Let's Keep Our Eye on the Sparrow
James D. Heckman, MD

First Vice Presidential Address
American Academy of Orthopaedic Surgeons
March 21, 1998
New Orleans, Louisiana

President Jackson, fellows of the American Academy of Orthopaedic Surgeons, family and friends:

I am honored beyond description to serve as the next president of this, the greatest professional society in the world, and I shall do everything in my power to uphold the confidence you have vested in me.

Shoulders

It was Sir Isaac Newton who said, "if I have seen further, it is by standing on the shoulders of giants." Certainly, that is where I am standing today. Before I begin my formal remarks, I want to express my appreciation to all those giants in orthopaedics who have preceded me in this office. I hope to emulate the standards set by them.

From their ranks, I want to thank four in particular who have strongly influenced my career:

I want also to thank my parents for standing shoulder to shoulder in support of my career at every turn. It certainly was through his example that my father taught me to be a good doctor and through his satisfaction that I learned how much fun it is to be an orthopaedic surgeon.

As I get more involved with this job, it becomes very apparent that one really needs more than the shoulders of giants to stand on. Not infrequently, one also needs a shoulder to cry on. For all the love and support that they have given me throughout the years, let me publicly say thanks to my immediate family, our children Coleman and Betsy, and especially to my dear wife Susan. I love you guys.

The work at home must go on while the Heckmans are traveling around the world representing this great organization. My thanks also goes to my partners, faculty and staff in the Department of Orthopaedics in San Antonio for keeping their shoulders to the wheel, particularly during this coming year.

Finally, thanks would not be complete without acknowledging the superb staff in the Academy's office in Chicago, or as Carl Sandburg called it, the "City of the Big Shoulders." Led by our executive vice president, Bill Tipton, the Academy staff is world class and simply wonderful.

I will conclude my thank yous by reminding everyone of this quote from Sir F.M.R. Walsh who, at his address as president of the Canadian Medical Association in 1952 said, "Medicine is the oldest learned profession in the world, and it is rooted in its past. Each successive generation of doctors stands, as it were, upon the shoulders of its predecessors, and the fair perspectives that are now opening before you are largely the creation of those who have gone before you."5

As I stand proudly on the shoulders of the great individuals who have preceded me in this office, the direction in which this Academy is going is very clear. Guided by a strong strategic plan that keeps us focused on the important issues and working in collaboration with an incredibly talented Board of Directors, it is my promise to you that over the next year a lot of very important and positive events will occur. In each and every case, the steps that we as an Academy Board take will have one primary motivating factor: the welfare of our patients will always be our highest consideration.

Here in New Orleans, home of Dixieland jazz, many great songs have been spawned. One of the greatest of those and one that you will hear sung frequently, whether in bars or churches, is entitled, "His Eye Is on the Sparrow." I have chosen as the theme for this talk the phrase "Let's keep our eye on the sparrow" to remind us that whatever we do in our professional lives must be focused on the welfare of our patients. All other considerations, whether they be political benefit, personal achievement or economic satisfaction, must be secondary.

One of the obligations one has when preparing this speech is to read the talks of one's predecessors. Over the years, many hot political, socioeconomic, healthcare and/or educational issues have arisen and temporarily taken front stage. But consistently, overall, one enduring theme began with Willis Campbell's speech in 1934 when he said, "The main objective [of the Academy] is an unselfish one, that is, the development of the specialty for the best interest of the patient and not for personal or collective aggrandizement..."1

This absolute imperative to keep our patients' welfare in the forefront has been a part of every first vice presidential speech since that time. As we set the agenda for the coming year, let's keep our eye on the sparrow and always do that which is in the best interests of our patients.

Unity

One overarching theme that can accomplish this objective and can be developed within the Academy structure, among orthopaedic societies, and even in our local orthopaedic communities is that of unity. This year, we will strive to further unify orthopaedics in several ways.

The Academy has three major focuses of activity represented by the three Councils: Education, Research, and Health Policy and Practice. When these three councils were created 10 years ago, it was hoped that these three related, but fairly independent, activities would thrive in an organization structured to support their individual growth and development. That certainly has been the case, but an interesting phenomenon has occurred over the last couple of years: we can see a real fusion of all three of these endeavors occurring with the patient as the common element that unites them.

When I was chairman of the Council on Education, we were quite proud of the continuing education activities that the Academy produced. It was our goal to convey contemporary orthopaedic knowledge by as wide an array of media and opportunities as possible. This plan has generated a vast bonanza of well-produced continuing education courses, publications and audio-visual materials. What was lacking, however, was a common thread directing our educational programs. Over the last two years, the Council on Education has taken a critical look at the educational needs of the practicing orthopaedist. It has correctly and clearly identified the importance of increasing the emphasis on value generation when planning the content of all of our continuing education activity. Applying this principle will greatly enhance the value of the educational experience to each and every one of us and, in turn, make it that much more relevant to our patients.

One way to enhance the value of the continuing education experience lies in our ability to assess outcomes data generated by large numbers of patients undergoing orthopaedic care. These outcomes data provide the basis for the development of practice guidelines, algorithms and clinical pathways. Generation of outcome data has become the most important task of the Council on Research and Scientific Affairs. Specifically, the Task Force on Data Management has been responsible for the development of the Academy's forward-thinking, standard-setting clinical outcomes research program, which is now affectionately known as MODEMS. What could be more patient-oriented than developing a continuing education program that is based in great part on the patient's perception of the benefit of our intervention? This example shows how the educational and research endeavors of the Academy have become very much intertwined.

The third major focus of the Academy is on health policy and practice. Often, pocketbook issues push to the forefront of our concerns in Washington. While the Academy will still continue to provide as much relevant, objective data as we can to the health policy makers to support the economic interests of the practicing orthopaedic surgeon, our greatest advances in Washington continue to be those which focus on the welfare of the patient. Our most notable example of success in this area has been the Patient Access to Specialty Care Coalition. Under the able direction of Nick Cavarocchi, this coalition has enrolled more than 100 physician- and patient-advocacy groups and lobbied very effectively to maintain a direct and open pathway for our patients to the specialist of their choice. The coalition has been successful because its primary purpose resonates positively with the desires of our patients.

These examples clearly reflect how well integrated and interdependent are all three of our major Academy initiatives. As we move forward in the era of evidence-based disease management,2 further horizontal integration and interdependence of the various Academy endeavors will be essential.

Unity has been and will continue to be a strong characteristic of your Academy leadership as well. One concern which I hear voiced commonly from the fellowship is that there is a preponderance of academic orthopaedists running the day-to-day affairs of the Academy, somehow leading us away from the right course of action. Having spent my career there, I will agree that there are individuals in academic orthopaedics who find a safe harbor from the rigors of private practice in the academic environment, but I can assure you that very few, if any, of those individuals are in leadership positions in academic orthopaedics or our Academy today. The typical academic orthopaedist today is faced with severe demands to be efficient and productive in the clinical environment. Most of our departments receive minuscule amounts of financial support from our parent institutions. Indeed, for the most part, academic orthopaedic departments are expected to contribute positively to the bottom line of the universities in this country. In order to be successful, academic leaders must be astute businessmen who can deal not only with the vagaries of the private practice of medicine but must do so within the convoluted bureaucracies of academic institutions, usually in a complex multispecialty group practice setting. It is from these ranks of academic orthopaedists that a substantial portion of the leadership of this organization is derived. I can assure the fellowship that these leaders are extremely savvy about the issues of workforce, healthcare reimbursement and other practice issues. Furthermore, overall, your Board of Directors is very representative of practicing orthopaedic surgeons. This past year, nine of the 16 members of the board characterized their activity primarily as the private practice of orthopaedic surgery.

The close relationship that has developed between the Academy leadership and the Board of Councilors has further enhanced a sensitive and clear understanding of the current circumstances of the practicing orthopaedic surgeon. Every fellow can rest assured that the decisions arrived at by the Board of Directors have not been and will not be made in a vacuum. But rather, they will occur through solicitation of grassroots input and consensus-building, leading to a unified decision that serves best the vast majority of the fellowship.

Unity is not only important within the Academy organizational structure. As we move forward to advance the care of our patients, we must do so with a united front across all of orthopaedics. Dr. Rockwood, in his landmark first vice presidential speech in 1984, urged us to "...keep the orthopaedic family together."4 As a consequence of that initiative, the Council of Musculoskeletal Specialty Societies was formed, and over the last decade we have seen substantial unification of purpose among the orthopaedic societies. Through the inspiration of Jim Strickland and under the guidance of Ken DeHaven and Doug Jackson, we have done much to build bridges within the orthopaedic community. Currently, our relationships with the American Orthopaedic Association, the regional orthopaedic societies, the Orthopaedic Research and Education Foundation, and the Orthopaedic Research Society are stronger than they have been in many years. We will continue to strengthen those bridges in very real ways over the next year.

In addition to organizational unification, I hope that during the coming year, we could place a higher priority on establishing and maintaining unified and collegial relationships with our fellow orthopaedists in our local communities. The pressures of the marketplace often strain collegial relationships within the local orthopaedic community. We must strive to overcome our urges to make the fellow down the street the target of our anger and concern as managed care encroaches upon our practices and our incomes. We must realize that our fellow orthopaedists are not the enemy. Indeed, in this fight to protect the quality of care given to our patients, he or she is our best ally.

I sometimes wonder if we could learn a lesson from our colleagues in the legal profession. After completing a rather contentious deposition for one of my patients, I am always amazed at the lawyers' behavior. During the deposition, they aggressively and sometimes malignantly attack each other, but as soon as the court reporter turns off the machine, the two are discussing where to go to lunch or play golf! Despite the competitive nature of their encounter, the two maintain a degree of professional respect toward one another. If even lawyers can do this, perhaps we can learn something from their example. Let's not make snide or demeaning comments about our orthopaedic colleagues in an off-handed way in public or in front of patients. Rather, let's use the proper forums of peer review and quality assurance within our local professional organizations to constructively criticize when we feel the best possible care has not been provided. Let's join together in our local communities to share continuing education experiences, treat our fellow orthopaedists with collegiality and respect, and focus together to counteract the egregious behavior of the industries and institutions which threaten the quality care given to all of our patients.

To summarize my emphasis upon unity, we must stand united within the Academy, among orthopaedic organizations and even in our own communities as we keep our eye on the sparrow, doing what is best for our patients.

Academy Activity

Now I would like to address some of the initiatives that will characterize the activity of your Academy during the coming year.

In this setting of dramatic changes in the practice of orthopaedic surgery, as I indicated above, the presidents who have preceded me have reached out to the other national orthopaedic organizations in positive ways. One of the important joint initiatives supported by the Academy, the American Orthopaedic Association, and many of our specialty societies over the last two years has been a study of the orthopaedic workforce which was conducted by the RAND Corporation and will be published in our official scientific journal, The Journal of Bone and Joint Surgery, this month. The issues of workforce will be of paramount concern during the next year.

In this country, there are almost 20,000 orthopaedic surgeons who are those physicians most expert at providing care for all aspects of the musculoskeletal system. With the advent of managed care, we are now hearing more and more that there are too many orthopaedists to provide care for the American population. Indeed, managed care models say that there are 50 percent too many orthopaedic surgeons, and the RAND study, which is based upon a demand model, says that there are 20 percent too many of us and that this oversupply could continue for at least the next 20 to 30 years.

Needless to say, these statistics are distressing and they represent the most common cause of concern raised by you, the fellowship. In particular, there is the abiding concern that this oversupply of orthopaedic surgeons will increase the competition for the existing orthopaedic patient population base. These concerns have had unfortunate consequences leading to an increase in competition and a decrease in collegiality, and even professional respect among fellow orthopaedic surgeons. We need to address this problem.

While the problem is real, some of the simple solutions that have been proposed will have little effect upon workforce numbers:

We have heard the question frequently: "Why doesn't the Academy cut the number of residency positions?" Because the members stand to benefit directly financially from any steps the Academy would take to influence the number of residency positions, this is not a practical solution for this Academy nor any similar association to take. The Academy can, however, provide useful information to decision-makers who can influence the number of residency positions. This spring, we will present a symposium at the American Orthopaedic Association meeting in which we will bring together the leadership from the Residency Review Committee for Orthopaedic Surgery, the American Board of Orthopaedic Surgery, the Academic Orthopaedic Society, and other interested groups to discuss in an open forum the issue of workforce and how the number of orthopaedic residents being trained in this country can be influenced without raising the concerns of the Federal Trade Commission.

Given these options, I do not think the answer to the workforce problem will be found acutely in truncating the amount of musculoskeletal care provided by orthopaedic surgeons. Rather than attacking the supply side of this equation, I suggest that a better approach can be made on the demand side. Why not grow the practice of orthopaedics, expand our horizons, take the expert education and training that we have been provided both through our residency programs and through the continuing education programs of our Academy and deliver it in a broader context, to more patients, in more venues.

The RAND study3 clearly shows that one key element in the workforce equation is the demand for orthopaedic services that are reasonably priced. Who is better educated and trained to provide musculoskeletal care than we? Why do we need to sit and whine about podiatry and chiropractic encroaching upon our practices? Why not turn the tables and aggressively pursue that part of the market by promoting ourselves to primary care providers and the public as the best providers of care in these arenas?

There are several ways in which we can accomplish this objective:

Whatever avenue we take, all of these efforts should be directed at expanding our scope of practice and enhancing our presence in the marketplace, always with the goal of providing the very best care to patients with musculoskeletal problems, any time, anywhere. It is in this way that we can take some very positive steps to address the workforce issues that will continue to face us over the next two decades.

I will task the Board of Directors this year with creating a menu of viable, reasonable, attractive, and patient-care-directed methods of expanding the scope of orthopaedic practice.

As we move into the era of biological solutions to biological problems, we will have an artificial meniscus, we will be able to reconstitute articular cartilage, and we will be able to further enhance the fracture repair process. But we will be able to do these things only if we continue to allocate a certain proportion of our time, energy and resources to both basic and applied research. Over this next year we are going to focus on methods to incubate and promote the development and clinical application of new orthopaedic surgical technologies that will make the practice of orthopaedics 25 years from now as different as the current practice of orthopaedics is from what it was 25 years ago.

The combination of all of these efforts should expand the scope of practice to such a degree that in 25 years, there will be a demand for more, not fewer orthopaedic surgeons.

Education

In this discussion of the directions for the coming year, I have addressed major health policy and research issues and left for last my most abiding and fervent interest in the Academy's role in orthopaedics, and that is education. Having spent my career as an educator, I want to reassure everyone that, despite the dramatic changes that are taking place in the healthcare arena, despite the apparently monumental restructuring of our organization itself, despite our apparently myopic focus on health policy issues, and despite the horrible distractions caused by our litigious environment, the major endeavors of your Academy over the next year will be focused on enhancing the already rich and robust educational offerings. This endeavor will take many forms.

The Council on Education is continually reassessing and reevaluating our educational programs. Through its initiative entitled CME-2001, the Council will incorporate the concept of value generation into each of its offerings. We receive feedback from our outcomes research initiatives that demonstrates the effectiveness or ineffectiveness of specific orthopaedic interventions for specific diseases. This information will be put directly into our continuing education programs so that the clinician will be able to identify those interventions that are of value to the patient and those that provide little or no enhancement of the patients' quality of life. In order to achieve this objective, we need to nurture and aggressively support the development of a musculoskeletal outcomes database. To this end, your Board of Directors at its December meeting recommended the creation of a separate not-for-profit corporation called the Musculoskeletal Education and Research Institute and committed $1 million of our reserves to fund its operation over the next two years. This organization will promulgate outcomes instruments, collate the information derived from those instruments, and provide useful feedback to the individual practitioner. It will be a broad-based organization comprised of individuals from within and without orthopaedic surgery. The Board of Directors has made a strong commitment to this initiative, hoping that within the next two years the outcomes database will be sufficiently large to provide useful information about many musculoskeletal conditions. To enhance its chances of success, I am calling upon the Council of Musculoskeletal Specialty Societies to become more actively involved in this process. Already a couple of our subspecialty societies have committed to use the outcomes instruments that have been developed through the MODEMS program, and I am going to ask the leadership of COMSS this year to encourage all of the specialty societies to become active participants in that program.

The second focus of our educational endeavors this year will be in surgical skills. Your Academy is committed to the enhancement of surgical skills for all orthopaedic surgeons. Despite the fact that, as I said earlier, there is much more to orthopaedics than surgical intervention, the thing that distinguishes us from all others is our surgical skills.

One practical program that we have initiated at this annual meeting is an effort to eliminate the rare but unfortunate occurrences of wrong-site surgery. Characterized by the theme, "Mark Your Site," this program if implemented and enforced in the surgical suite has been shown to virtually eliminate the chances of operating on the wrong limb or body part. I hope that you will take the information about this program home and start to use it right away.

With the Arthroscopy Association of North America, we presently have the most sophisticated state-of-the-art surgical skills education facility in the world in the Orthopaedic Learning Center at the Academy's headquarters in Chicago. This year will see a major advance in the long-term support and endowment of that facility to further enhance it with:

In addition, the Academy's support will provide a mechanism whereby the continuing escalating costs of surgical skills education for the fellowship will be held in check at least for the next five years so that the cost of learning does not exceed its value.

This financial commitment to surgical skills education is a landmark decision on the part of the Board of Directors. It endows what we as an organization are all about: enhancing the education of the orthopaedic surgeon.

This Annual Meeting remains the preeminent educational event in American medicine. Thanks to years and years of effort from the staff and volunteers, what you are experiencing today is a showpiece for continuing medical education. While some may call it a wild and crazy circus that tries to do too much for too many folks in too long a time, over a three-year period 80 percent of the fellowship attends this meeting. It is admired by many medical specialty societies who try to emulate our success. In these changing times however, it is necessary that we remain contemporary, and after a very critical self-appraisal that was conducted this past year, we are going to be adapting and modifying the Annual Meeting over the next two years to even better meet the educational needs of the fellowship.

Finally, in the educational arena, we look aggressively toward the future. There may be a time not too far off when surgical skills education and all that you can acquire at the Annual Meeting except perhaps sharing a meal with a colleague can be accomplished through virtual reality as you sit at your home computer. While I am not sure how Bill Gates could ever transport Bourbon Street to my office, we must be prepared to embrace effective new educational modalities as they come along. Thus, this next year we are going to continue to explore and experiment with new methods of continuing medical education such as teleconferencing, live surgical demonstration projects, and the more esoteric medium of virtual reality. Whatever seems to be a possibly effective means of delivering orthopaedic knowledge will be explored and tailored to the needs of the practicing orthopaedic surgeon.

This is a bold agenda for the coming year. It will be accomplished as we go through some structural changes which have become absolutely essential to protect the major educational and research missions of our Academy. Your Board of Directors will operate under the guidance of an overarching strategic plan which insures that the patient will remain the primary focus of all of our activity. I am deeply honored to serve as president of this fantastic organization and I simply ask as we go forward this year, "Let's keep our eye on the sparrow." Doing so we cannot go wrong.

Thank you very much.

References

  1. Campbell, W.: Presidential address to the American Academy of Orthopaedic Surgeons, 1934.
  2. Ellrodt, G.; Cook, D. J., Lee, J., Cho, M.; Hunt, D.; and Weingarten, S.: Evidence-based disease management. JAMA 278(20):1687-1692, 1997
  3. Lee, P.P.; Jackson, C.A.; and Relles, D.A.: Demand-based assessment of workforce requirements for orthopaedic services. J Bone Joint Surg 8OA(3):313-326.
  4. Rockwood, C.A. Jr.: Keep the family together. J Bone Joint Surg 66(5):800-805, 1984.
  5. Walsh, F.M.R.: Presidential address to the Canadian Medical Association, 1952.

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