will fight change and protect others is an expedient and effective method for building and retaining a base of support. The best illustrations of this come not in medicine, but perhaps in politics. In the movie “American President,” President Andrew Shepherd (played by Michael Douglas) has his bid for re-election threatened by Senator Bob Rumson (played by Richard Dreyfus). Rumson is the quintessential critic—building his political base and running his campaign solely on negative messages about the president, the president’s programs—and even the president’s girlfriend. When President Shepherd finally chooses to fight back, he makes an unscheduled appearance at a White House press conference and exposes Rumson—and all critics—for what they truly are:
“We have serious problems to solve and we need serious people to solve them. And whatever your particular problems are I promise you, Bob Rumson is not the least bit interested in solving them. He is interested in two things and two things only—making you afraid of it and telling you who's to blame for it.”
Critics prey on human fear, constructing convincing and often logical arguments that we should fear change, that the “old ways” of doing things should be preserved, that others are at fault for the negative state of affairs, for the challenges, and for the Armageddon they see ahead. These individuals convince others to view the world as they do—and to support them in a battle to resist change.
Criticizing is far easier than creating—one can find the parts from which to assemble a vicious criticism lying around anywhere. They can be found in existing knowledge, in current practice, and in any expressed opinion contrary to either of these. The critic simply sits back and judges the acts of men, while the creator shapes and forms and directs, animating words on a page or ideas in space or actions in the real world to become a powerful medium of human truth and emotion. There is no risk for the critic, no one threatening his eagle-eye view. He’s not making anything, after all, and at the end of the day no one will hold him accountable for his opinions. For the creator, however, a great deal is at stake—career, reputation, integrity, and sometimes livelihood. Yet for the same reason that the creator has much to lose, he also has everything to gain.
No one would argue that medicine in America is under enormous pressure—patient expectations, reimbursement, hospital-physician relationships, federal regulations, even the role of an orthopaedist in patient care—these and many other issues are pressing in on us, threatening rapid and sweeping change. Our profession can lead and grow, but we must first recognize opportunity, see potential, be creative—altering our paradigm and mindset to realize possibilities. The AOA is an organization dedicated to leadership in the profession of orthopaedics. The AOA has a 124-year legacy of innovation and it continues to strive for—and often succeed at—creative leadership. Before I close the address, I will outline but two of many AOA programs that I believe serve as excellent examples of application of the principle of creative leadership.
The first is the Orthopaedic Institute of Medicine (OIOM). The AOA Critical Issues Committee recognized there is a clear need for consensus statements on issues crucial to our profession and to the care of our patients. Such statements, if issued in an unbiased fashion by a credible leadership group, could make a profound impact. The AOA believed it was well positioned to lead in this regard. In November 2005, the AOA established a task force charged with proposing a model for an Orthopaedic Institute of Medicine that would create and issue work-products on leadership topics impacting the profession of orthopaedics. That task force, in June 2006, brought its recommendations to the Critical Issues and Executive Committees. They recommended an OIOM:
That relied on experts with a variety of perspectives, training, and positions—inside and outside of medicine;
That conducted one project per year, with a report to result from each project; and
That developed project reports that were independent of the AOA (to assure integrity and credibility of the OIOM).
Between June and November 2006, the OIOM model was further refined to fit within the AOA organizational structure. The AOA presidential line approved the refined model and prioritized the initiative as very high. The Executive Committee approved the structure and the funding for the first project, as well as the seating of the OIOM Council. A variety of topics were considered for the first product, including ethics and professionalism, conflicts of interest, fragility fractures, and pain management. The topic chosen, however, was the impact of Emergency Department call for patients with musculoskeletal injuries. After twelve months of work on this topic, the OIOM produced, in January 2009, a thoughtful, well-researched, comprehensive, and highly unique report on this topic. The report (available through the AOA free of charge) does not simply state the problem, but proposes constructive and practical solutions—including providing six “case studies” that can serve as examples of how the issue might be solved in a given community, providing substantial creative leadership on this important topic.
The report clearly meets the goals of the OIOM: it is in-depth, focused, and unbiased. It makes concrete and constructive statements about solving a problem that affects our profession and our patients. It has been widely acclaimed and endorsed by a number of medical groups. The success of this first project has led the OIOM to pursue a second project, on industry-surgeon relationships in orthopaedics. In keeping with the OIOM’s structure as an independent group at an arm’s length and beyond the influence of the AOA leadership, I cannot know the contents of the OIOM report until it is completed and ready for release. I am confident, however, it will be unbiased, unique, constructive, and at least as impactful as the emergency department call project was.
I draw an analogy between Joseph Lister and the OIOM—it does very creative, important, and innovative work, yet it can do so in relative privacy until its report is produced and distributed. Creative leadership is evidenced even more strongly, however, in the Own the Bone Program. Own the Bone faces a situation much more like that of Edward Nourse, doing its work in public, having to look its critics in the eye every day while it provides leadership, innovates, and helps solve a highly important problem.
Own the Bone provides leadership on a massive public health issue in the United States—the care of patients sustaining a fragility fracture. 2004 data indicate there were over 1.5 million fragility fractures in the United States. What is even more striking, however, is that there are—each year in the U.S.—three times as many fragility fracture as heart attacks, six times as many fragility fractures as strokes, and seven times as many fragility fractures as cases of breast cancer. And while we hear every day in the media about prevention of heart disease, stroke, and breast cancer, we hear very little about the prevention of fragility fracture. There is a huge opportunity for leadership in this area.
The issue is not with the fracture care—we have done and continue to do this quite well. The issue is with care beyond the fracture—the education, evaluation, and treatment of the underlying bone disease. Two very well-conducted recent studies indicate that only 20% of Americans—one in five—receive appropriate care after sustaining a fragility fracture. And, beginning with the Surgeon General’s report on the nation’s bone health in 2004, national attention has been building. The Medicare program has included bone health measures into its PQRI program and The Joint Commission has field-tested standards related to bone health. And, most frighteningly of all, lawsuits are now being successfully prosecuted against orthopaedic surgeons for “failure to diagnose” osteoporosis in a patient who sustained a fragility fracture. In all of this, orthopaedics—our chosen profession—is perceived as not caring about the bone health of patients, about not caring for anything beyond the surgical care of the fracture. Own the Bone is a tool that may help to change this perception.
In November 2005, the AOA launched a pilot program in fourteen centers, each championed by an AOA member. In November 2006, the preliminary results were presented to the Executive Committee. These results indicated that, in most measures, a fourfold increase in performance could be achieved with a simple, orthopaedist-only program. The Executive Committee agreed the project should continue, with plans for a multidisciplinary program that would incorporate support and sponsorship from outside the AOA. The results of the pilot project were subsequently published in The Journal of Bone and Joint Surgery. One year later, in November 2007, a multidisciplinary, web-based program had been developed and sponsorship and support had made substantial progress. The AOA Executive Committee recommended a national rollout of the program, with continued efforts at sponsorship and collaboration with other groups.
The following two years were spent fine-tuning the program, developing and seeking guidance from a multidisciplinary advisory board, developing and perfecting a web-based registry, assuring the program would be a truly turn-key approach, and expanding sponsorships and collaborations. In June 2009, the national launch of Own the Bone occurred and enrollment efforts began. The intervening two years have been a story in hard work and success. At present, 110 hospitals or groups have enrolled or are in the process of enrolling in the program. These groups represent twenty-seven states and have entered nearly 2400 patients in the registry. Own the Bone has received program support of over $3 million in grants and sponsorships since the start of the program.
Perhaps of even more import for the AOA than the enrollment or sponsorship success of the program is the national attention and collaborations the program has produced. The program is governed by a multidisciplinary advisory board of individuals of substantial national prominence in bone health. The Own the Bone Educational Alliance partners have contributed immeasurably to providing educational materials and to spreading the word nationally. The Own the Bone Organizational Alliance has brought a large number of other medical and professional associations into the fold to help promote the program on a national level. Largely because of Own the Bone, the AOA was invited to participate in the National Bone Health Alliance—including having a seat on the group’s governance committee. The AOA is participating with the American Society for Bone and Mineral Research on an international task force looking into best practices in bone health; Own the Bone—one of the only comprehensive turn-key programs in existence to date—should feature prominently as a “best practices” program. These, and many other collaborations, have had an immeasurable positive impact on the AOA’s—and orthopaedics’—national recognition as a group who cares deeply about this massive public health issue.
Embedded in the earth at National Harbor, Maryland, the site of the 2012 AOA Annual Meeting, is a seventy-foot statue of a giant, entitled The Awakening. The statue consists of five separate pieces buried in the ground, giving the impression of a distressed giant attempting to free himself from the ground. The left hand and right foot barely protrude, while the bent left leg and knee and the right hand jut into the air. The bearded face, with the mouth in mid-scream, struggles to emerge from the earth.
When we look at this statue we might ask “Is this us?”, “Is this our response to the pressures our profession and U.S. medicine are under today?” On deeper reflection, we should examine whether, like this giant, we are striving to free ourselves from the burdens that constrain, creating a new life, a new beginning, making our own good news. Or perhaps we are struggling to maintain the existing paradigm, our former professional way of life, writhing in vain while sinking ever deeper into the earth.
The AOA, and each of its members, has great opportunities to be creators. This association of leaders—and our profession—needs to search for the opportunity amidst the opposition that threatens the status quo of our clinical, academic, and educational missions. Joseph Lister and Edward Nourse took enormous risks to find more successful, more innovative, and more forward-looking methods amidst the opposition in their individual situations. While the benefits we might find in being creative leaders are not as clear as those Lister’s methods promised, we must take risks to innovate and create. And very much like Edward Nourse, our efforts at creative leadership will be roundly criticized by many—including many of our peers, who will urge us to fear change, and entreat us to find safety and comfort in fighting for the status quo. The AOA has a rich legacy of exhibiting creative leadership for our profession. We, as an association and as individuals, must find the courage, the foresight, and the fortitude to continue to be creators, to continue to make our own good news for all to see.
If we can do this, we may find that at night, that time of day when our heads may swirl with words of judgment and with anger at those we attempt to blame for the forces challenging us, they instead sink like anchors to our pillows. We sleep, and we smile, because today we have made something. We have risked it all, and tomorrow we will do it all again.
Thank you for affording me the humbling privilege of serving as the 124th president of the American Orthopaedic Association.