Fellows, honored guests, board members, speakers, and, most
importantly, the Fellowship Class of 2004:
I have had the unique opportunity to fill the president's shoes. While a
resident at the Massachusetts General Hospital in 1969, an unexpected tennis
challenge arose, something not infrequent in my career, and I hadn't brought
my tennis gear. Dr. Herndon lived in an apartment across the street and was
kind enough to let me use his sneakers... I wish I could say the match was
6-0, 6-0!
First, please join me in expressing appreciation to the many spouses,
parents, teachers, friends, and significant others for their support of the
new fellows during their long formative years.
It is a rare privilege and a great personal honor for me to address you on
this most important occasion. I am filled with awe, humility, and inspiration
to join the list of people preceding me in this capacity.
Today you are being inducted into the American Academy of Orthopaedic
Surgeons (AAOS). You have probably wondered what it is to be a member
of the Academy. Well, today I will share my concept of the Academy's
vicissitudes, foibles, successes, and failures and synthesize it as: "It
is what it is"—truly the secret of most of life's
imponderables.
Today you become a member of one of the largest and most respected medical
organizations on the planet. You represent the future replacements for all of
the Academy's leadership; some of you will fill their shoes. By virtue of your
induction, you will raise the level of computer literacy among our fellows by
300%!
Well... It is what it is.
Many challenges face orthopaedic surgeons over the next decade: the
malpractice crisis, increased federal regulations and scrutiny, decreased
reimbursement, and the ability of our specialty to remain whole without
fractionalization.
I have formulated my counsel into a set of Crawfordian directives about
ethics, mentoring, partnering, malpractice, error prevention, specialization,
technology, remaining current, cultural diversity, taking control, giving
back, and family.
Ethics. Ethics sometimes become whatever your mother taught you.
Ethics define what is right or wrong in human behavior. Ethical guidelines are
inspirational, defining what a physician ought to do, and thus they are not
legally binding and not enforceable. It is amazing in academic forums how
often, even when one has been apprised of entrenched blocks to decision-making
based on flawed data (commonly called biases), one is unable to choose
appropriate behavior. Some of you have a tremendous debt burden, and the call
to unethical behaviors can be seductive.
It is what it is.
Mentoring. Hopefully, you love this specialty and will pass on
your passion and wisdom to those aspiring to fill your shoes. The ideal or
quintessential role of a mentor is to be a resource and to help in making
decisions about partners, contracts, and salaries when entering the business
of medicine. My mentors always told me how hard they worked and how many hours
they put in to get where they were. To some older doctors, long hours, late
nights, and always being on call were a testimony to their devotion
to medicine. You will always have a more credible tale because you can always
profess that you were training before the eighty-hour rule, and you
only left the hospital every other Sunday except for the day off after your
child was born or to mourn a family member.
Being a member of the AAOS will give you instant credibility. Be a mentor.
Talk and listen to students, all learners, patients, anyone interested in
musculoskeletal issues. Mentoring enhances your image and supports the goals
of perpetuating and propagating our fellowship.
It is what it is.
Partnering. Establish a partnership with your colleagues,
referring physicians, and patients. Discuss lab reports, x-rays, and physical
therapy progress with them and hear them out. "I don't know" is a
good answer when asked a question you don't know the answer to. You too are
human. They will understand and appreciate your honesty. Pediatric
orthopaedists have special challenges. My fourteen-year-old patients with
scoliosis usually get the answers to all of their questions from the Internet.
They have answers, but they are interested in my opinion on the basis of their
trust. You can't blow them off. You have to be honest. Let your patients
participate, give them choices, options.
It is what it is.
Malpractice. The premiums for professional liability insurance
have reached a level that threatens the very financial viability of medical
practice in many areas of the United States. "Junk lawsuits"
against health-care providers may be driving up health-care costs and are
driving some physicians out of business—especially those performing
high-risk procedures. We live in a litigious society. Americans sue each other
at the slightest provocation. They sue doctors over misfortunes that no doctor
could prevent, sue when their injuries are severe but self-inflicted, when
their hurts are trivial, and when they have not suffered at all. Many sue
because they have come to believe that they have the right to impose the costs
and burdens of a lawsuit on anyone who angers them regardless of fault or
blame. Doctors spend, or perhaps waste, fifty to 100 billion dollars each year
on defensive medicine. Malpractice allegations may be unfounded in as many as
80% of the cases. It is indeed a source of frustration. Semmelweis may have
missed the mark on the germ theory, but what he did discover was a phenomenon
just as remarkable: the idea that physicians may themselves be responsible for
the morbidity and mortality of patients. The father of antisepsis was, in
fact, the father of iatrogenesis—physician-induced disease.
Error prevention. Error prevention is our best defense, a
challenge championed by our president in his sentinel article "One More
Turn of the
Wrench."1 The
Institute of Medicine in its report To Err Is Human: Building a Safer
Health System2,
suggests that as many as 98,000 patients each year are fatally harmed by
medical errors. Medication errors, inappropriate and poorly conducted surgical
procedures, wrongsite surgery, and failure to diagnose limb and
life-threatening conditions may be preventable. The overwhelming majority of
untoward events involve a communication failure.
What about instituting a "time out" requiring surgeons, nurses,
and anesthesiologists to "huddle" to verify the correct surgical
site and procedure prior to beginning the incision? What a remarkably unique
concept—surgeons, nurses, and anesthesiologists being required to
communicate prior to making an incision!
Fear not, however. In spite of the negatives regarding physicians, a recent
Wall Street Journal poll showed that 63% of the public trusted their
doctors to do the right thing; however, 65% trusted nurses to do the right
thing for the health care of the general public.
It is what it is.
Specialization. When I was a resident, orthopaedic surgery was one
of the three "O" specialties—ophthalmology, otolaryngology,
and orthopaedics—leading to a Rolls-Royce, and it was high on the list
of medical students' choices. No more. The top three specialties now are
dermatology, anesthesia, and radiology. Not only is income not an issue but
family and lifestyle have risen as priorities.
If you went into this specialty to help others, there are tremendous
opportunities waiting for you. Our society's current emphasis on fitness and
exercise virtually guarantees you an unending supply of arthritic patients and
chronic pain sufferers for your practice lifetime. They, or perhaps I, should
say we deserve your best.
It is what it is.
Technology. Over the past thirty years, significant advances have
occurred in the care of patients with musculoskeletal conditions because of
the ingenuity and perseverance of orthopaedic surgeons. Stem-cell and
gene-therapy research will come to fruition during your careers. Cutting-edge
technology and often contradictory studies now seem to appear every day,
making it hard for readers concerned about their own and their family's health
to sort out what is accurate and important. The implant and pharmaceutical
industry is now marketing directly to consumers, or should I say to patients.
Medications are touted directly during television commercial breaks without
physician involvement. Remember the Super Bowl? "When the moment is
right, will you be ready?" The treatment of erectile dysfunction was the
compelling, competitive pharmaceutical touted during the Super Bowl, but is
that more disturbing than a golfing icon pitching a specific total hip
replacement product, inferring equal if not greater performance? We won't
consider the possibility of "equipment malfunction" with either
product!
It is what it is.
Remaining current. It is extremely important to remain current and
keep up. Those who are not interested in academics should attend hospital
specialty conferences and "town-gown" grand rounds. As a service
director, I am now being challenged to initiate performance-based
credentialing, a JCAHO (Joint Commission on Accreditation of Healthcare
Organizations) requirement to rate all certified hospitals in the future. Get
ready.
It is what it is.
Cultural diversity. The diversity of the races is extremely
important. Look around you and the faces will reflect the changing colors of
America. You are a rainbow of cultural, ethnic, educational, and geographic
diversity, making you uniquely equipped to assume our Academy's leadership in
the twenty-first century. Remember where you came from and, in most cases,
from whom and on whom you honed your craft and what they looked like. A lot of
them may have looked like me. Having cross-cultural sensitivity and practicing
culturally competent, compassionate care will be a way of getting along in
your practices. No longer will we be able to take care of only patients who
look just like us, whoever "us" is. We are approaching a true
American melting pot that will not be Eurocentric in complexion. All of us
should explore our biases and achieve cultural competence.
The 2003 Institute of Medicine report entitled Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health
Care3
highlighted the disparities between physicians and minorities, prompting the
American Medical Association to focus on becoming more inclusive. African
Americans, Native Americans, and Hispanics are at least twice as likely to
suffer diseases and encounter serious complications. We African Americans also
die younger than any other racial group. Awareness of health-care disparities
will allow you to develop patient-education programs for your staff. We must
be prepared and willing to respect and serve all humans, including those in
same-sex relationships and those with multiple piercings, too many tattoos,
and multicolored hair. This is an awesome responsibility but one that you in
this room are probably better prepared for as a group than are many other
humans.
Significant errors are made because of a lack of communication or a
misunderstanding, and some are directly related to cultural
misinterpretations. In some cases, our society produces biases so conditioned
that you cannot relieve them by education. The AAOS is preparing a culturally
competent musculoskeletal curriculum. It is important; we are messing with
people's lives! However, one speech doesn't change behavior. Culturally
competent compassionate care of our patients should be paramount. This becomes
a nonissue if you exercise the F-squared (F2) principle: to treat
all humans as though they were either family or friends.
It is what it is.
Taking control. Remember, you are the masters for change. I
implore you to think now of the opportunities as well as the challenges that
you will have over the next twenty years. You will be tasked by a number of
organizations for participation and for financial contributions, including
local, national, political action, and research organizations. Be a
visionary—remain ahead of the game and don't be afraid of thinking out
of the box. You're in the driver's seat. There are opportunities for
collaborations and selective mergers to avoid fellowship fractionalization and
to obtain more efficient time commitments and lower costs for greater
educational value. Your Academy is interested in your thoughts. The current
response rate to surveys, polls, and questionnaires is less than 20% and
cannot be validated. Please consider volunteering. You have more time at this
point in your career... now... than ever to become active and give your
input.
Giving back. Will Rogers commented, "A man makes a living by
what he gets. He makes a life by what he gives." Consider the
Orthopaedic Research and Education Foundation in your giving. Remain active
with residents, physician extenders, assistants, and nurse practitioners. Join
committees. Remember, the person who best represents you is you.
It is what it is.
Family. Finally, and most importantly, is family. Many of you men
stayed home and changed diapers, took the kids to music lessons and soccer
practice while she was on call... and vice versa. This day is another jewel in
the family crown. Always remember family. We're all a part of our family's
dreams. Don't be afraid to dream. Dream and hold fast to your dreams. For if
dreams die, life is a broken-winged bird that cannot fly.
Now, when asked "What is the American Academy of Orthopaedic
Surgeons?" you know what it is: the preeminent society for the study and
management of musculoskeletal conditions in all human beings on the planet.
Please join me in welcoming our new fellows into the honorable and noble
fellowship of the American Academy of Orthopaedic Surgeons. It is what it
is.