It is an honor and pleasure for me to address you as the incoming 121st President of the American Orthopaedic Association (AOA). Today, I will speak to you about the AOA's commitment to leadership and how, through recent changes in its activities, it has embraced the challenge to "stand up and be counted." But, first, I want to mention how my institution, the New York Orthopaedic Hospital, has been closely associated with the AOA and how I chose the title "Stand Up and Be Counted."
The New York Orthopaedic Hospital and Dispensary was founded in 1866, and there have been nine directors1. The Hospital sold its building in 1950 and became part of the Columbia Presbyterian Medical Center and now New York Presbyterian Hospital and Columbia University. Of the nine directors, three have been presidents of the AOA: Newton M. Shaffer, Harold M. Dick, and myself. Newton M. Shaffer, our second director, was one of the founders of the AOA. As nicely outlined in Dr. Urbaniak's A History of the American Orthopaedic Association, a preliminary meeting to discuss the formation of the AOA was held in Shaffer's New York apartment2. The AOA was formed in 1887 as the first orthopaedic association of its kind, and Newton Shaffer was the second president in 1888, following Virgil Gibney.
The third director of the New York Orthopaedic Hospital, Russell A. Hibbs, one of the most famous orthopaedic surgeons in the history of our profession, was initially rejected. It appears that several influential AOA members did not like the manner in which he replaced Newton Shaffer as director of the New York Orthopaedic Hospital, and they blocked his admission. However, he was later unanimously accepted on the merit of his work concerning spinal fusion. Harold Dick was our eighth director and the 109th President of the AOA. However, it was the work of the sixth director of the New York Orthopaedic Hospital, Frank E. Stinchfield, that provided me with the title and inspiration for this lecture. Frank Stinchfield was one of the greatest orthopaedic leaders of the twentieth century. He possessed remarkable vision and wisdom. "Stand Up and Be Counted" was the title of his 1963 Presidential Address to the American Academy of Orthopaedic Surgeons3. In this address, he states "We orthopaedists have problems—many problems … but let us consider them … and take care of them, because to survey our problems is to behold our promise." He highlighted five areas where we needed to improve: trauma, recruiting of students, education, funds for research, and participation in allied organizations. He implored us as a specialty to have the strength, faith, and conviction to "stand up and be counted."
As Dr. Stinchfield noted, time passes on and today we are confronted by some of the same problems and some new ones that are proving to be just as difficult, if not more difficult, to face and overcome. That is why today, we, as an association and as individuals, must have the moral conviction to "stand up and be counted." At the start of this new century and millennium, the leaders of the AOA decided to focus the organization's attention more toward leadership. Change is always an opportunity to improve.
The AOA mission statement became "To identify, develop, engage and recognize leadership to further the art and science of orthopaedics." In other words, it was time to stand up and be counted.
First, the AOA changed the educational format of the annual meeting and expanded the scope of activities at this meeting. The educational programs shifted to a symposium format that confronted critical issues in our profession. These ideas were developed and nurtured in a newly formed Critical Issues Committee. In this forum, intense and creative discussions provided a new direction for topics such as:Integrating evidence-based medicine into clinical practiceResuscitating orthopaedic trauma emergency careDirect-to-consumer marketing: a boon or boondoggle?Orthopaedic surgeons: artists or scientists?
Integrating evidence-based medicine into clinical practice
Resuscitating orthopaedic trauma emergency care
Direct-to-consumer marketing: a boon or boondoggle?
Orthopaedic surgeons: artists or scientists?
The theme of the annual meeting also emphasized various aspects of leadership. Incorporated into the annual meeting were special emphasis groups such as the Emerging Leaders Program and the Resident Leadership Forum that focused on younger future leaders.
The AOA was focusing on one of the principles to achieve successful governance taught to us by consultant Glenn Tecker, author of several books on governance4, who advised: "Do not only work in an organization, but on an organization."
We also adopted a Tecker method to realize improvement, i.e., "the Mega Issue." This is a process by which we evaluate our strengths and weaknesses as well as what we know and do not know. Then, we thoroughly discuss the issues, draw conclusions, and decide on solutions (action plans) that day. In an effort to expand its emphasis on leadership, the AOA, in conjunction with Northwestern University's Kellogg School of Management, developed a series of six engaging and interactive Leadership Management Modules that aligned with the mission of the AOA. The topics they address include the following examples:Using research to advance organizational successEssential human resource skills for optimal asset utilizationBe equipped to better compete in the marketplace
Using research to advance organizational success
Essential human resource skills for optimal asset utilization
Be equipped to better compete in the marketplace
In 2003, the AOA successfully merged with the Academic Orthopaedic Society, solidifying its position to deal with issues concerning graduate medical education and to include all academic leaders. Today, the Academic Leadership Committee plays an active and vibrant role in our association. In addition, the Executive Committee requested the membership committee to revise the admission process so that it would include leaders and potential leaders in orthopaedics who may have important professional achievements other than academics, as they might contribute to our organization. The membership committee streamlined the process, switched to an electronic system, and simplified criteria into four domains:Professional positions held and professional employmentScholarship and researchLeadership in orthopaedics and medicineLeadership in community service
Professional positions held and professional employment
Scholarship and research
Leadership in orthopaedics and medicine
Leadership in community service
This will allow us to reach out to a broader spectrum of individuals who may help our organization.
However, one of the most important ways that the AOA continues to be a transforming organization is through the expanded role of the Critical Issues Committee. It has become home for ethical and leadership issues that require development over a period of time and the establishment of a process. We are actually following one of the examples in John Maxwell's book, entitled The 21 Irrefutable Laws of Leadership: Follow Them and People Will Follow You, which is "Most people overestimate the importance of events and underestimate the power of process."5 Both an event and a process are needed for success. It is interesting to note that process is a culture-related issue that changes people, but a process is difficult to establish.
Some topics addressed by the Critical Issues Committee include the following examples:"Own the Bone," a multidisciplinary, comprehensive educational project to emphasize the magnitude of fragility fractures and promote evaluation and treatment.The Orthopaedic Institute of Medicine, patterned after the Institute of Medicine, to establish independent, unbiased opinions about issues that challenge our profession. Interestingly, the first topic the Institute chose to research was one of Dr. Stinchfield's concerns in 1963: orthopaedic trauma care.The Fellowship Match—an effort to bring order and consistency to the match process by adopting a universal fellowship match.
"Own the Bone," a multidisciplinary, comprehensive educational project to emphasize the magnitude of fragility fractures and promote evaluation and treatment.
The Orthopaedic Institute of Medicine, patterned after the Institute of Medicine, to establish independent, unbiased opinions about issues that challenge our profession. Interestingly, the first topic the Institute chose to research was one of Dr. Stinchfield's concerns in 1963: orthopaedic trauma care.
The Fellowship Match—an effort to bring order and consistency to the match process by adopting a universal fellowship match.
Needless to say, this agenda has created an ever increasing burden to our staff who have always more than met the challenge.
I have saved for last one of the most vexing and difficult problems to confront our profession: conflict of interest. In March 2005, the Department of Justice through the U.S. Attorney's office in Newark, New Jersey, issued subpoenas for five of the major prosthesis manufacturers6. They were charged with violating the Federal Anti-Kickback Statute, which was enacted to address the concern that "business practices and/or relationships have the potential to negatively impact ways in which care is delivered."6
Stryker decided to cooperate, and the other four manufacturers decided to fight the charges. The result was a conviction resulting in fines in the hundreds of millions of dollars. Furthermore, in September 2007, the companies entered into an eighteen-month deferred prosecution agreement period. During this period, under the scrutiny of government-appointed monitors, business practices would be brought into compliance with federal law. If this was successfully completed, the charges would be lifted.
Financial conflict of interest is also a problem and a challenge for orthopaedic surgeons. This is highlighted in the monograph by the Association of American Medical Colleges (AAMC) entitled "The Scientific Basis of Influence and Reciprocity: A Symposium."7 Briefly, it included the following conclusions:Financial conflicts of interest can undermine the credibility, integrity, and trustworthiness on which rests the privileged status of academic medicine in contemporary society.It is demonstrated that the human tendency is to expect—until proven wrong—that favors will be paid back.All of this research suggests that physicians who will personally benefit from recommending a particular drug, treatment, procedure, or clinical trial will have no problem figuring out ways to justify that decision as being in their patient's interest.The solution is to eliminate financial conflicts of interest whenever possible.
Financial conflicts of interest can undermine the credibility, integrity, and trustworthiness on which rests the privileged status of academic medicine in contemporary society.
It is demonstrated that the human tendency is to expect—until proven wrong—that favors will be paid back.
All of this research suggests that physicians who will personally benefit from recommending a particular drug, treatment, procedure, or clinical trial will have no problem figuring out ways to justify that decision as being in their patient's interest.
The solution is to eliminate financial conflicts of interest whenever possible.
Is this reasoning simply academics presenting at an education forum? I think not. The public is now involved as demonstrated by an article on March 22, 2008, in The New York Times that noted how the focus of the Department of Justice will shift from companies involved in the deferred prosecution agreement to individual orthopaedic surgeons8. Yes—we have problems and we have to solve them. The AAMC has started to work on this problem, and the results of a task force on industry funding of medical education will be released later this year. One of the conclusions is that "Drug and medical device companies should be banned from offering free food, gifts, travel and ghost-writing services to doctors, staff members and students in all 129 of the nation's medical colleges."9
The AOA has and will continue to respond to this crisis in our profession. In November 2005, as a result of the work of a task force on professionalism, a white paper outlining the eight characteristics expected of professionalism was published. In 2007, a committee was formed to investigate and make recommendations concerning conflict of interest. Their work is ongoing, and this may be a topic for the Orthopaedic Institute of Medicine.
Currently, the AOA has formed a task force to develop an alternative method for industry to fund graduate medical education without conflicts of interest. This is in response to the new regulations placed on industry by the Department of Justice.
The AOA continues to confront some of the most controversial issues in orthopaedics. It is important for our leadership initiative to succeed. To achieve success, we only have to refer to the attributes in the pyramid for success laid down by John Wooden, the famed UCLA basketball coach who won ten national championships. Wooden, however, emphasizes that "Leadership is an imperfect science."10 Furthermore, "Successful leadership is not about being tough or soft, sensitive or assertive, but about a set of attributes. First and foremost is character."11
The AOA is in a unique position to influence change and provide leadership for the orthopaedic profession, our patients, society, and graduate medical education for our future. We have the right attributes, integrity, and the character to do so. In my opinion, the AOA has and will always "stand up and be counted."