Extract
President Bigliani, fellow members of the American Orthopaedic Association (AOA), Carousel Presidents and spouses, and invited guests:
President Bigliani, fellow members of the American Orthopaedic Association (AOA), Carousel Presidents and spouses, and invited guests:
I feel compelled to offer an immediate confession. Never before have I thought so long and so deliberately about anything I was going to say in my entire life. It has been twenty-five years since I first presented a paper to this organization in 1984, and, through that most auspicious association with this group, I am conscious, nearly to the point of complete distraction, of two things as I stand here this morning. I am absolutely humbled by the notion of serving as president of this esteemed organization, and I am acutely aware that you will more likely remember what we have for lunch today than anything of what I say in the next several minutes.
Prefacing an address titled as this one is, I am reminded that none of us accomplishes anything in a vacuum. I am no exception and am most fortunate to be able to share this occasion with my family. My parents are in every respect my mentors and inspiration. I know that my humility in this role is rivaled only by their pride in witnessing it. My three daughters, Gina, Carla, and Cristina: you remind me by your simple presence what really matters in life and continue to do so by your daily actions and life decisions as young adults. Lisa, now deceased, who has the best seat in the house for these proceedings, is the mother of those girls who kept me going, and Nancy, a wonderful wife and confidante, is willing and able, almost beyond belief, to understand and accept my complexities.
In orthopaedics, I am indebted to three mentors. Leland "Pete" Hall at Dartmouth. A professor of anatomy before becoming chief of orthopaedics, Doc Hall introduced me to the structure-function relationship of anatomy, and my fascination with it has never waned. Harry Gossling at the University of Connecticut. Dr. Gossling rescued my flagging orthopaedic interest during my bout with hepatitis as a general surgical house officer and showed me an inspired academic side of orthopaedics that I had nearly lost sight of. C. McCollister Evarts. Dr. Evarts was my chief as a resident, my chairman as a young faculty member in Rochester, and my dean as a new chair at Penn State. Mac is the consummate mentor and educator, but I am most fortunate to call him a friend. To him, I am most indebted for an exciting and fulfilling orthopaedic career and the perspective to appreciate it. Finally, I am grateful to my residents and faculty colleagues who have provided an environment that continues to preserve the fun in going to work each day.
My message this morning is in three parts. First, I will define the topic, then I will discuss mentoring in the context of orthopaedics and surgery, and finally I will draw some parallels between mentoring and the AOA.
This talk has been two introspective years in preparation and is as much a reflection on the role of the AOA in contemporary orthopaedics as it is a commentary on mentoring. Indeed, I believe the two are quite similar, and I will try to draw for you a parallel between them. First, let me remind you of Asheville, North Carolina, in 2007. For the duration of the election, I stood—trying to make myself invisible actually—next to a large plant in the back of the room. When the results were in, it hardly seemed like a victory for anyone. I departed Asheville that night in a rather solemn frame of mind for my thirtieth college reunion, concerned over what had seemingly torn the professional organization with which I most closely identified into two divided factions. This left me wondering critically, for the first time, what the true place of the AOA was in the modern orthopaedic hierarchy. During that trip north, I vowed that my audacious objective would be to seek a unifying theme in this address that might facilitate a process of rallying the AOA around its core mission. But, more importantly, I desired to achieve a broad definition of the appropriate place of the AOA in the context of contemporary organized orthopaedics. That is my lofty, yet humble, intent today. By necessity, I will speak more from the heart and with less scientific rigor than many of the scholarly addresses that have preceded me at this podium. As has become customary, I read all of those addresses, back to the beginning, with purpose; in addition, I read The American Orthopaedic Association. A Centennial History, by Brown, Brashear, and Curtiss1, and Jim Urbaniak's A History of the American Orthopaedic Association2, which I commend as required reading for all members of the Association. Collectively, it was an invigorating and instructive experience that crystallized many of my thoughts. I will share excerpts that I am certain will rouse your enlightened understanding of, and commitment to, our leadership organization.
In choosing my subject, I found only two topics that were both my passion and seemed to fit the bill for unifying this diverse group, namely, the education of future orthopaedic physicians and the mentorship of those young surgeons. However, education begged the perennial rebuttal of our non-university members as an academic topic of limited scope and relevance to them—representative, some might claim, of the challenges that beset our Association. When I floated the idea to a few members last year in Quebec, the response was predictably underwhelming. Yet, as I learned more of the rich history of the Association through the chronicles of past presidents, it was clear that mentorship held a deeper meaning that was woven into the fabric of our Association as well as the broad spectrum of individuals that comprise its membership. Mentoring is common to us all, in all practice scenarios; it is a process that represents what we do and the spirit in which we do it3. I, like many of you I suspect, have often wondered about and struggled with the tangible reality of the abstract term leadership in our mission statement. Mentorship is a tangible embodiment of leadership, as defined in our mission to "identify, develop, engage and recognize leadership to further the art and science of orthopaedics."4 Accordingly, through some reflections on mentoring, I will strive to provide you with a framework for a deeper and more grounded appreciation of this organization, a unified view of its role in contemporary organized orthopaedics, and my perspective of your responsibilities as a member when you are offered, and accept, the invitation to enter this hall. Our obligation to mentoring is personal by virtue of our career choice and station within our profession. In his presidential address of 2006, Terry Light said that we have been given the gift of an orthopaedic education and the love of our specialty, which creates an obligation to educate and inspire the next generation of leaders5. That is mentoring. Our heritage of mentoring is organizational; that is the essence of what the AOA has done within our profession for the past 122 years and the historical context that I hope to frame for you.
In Greek mythology, specifically The Odyssey by Homer6, Mentor was a schoolteacher and the servant of Odysseus, and he represented the human characterization of the immortal goddess Athena. When Odysseus parted from his wife Penelope and left the island of Ithaca to sail off to war in Troy, he entrusted the care of his son, Telemachus, to Mentor. On his return some twenty years later, Odysseus found that Telemachus had turned out to be a brave, honest, and respectable young man. Mentor had not only taught Telemachus but had inspired him to fend off disingenuous suitors of his mother as well as to believe in the survival of his father. Mentor turned out to be not only a teacher in the strictest sense but also a role model and guardian responsible for the emotional and intellectual development of Telemachus; the powerful example that is given is that of a substitute father for a son. Webster's Dictionary defines a mentor as a "trusted counselor or guide; tutor, [or] coach."7The American College Dictionary defines a mentor as a "wise and trusted counselor."8 Perhaps not surprisingly, the community of professional educators has given this topic the greatest amount of thought and cuts closest to its practical application for our purposes. Anderson and Shannon, in the Journal of Teacher Education, further define a mentor as a "sponsor, encourager, and friend to a less skilled or less experienced person for the purposes of promoting the latter's professional and/or personal development."9 Sullivan, of the Association for Supervision and Curriculum Development, in 1992 described the mentor, quite practically, as an "opener of doors."10 From our medical educator colleagues in London, mentoring was described as "the process whereby an experienced, highly regarded empathic person guides another individual in the development of their own ideas, learning, and professional development."11 In a workshop dedicated to the subject, the Royal College of Physicians suggested, rather provocatively, that "good doctors are not necessarily good mentors, and mutual respect between the mentor and mentee is essential."12
It is instructive at this point to pause, as we more clearly define a mentor, for the purpose of clarifying what a mentor is not. Specifically, role modeling is often used interchangeably, and incorrectly, with mentoring. Role modeling is a passive and unidirectional exercise of providing a positive example, which may be done either consciously or without intent. In contrast, it should now be apparent that mentoring is an active bidirectional process that requires both coaching and nurturing and demands conscious participation. An effective mentor is more than a teacher or role model and transcends the role of an educator. An effective mentor is the guardian and promoter of the young physician's personal and professional development. So, mentoring is the act of nurturing the emotional and intellectual growth of another person to the point that, and here comes the hard part, he or she is your peer and equal and, ideally, has eclipsed your own accomplishments with the tools and opportunities that you have provided. This requires a special person, with just the right balance of self-confidence and humility, which may be a challenge for any one of us to achieve on any particular day.
In the business world, the presence of mentors is readily apparent as two-thirds of successful executives acknowledge having had a mentor. Despite this, however, they attribute their success more often to luck or their own individual talents13. From this, it is evident that medicine has no monopoly on unabashed hubris. However, in his book entitled Outliers: The Story of Success, Malcolm Gladwell would have us think otherwise of the importance of talent and ambition in the formula for success14. He suggests that success develops through a confluence of opportunity and ability that presents one with the chance to succeed, and it really, most often, is chance that is the determiner. From Sir William Osler's often-quoted passage "The Master-Word in Medicine,"15 the need for mentors in medicine should be self-evident; physicians in-training have a need for emotional, as well as medical, intelligence and maturity that is facilitated by an effective mentor. Yet, in contrast to business, in medicine, relationships and emotional intelligence (that typically benefit most from a mentoring relationship) are frequently deemphasized in deference to an emphasis on raw intelligence. While mentoring is perceived as an important part of academic medicine, the evidence to support such a belief is soft; in a recent literature review on the subject, less than 50% of medical students and only 40% of surgical faculty identified mentor guidance as important in their own development16. In short, the relationships that are necessary for effective mentoring are not as easily nurtured in medicine as in business. Specifically, I contend that, in the surgical disciplines, we typically discount the very skills that are needed to be effective mentors.
So, my hypothesis is that you, as a procedurally oriented orthopaedic surgeon, contrasted with what Arthur Steindler, our forty-seventh president, characterized as an orthopaedic physician17, are not intrinsically good mentors by nature. Leadership skills and styles that are effective in the operating room are often not effective in mentoring. We, as surgeons, are taught to make decisions with incomplete information, to have the courage of our convictions and not look back, to be authoritative in the moment, and to reflect later privately rather than publicly. Surgeons, candidly put, often have egos that are more hungry than secure and, by virtue of this fact, they are not intrinsically good mentors. Couple this with the realities of the present generational differences with our residents and junior faculty and we have an often untenable situation that more often produces failures rather than successes of mentorship. Generation Xers and the Millennials have a strong sense of work-life balance (which many of us secretly envy), desire immediate gratification, and will donate their money before their time18. Does this, by chance, sound like any of your recent faculty recruits? While it is not imperative for us to agree with these values, we must certainly understand and appreciate them in order to effectively mentor our residents, students, and junior faculty.
But you are not just any orthopaedist. By virtue of the fact that you are seated in this room, you come from a subset of orthopaedists in North America that represents less than 5% of those practitioners who are fellows of the American Academy of Orthopaedic Surgeons (AAOS). It is not optional for you to master the process of becoming an effective mentor; it is your obligation as an identified leader in orthopaedics to do so. Our profession is counting on you to do such work, to mentor the next generation, whether as academicians in university practice or community orthopaedists. Therein lies your "obligation of membership" in this organization as a leader, from our mission statement, to "identify, develop, engage and recognize leadership to further the art and science of orthopaedics."4 We have an obligation of mentorship of the next generation for the continued advancement of our specialty. To that end, it is instructive to understand the development of the successful mentoring relationship as well as common barriers to effective mentoring.
I believe that four principles determine the success, and therefore predict the failure, of mentoring relationships; these are style, ego, selection, and time. The principle of style is simply that it matters. Many surgeons, for reasons that we have already articulated, have ineffective styles that must be changed or overcome. Moreover, one style does not necessarily work in all situations or with all individuals, so the highly successful mentor possesses a repertoire of styles that can be utilized as appropriate for each individual situation or mentee of a particular generation or background. Ego is the next, and perhaps most important, principle. Most ineffective surgeon-mentors cannot modulate their own ego. That is to say, they are unable to suppress their own ego and derive personal satisfaction from the success of their mentee. If you are perceived to be in pursuit of the same accolades and awards as your protégé, it is unlikely that you will be an effective mentor to that individual. The third principle, selection, suggests that mentoring is simply not for everyone—surely not the faint of heart nor weak of ego. But, as I have already intimated, in your position as a leader in orthopaedics you are expected to have figured it out and to be able to perform effectively as a mentor. While this, of course, does not guarantee success, it is your obligation to be successful in the endeavor. Finally, similar to the cultivation of other relationships, effective mentoring takes time. This requires a commitment on the part of the mentor to create a framework of repeated contacts in which the relationship develops. Impromptu availability is an adjunct but does not substitute for planned meeting times. This requires effective management of competing priorities since the inability to make time is interpreted as a lack of engagement and quickly leads to failure of the mentoring relationship.
Mendler, in the Journal of Emotional and Behavioral Problems fifteen years ago, outlined the ten stages of the development of an effective mentoring relationship19. They include attraction, cliché exchange, recounting, personal disclosure, bonding, fear of infringement, revisiting the framework, peak mentoring, reciprocity, and closure. The first five stages, attraction through bonding, represent relationship-building between the mentor and the protégé—the fit, if you will. The desired outcome is harmony in the relationship and is most reliably achieved by the mentor possessing a diverse repertoire of interaction and communication styles. The sixth stage, fear of infringement, is when problems in the relationship are most likely to develop. It is in this stage that the mentor anticipates the impending transition from educator and superior to a relationship based on shared experiences as a colleague. The mentor considers concession of the position of authority in this stage; a secure, but not overbearing, ego is a prerequisite. It is in this transition that we recognize the difference between a teacher and a mentor, between a great chair and a mediocre one, and between a great leader and a nervous one. Being able to derive one's own satisfaction from the success of those around you is the essential quality for passing through this stage; without this, the evolution from teacher to counselor and colleague is never allowed to develop. In the next stage, revisiting the framework, the mentor accepts the transition in the relationship and the role of educator and superior is relinquished for a more collegial interaction based on shared experiences. Here the mentor is transparent and shares uncertainty about personal challenges in a manner that tells the protégé that a state of collegial relations has been achieved. The last three phases—peak mentoring, reciprocity, and closure—are the most productive stages of mentoring. Mutual benefit is evident to both parties in the form of reciprocity, which creates an enduring relationship that provides a basis for continued interaction, both on professional as well as personal levels.
One often overlooked benefit of the mentoring process to our hierarchical system of governance and leadership is that of succession planning. The effective transfer of intellectual capital of senior practitioners, acquired over decades of practice and life experiences, to more junior physicians in the early stages of practice is necessary for the efficient advancement of medical knowledge—as well as the human race in general. This materially benefits society and the progress of medical practice and returns the gift of great satisfaction and accomplishment to the altruistic mentor. Unfortunately, realities of the competitive marketplace introduce hazards into this otherwise productive mentoring relationship and exchange of ideas. Physicians are typically competitive individuals who are self-reliant and find it difficult to ask for help. For the mentored, the notion of having a mentor may imply weakness or a need for remedial assistance. This must be overcome. For the mentor, financial or intangible disincentives to sharing valued information or time with a protégé who might be in a competitive practice are real issues that pit personal interests against advancement of the greater societal good. Leadership must be exercised in these instances; hence, our obligation to mentor subsequent generations in the interest of advancing the art and science of orthopaedics.
The highly effective mentor exhibits several characteristic traits: he or she is accepting of the individuality of the mentee and their different starting points, shares knowledge completely and unselfishly, is encouraging and supportive while offering constructive criticism, sets the bar high but with rest points along the way, is honest and easily admits to not knowing, has an ego that is secure with his or her own personal accomplishments, shares common challenges and quests, and welcomes collegiality when appropriate20.
The challenge of effective mentoring in orthopaedics is best illustrated by providing some entertaining, yet sobering, real-life examples of failed mentoring in people that you and I know—and perhaps have even worked with over the years. For this, I exercise poetic license in adapting some examples of teachers as portrayed by David Green in his 2004 Founders' Lecture, "On the Shoulders of Mortals,"21 to the American Society for Surgery of the Hand … with a little help from The New Yorker. The four illustrative examples that I will discuss are the uncommitted phony, the perfectionist-turned-tyrant, the insecure egocentrist, and the begrudger. I will start with the uncommitted phony; this individual is sporadically involved and often distracted by things that are "more important" than the protégé. Intimidation and bluff are used by the mentor to deflect questions to which answers are not known. Quickly, the mentee perceives a lack of sincerity and honesty in the mentor, and the mentor loses the respect of the protégé through a simple inability to say "I don't know." The failure in this relationship occurs early, at Mendler's stages of attraction and personal disclosure19. The picture is a not-so-perfect David look-alike that perhaps even Michelangelo would not recognize! Next, the perfectionist-turned-tyrant; this mentor-hopeful continually sets the bar high, striving for perfection and leading by example. This is not a bad thing, but relentless pushing without reprieve quickly wears out the mentee. The error is in providing no compliments or reassurance to the protégé as a "rest stop" over the course of a long process of learning and advancement. The mentor is perceived as being aloof and distant, and the interaction becomes tedious and overbearing for the protégé. This mentoring relationship stalls at the stage of bonding19. The New Yorker cartoon shows a patron ordering dinner, saying to the waiter: "I'll have the misspelled ‘Ceasar’ salad and the improperly hyphenated veal osso-buco." The insecure egocentrist is next; this mentor-hopeful is demeaning and intimidating to the protégé in response to questions, for the apparent purpose of self-aggrandizement. The mentee is used as an ego-builder for the insecure teacher, who is quickly perceived as being arrogant, pompous, and unapproachable—and, therefore, ineffective. This relationship fails where casualties most often occur with the insecure mentor, at the fear-of-infringement stage19. In the cartoon, a physician towers over an embarrassed patient scantily clad in a hospital gown saying, "Humiliation is a very important part of the process, Mr. Keifer." Finally, the begrudger shares knowledge incompletely and in bits and pieces, being supportive of the mentee only to a limited and predefined extent. There is normal progression to the point of independence of the mentee, but the mentor cannot fully relinquish the role of "superior" to the "subordinate"; in this case, the mentor is incapable of generational advancement. Failure occurs at the stage of revisiting the framework19. In this cartoon, the boss behind the big desk barks out to the employee, "I don't have to be a team player, Crawford. I'm the team owner."
In the end, the highly effective mentor learns to derive personal satisfaction from the accomplishments of the mentee, which perpetuates a healthy relationship on both a professional and personal level to the benefit of both parties. Absent that collegiality, as in this cartoon, the condescending chief executive requests of the junior staff associate, "I'd like your honest, unbiased and possibly career-ending opinion on something." We are each no more than a blink in the course of time on this planet. When we have the ball, our task is to advance it, and then hand it off to the next person to take it even farther. This is our personal obligation to mentoring the next generation and our personal demonstration of leadership. Whatever we might have contributed is wasted if we take it to the grave without freely passing it on. Without effective mentoring, we ignore our obligation to the generational advancement of medical knowledge and practice. Succession planning should bring great satisfaction to the mentor, in contrast to the unanswered beeper in the closed coffin of this failed mentor.
Now, what has all this to do with the American Orthopaedic Association, your obligation as a member, and our role in organized orthopaedics in the twenty-first century? I suggest that it has a great deal to do with it. My premise is that the heritage of the AOA is as the mentor of organized orthopaedics, much as all in this room have an obligation by virtue of their professional stature to mentor the next generations of orthopaedic physicians; the mentor metaphor has characterized the role of the Association in the twentieth century and should remain so in the twenty-first century and beyond.
A brief tour through history is instructive. Founded in 1887, our Association originated with an elite group of fourteen men who mustered only a split vote in favor of establishing the Association. The AOA grew in popularity and gradually accumulated in its ranks the fathers of orthopaedics in the beginning of the twentieth century. In his presidential address in 1895, John Ridlon suggested, relative to the growth and prosperity of the AOA, that the organization should "invite to membership every surgeon in the country who was known to have done any considerable special work in orthopaedics."22 However, following the First World War, the Association was challenged by rapid growth in both the interest and number of orthopaedic surgeons who returned home with field experience in managing traumatic extremity wounds but had little formal education in treating maladies of the musculoskeletal system. This prompted Herbert Galloway of Winnipeg, in his presidential address of 1919, to initiate a call for a "readjustment to changing conditions."23 He recognized in the war experience a danger that some returning surgeons would be "recognized as orthopaedic specialists but lack general surgical training and may in the future be tempted to accept cases in which their general surgical knowledge makes them unfit to undertake but not the courage to refuse." He went on to note the "only safeguard is conscience and individual honesty."23 Hence, this was the basis for his plea to raise the standard for membership and require as a prerequisite a fellowship with either the American or Royal College of Surgeons. For the next decade, nearly every presidential address uniformly included a reference to preserving the selectivity of membership and the need for establishing formal standards for orthopaedic education. In 1928, A. Mackenzie Forbes stated: "In order that membership may always be a privilege, I feel that we should ever agree that our numbers should be limited. Our Association should not be a school for those who aspire to be orthopaedic surgeons, but rather, it should be a union of the masters of orthopaedic surgery whose aim and object should be the propagation of knowledge."24 The leadership of the Association perceived these two issues to be a great threat to the organization and, ultimately, the specialty. Consequently, the years between the two World Wars proved to be the most pivotal in the evolution of the AOA. Decisions made in those decades laid the foundation for how the Association would forever relate to the world of organized orthopaedics; they established the role of the AOA as parent and, ultimately, mentor in orthopaedics.
During his presidential year of 1931, Willis Campbell suggested the creation of another orthopaedic organization that would house all practitioners, irrespective of age or accomplishment, and serve the need for their continuing education25. The next year, William Gallie of Toronto declared a "guest problem" in the AOA and decried an abuse of nonmember attendance that "threatens the value of our scientific sessions and the social side of our Meetings."26 This led to a guest invitation policy to the Annual Meeting that stands to this day, modified to prohibit invitation to any individual more frequently than every other year. This substantially excluded from membership or participation most of the young surgeons entering the practice of orthopaedics at that time. Ultimately, the AAOS was established the following year, in 1933, and the American Board of Orthopaedic Surgery (ABOS) in 1934, effectively discharging primary responsibility for the continuing education and certification of young practitioners in the field. In so doing, the AOA began its role as parent, and effectively mentor, to the larger community of organized orthopaedics that it had begun to create. In addressing this proliferation of offspring from the AOA, Melvin Henderson of Rochester, Minnesota, commented in 1934, "As the science and art of orthopaedic surgery have increased in range and scope, the activities of any one rather small group have been found insufficient to cope with this problem. Leadership has been accorded the American Orthopaedic Association, and the Association has not failed … [I]ts members in various groups have organized other societies to aid in keeping the specialty on a sound footing… . We must support the other societies … the group from which our membership will be recruited and from which will come those who will take up our work as we drop it."27 In his A Centennial History, Thornton Brown, AOA President in 1979, astutely noted that "in retrospect, the two decades separating the World Wars were a time when the Association made a critical decision as to whether it would continue to be the major national society representing American orthopaedics. To the query, ‘to be, or not to be?’ its choice was ‘not to be,’ although one wonders whether the members as a whole really understood that they had made this choice at the time."1
Nevertheless, the parenting role of the AOA continued and, with it, the implied role of mentoring those newly created organizations. In 1953, The Journal of Bone and Joint Surgery (JBJS) was independently incorporated in a joint venture with the AAOS that created a shared governance board equally comprised of AOA and AAOS members, along with the editor. In so doing, the AOA altruistically ended nearly sixty-five years of existence of the publication as its wholly owned subsidiary with the intent of maintaining the intellectual integrity of The Journal, free of conflict imposed by ownership2. As such, the AOA relinquished all prospects of financial reward that might accrue from continued ownership, despite unilaterally providing The Journal with a start-up loan to bridge it to financial independence. Imagine, just for a moment, how much different the financial health and independence of the Association might be today had The Journal been retained on our books as an asset rather than liberated for the benefit of our specialty! Two years later, as the brainchild of A. R. Shands Jr., president of the AOA in 1953, the AOA and AAOS again partnered, in 1955, to form the Orthopaedic Research and Education Foundation (OREF), whose mission was to "sponsor and finance scientific research for education in orthopaedics."28 So were created the "Big Four" offspring in organized orthopaedics: the AAOS, ABOS, JBJS, and the OREF, all direct descendents of the parenting AOA. But, as many of you know firsthand, once a parent, always a parent, and so the implied responsibility and method of mentoring these organizations were to be the source of ongoing consternation in the AOA for years to come, if not forever.
Shortly thereafter, in his 1957 presidential address, David Bosworth suggested that "Ours is, and should be, the association of the elders. By assisting others [i.e., societies], in matters pertaining to orthopaedic surgery, we ourselves will continue to grow and develop. When we refuse to so assist, we decline in stature and knowledge."29 Indeed, Bosworth was warning against the possible failure of a mentoring relationship between ambitious and accomplished organizations. Even more provocative was John Royal Moore in his presidential comments in 1960. He noted that "there is an inescapably great responsibility imposed upon the President by the rich traditions of this great parent American Orthopaedic Association. This responsibility has not lessened one iota with the growth of the Association's protégé, the American Academy of Orthopaedic Surgeons, that husky youngster now twenty-eight years of age that continues to grow though remaining commendably courteous, respectful, and receptive to parental counsel."30 No fewer than a half-dozen presidents have since directly probed this challenging relationship in their addresses: in 1979, Thornton Brown asked, "Can The Association, which started it all, now claim a clearly definable role?"31 Rather than the Roman "Senatus," as had been previously suggested, he likened the AOA to a "blue-ribbon committee appointed for some special purpose" with a meeting setting that was "reminiscent of a ‘retreat’ or ‘think tank.’" In 1983, Mankin suggested that, "despite a limited membership with a low operating budget, the activities of the AOA are far reaching."32 Two years later, in reaffirming Charles Gregory's 1973 warning that the AOA reject the proposition of assuming "an honorary peerage,"33 Evarts more directly asserted that "it is not sufficient just to belong to an elitist organization; we must recognize and develop our leaders and leadership in order to enable all of the orthopaedic organizations to begin to meet the challenges ahead."34 And, finally, in 1991, Gene Bleck concluded that the AOA "should be the idea brokers—the orthopaedic think tank in which each of us lends our scholarship, experience, observations, and wisdom."35 In aggregate, a substantial body of organizational wisdom has reflected on the challenges of maintaining a productive and mutually beneficial mentoring relationship between blood relative organizations that are both ambitious and accomplished in their own right. But recall that this relationship is not one of siblings or sister organizations, as has been inaccurately asserted in the past; it is parental in nature, that of a mentor and protégé. To that end, I am reminded of my father's stern admonition too many decades ago in response to some undoubtedly inappropriate adolescent behavior of mine when he said, "Remember, you may be taller than me [which I was], but you will never be bigger than me [which I even more obviously was not]."36
My fundamental premise is based on the metaphor of mentor and protégé. It is that the American Orthopaedic Association, in its role as organizational parent in the world of American orthopaedics, also occupies the critical and challenging role of organizational mentor as well. And, as parent, this responsibility to mentor never ceases, no matter how independent and able the offspring societies and organizations believe themselves to be or how old and irrelevant they suspect the parent to be. No exceptions. I believe that Jim Urbaniak said it best in his presidential address of 199437, when he firmly rejected the notion that the AOA was a "victim of our creations" by encouraging the growth of other orthopaedic organizations. He opined that "With the proliferation of so many great sister [which I would modify to offspring, as previously noted] organizations, however, it has admittedly become more difficult for The American Orthopaedic Association to maintain a leadership role… . [but] we have the rare advantage of owing no special allegiance to constituents, special interest groups, or industry. As a result, The Association is aptly positioned to provide objective leadership in controversial areas that may benefit all orthopaedic surgeons and the various subspecialty groups."37
One need not look far to realize the prophecy in Urbaniak's words. The AOA was instrumental during the decade of the 1980s in facilitating the acceptance of a process of recertification as proposed by the ABOS2. Great resistance was encountered from the fellows of the AAOS, but the AOA helped to organize a task force that brought together leadership of the three organizations in reaching agreement on a process that resulted in a time-limited certification that was in the best interests of patient care and safety. More recently, in just the past two years, the AOA has sparked the appearance of the "new five" as a sequel to the "big four." The "Own the Bone" program has been successfully launched and has attracted self-sustaining industry support; it has reclaimed skeletal health as the professional obligation of the orthopaedic practitioner despite lacking a procedural base, making it unattractive to the specialty societies and AAOS. The Orthopaedic Medical Education Grants Association (OMeGA) was organized as an unparalleled, nonconflicted effort by the AOA to address the challenges of distributing much needed industry funding to orthopaedic fellowship programs in our present-day environment that is so highly sensitized to conflict-of-interest issues. Funding is awarded on the basis of a merit-based assessment of fellowship programs by the real experts, the program directors and educators. The Universal Fellowship Match is soon to be a reality, having found its origins in discussion and a symposium at our Annual Meeting two years ago; its appearance marks a synergistic collaboration between the initial catalyzing efforts of the AOA in broaching a topic unpopular with some specialty societies and the implementation efforts of the AAOS and the Board of Specialty Societies, to accomplish the optimal outcome for resident and fellow education in orthopaedics. The birth of the Council of Orthopaedic Residency Directors (CORD) this year marks a full-circle traverse of the parent-mentoring cycle. Born of the AOA as the Association of Orthopaedic Chairmen (AOC) in 1974, the AOC then evolved into the Academic Orthopaedic Society (AOS) in 1991 in order to broaden its faculty membership. In 2003, the AOS merged into the AOA in an effort to provide a stronger financial base for academic orthopaedics. In turn, in an effort to formalize the place of orthopaedic educators in the AOA, and provide a platform from which to interact with the Accreditation Council for Graduate Medical Education (ACGME) and other program director associations, the CORD was created within the AOA this year. Finally, the Orthopaedic Institute of Medicine provided its first document guiding the ethical conscience of orthopaedic physicians with respect to emergency-room call coverage. It has, indeed, been a busy couple of years. And for those accomplishments, we are indebted to a great staff, under the tireless leadership of Kristin Glavin, and a remarkable succession of presidents who have preceded me, most notably, Louis Bigliani, with whom I have had the pleasure to work most closely this past year.
Yet there remains much for us to do. Establishing greater financial independence for our Association with appropriate management of conflicts of interest and lessening of our dependence on support from industry is an imperative for our continued existence. Is complete abstinence from even unrestricted educational support from industry necessary outside the creation of clinical practice guidelines, or are there reasonable parameters under which such support can be accepted to underwrite important programs without the cloak of bias and reciprocity? The maturation of OMeGA as the preferred vehicle to objectively, and without conflict, award the much needed financial support from industry to graduate and postgraduate programs of medical education will require continued oversight and monitoring. If we stay the course on the high road that is completely devoid of conflict of interest, I am confident that the OMeGA process will surface as the morally and ethically correct method by which we can continue to receive financial support from industry for fellowship education. The recent call by the Institute of Medicine for greater restrictions in resident work hours will require our most thoughtful guidance and leadership. The AOA, through its academic educators, Council of Residency Program Directors, and Department Chairs, represents the voice of orthopaedics in this dialogue between the ACGME, the Institute of Medicine, and society at large. We must strive to reconcile the need for responsible action on behalf of patient safety, with our obligation to provide an optimal educational environment that preserves the ethos of professionalism inherent in the practice of medicine and, in turn, ensures the safety of future generations of patients by producing the highest quality and most committed physicians to provide their care. Finally, resolution of the conflict-of-interest crisis that has beset medicine in general, and impugned the credibility of our specialty in particular, sits as our highest priority. Members of our profession, as well as our own specialty, have behaved irresponsibly and unethically in ventures with industry. This has understandably eroded the public trust and seriously compromised the prospect of our future collaboration with corporate America. It will also demand our most thoughtful consideration in crafting a new paradigm in which we may once again function ethically and effectively with industry to advance the practice of medicine. From a historical perspective, A.J. Steele, of St. Louis, provided a starkly different observation in his presidential address of 189338:People not only marvel at the amount of charity work that we do, but also at our unselfishness in giving our inventions and experience to others. They say, "Why not patent the machine and make money thereby?"—not knowing that it is contrary to the spirit of our calling. No; we give to the world whatever we have that is new and good. We even vie with each other in the celerity with which we shall tell what we know, jealous lest some other one shall, on a given subject, get into print first. Liberal in our views, charitable in our acts, and benevolent to all—this is our animating spirit.38
People not only marvel at the amount of charity work that we do, but also at our unselfishness in giving our inventions and experience to others. They say, "Why not patent the machine and make money thereby?"—not knowing that it is contrary to the spirit of our calling. No; we give to the world whatever we have that is new and good. We even vie with each other in the celerity with which we shall tell what we know, jealous lest some other one shall, on a given subject, get into print first. Liberal in our views, charitable in our acts, and benevolent to all—this is our animating spirit.38
How times have changed our lives and profession! Whenever a pendulum resets its position, it must overswing before inevitably finding a new resting place. Rather than simply listing the "do nots" in affairs with industry, we must provide the leadership necessary to frame the characteristics of a positive, ethical, and productive collaboration that will further the standard of medical innovation as it has in the past.
If you had any doubts, it should be ever apparent that the AOA is no honorific society without a purpose.
In closing, I will take full advantage of Fremont Chandler's 1952 observation that the presidential address provides "traditional freedom from rebuttal"39; as such, I will be provocative as I enjoy being from time to time. I believe that the American Orthopaedic Association must revel in the accomplishments and successes of its offspring as does a proud parent, openly sharing experiences for the mutual benefit of all organizations when that offspring has attained adulthood. Specifically, the AOA must be true to its role as mentor in dealings with the AAOS. We must be comforted by a secure ego and reassured by the special place in the hierarchy of orthopaedic thought held by our Association. There will always be much for us to do in guiding the conscience of orthopaedics. Likewise, the American Academy of Orthopaedic Surgeons is a star protégé, larger in size but never bigger in stature than its parent. A reflective AAOS as protégé will always afford respect and deference to the AOA in dealing with it as its parent. These principles should guide future interactions of these two giants in organized orthopaedics; never before has the need for complementary activity between the two organizations been greater than in the current environment of constrained resources. Competition is inexcusable, and redundancy and duplication of effort is wasteful of both financial, as well as human, resources. As individuals in this leadership organization we call the AOA, we have a clear and challenging obligation to mentor the future generations of orthopaedic physicians. Pass on your acquired wisdom and experience to the next generation, not for a price but for the simple privilege of passing it on and advancing the ball. That leadership mission unites all who are in this room. And as members of greater professional organizations, we take on the attributes and roles of those respective organizations; the heritage of the AOA is as mentor to organized orthopaedics. None of us is bigger than the organization to which we belong, and no individual can change the role of any organization based on personal beliefs or agenda. When in Rome, do as the Romans do. When you enter this hall, you leave your anatomical or topical specialty hat at the door; in so doing you accept the challenge and individual responsibility of being a mentor as well as being part of a mentoring leadership organization. Neither is easy, but both return great dividends in personal satisfaction to those who partake.
In the end, Mark Twain had it perfectly: "Always do right. This will gratify some people and astonish the rest."40
Thank you for the humbling privilege of serving as your 122nd President.
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