April 2003 Bulletin

Looking Ahead:Volunteerism and the future of AAOS

Moving into 2003, the Academy is working harder than ever to better understand members’ needs in the areas of education and advocacy and to meet those needs with new programs and initiatives. Of equal importance is our ability to understand the future of volunteerism in organizations such as ours. It is clear that these two issues are critical to the long-term vitality of the AAOS.

Last December, the Board of Directors conducted a one-day workshop on the future of voluntary membership and volunteerism in organizations like the AAOS. The Board used this opportunity to focus on two key questions. Who is the AAOS member of the future? And, who are the AAOS volunteers of the future? What are their needs and how can the AAOS continue to have volunteers contribute their time to the organization? Not only do we need to continue to engage our membership in volunteer opportunities that sustain the organization, but also we must be recruiting new members who value membership and participation in organizations such as ours.

The Board’s interest in volunteerism and membership was stimulated by concerns coming out of the "AAOS in 2005" planning initiative. Specifically, volunteer time will be less in 2005 and continue to erode as members become less willing to commit to participate in the many volunteer leadership and educational roles that make the Academy strong.

These concerns were amplified by findings from the AAOS Membership Segmentation Study that focused on member voting practices and perceptions. It was found that while membership has increased, the percentage of members who vote for the Nominating Committee has declined from 40 percent to 28 percent over the past nine years. Focus groups conducted at the 2002 Annual Meeting revealed that those who vote do so because they believe they have a duty to be involved. Non-voters reported that they have no time, were confused by the process and not familiar with the candidates. Those who did vote tended to be older. The study concluded that member voting would be increased by a more balanced, diverse slate of candidates enhanced packaging of candidates, and a call to immediate action.

First to address Workshop participants was Tom Sander, Executive Director of the Saguaro Seminar at Harvard University, the group that conducted research for the book Bowling Alone in America. The focus of Mr. Sander’s remarks was social capital and the AAOS. In this case, social capital refers to the very real benefits that flow from membership in a group like the AAOS; benefits to our members and our profession. Examples of these benefits include access to information, ability to facilitate collective action and links to people with similar professional interests. These benefits need to be understood and accessible to members if they are to realize the full potential of belonging to the Academy. Volunteers in particular need to understand the value of participating not only for the good of the organization, but also for themselves personally.

The Academy needs to ensure that it is offering members and volunteers opportunities for increasing this social capital by capitalizing on those ways that members can work together to create value in the AAOS as a social network. By doing so, the AAOS will be better able to attract new members and to recruit existing members to volunteer roles within the organization. Dr. Sander left the group with several questions for further discussion:

Although the benefits of belonging to the AAOS may be clear to many of us, we need to do a better job of re-examining the value of the Academy in changing times, making adjustments in our programs and benefits and communicating them to our members and prospective members. As leaders, we must also be looking for new ways to engage members in volunteer roles and promote their long-term commitment to participation in the AAOS.

The second Workshop speaker was Robert Olsen, Research Director for the Institute for Alternative Futures, based in Alexandria, Va. Mr. Olsen outlined a series of strategic issues or conversations that the AAOS should have to prepare for the future. These themes ranged from the need to create meaningful relationships and social purpose within our organization, to the need to tolerate and encourage greater member independence and individual responsibility. He explained that organizations of the future must move toward greater organizational openness and accessibility and create a culture of continual member learning.

As we have discussed in the past, Dr. Olsen re-emphasized that professional associations like the AAOS will need to accommodate the needs and interests of five distinct generational groupings in order to create "generational synergy" across our membership. These groupings range from the "greatest generation" that fought in World War II to the Baby Boomers to the Millennial Generation, born after 1982. Because the Academy membership will always span these generational groupings, we need to determine the best ways for capitalizing on the strengths and talents of each generation in planning for the Academy of the future.

At the conclusion of the Workshop, the Board developed a set of recommendations aimed at ensuring continued volunteerism and membership in the AAOS and a tentative action plan for moving forward. These included the following:

Be a welcoming organization.

Personally, I would like to ensure that our leaders, especially the Presidential Line and the BOD, have a "recognizable face" to our members. Toward this goal, the Presidential Line will speak to three members each month on one of its conference calls to learn about their interests and views. I have asked that the Presidential Line and the Executive Vice President attend as many regional and state society meetings as possible. Additionally, Stuart Hirsch, MD, Chair of the Council of Communications, has accepted the challenge of implementing the above workshop recommendations.

Please contact me directly with your thoughts about this initiative, particularly if you have new ideas for communicating with and engaging our members. I would also like to hear from those of you who would like to be involved in implementing these recommendations.

Professional liability crisis

There is no doubt we are in the midst of a severe professional liability crisis. Please read the article on our new liability reform initiative on page 34 in this issue of the Bulletin. Orthopaedists in at least 16 states are facing unacceptable increases in their premiums or at worst having difficulty in even obtaining malpractice insurance. Efforts are ongoing in these states to support legislation that approaches or equals what physicians in California have with MICRA. These actions are vital for all of us so we can provide care to our patients, even those with high-risk medical conditions. (See Progress made on tort reform initiatives.)

Patient access to care is difficult if not impossible in some regions. Our liability system is dysfunctional and eventually needs to be totally re-engineered. Models of self-insurance by patients, insurance programs similar to auto insurance required of owners of motor vehicles or that of Workers’ Compensation have all been proposed. In my opinion this change where "blame" is removed is vital for true reform. It won’t occur until the incentives in our current system are changed.

The change that is needed is best accomplished at the Federal level. Currently President Bush, the House of Representatives (passage of HR 5) and, to some extent, the public support professional liability reforms at the Federal level. The efforts are all directed toward a MICRA-type program. Even though MICRA-type legislation doesn’t go far enough in my opinion, it is essential now. We must continue to work on changing the culture of professional liability, but it will be a long haul. We should keep such major long-term change in our sights.

By now each of you has received a letter from the Presidential Line and Executive Vice President asking for a $1,000 donation to establish the financial base needed to fight for reform. The BOD has approved placement of $1,000,000 of the AAOS endowment in a restricted fund specifically for liability reform. We should support these efforts and support the American Association of Orthopaedic Surgeons’ efforts to raise enough money from its members to make a difference in the political process.

Patient safety tip

A recent article appeared in the New England Journal of Medicine entitled "Risk Factors for Retained Instruments and Sponges After Surgery, by Atul Gawande, MD, and others. The authors reviewed the medical records associated with all claims of incident reports of a retained surgical sponge or instrument filed between 1985 and 2001 with a large malpractice insurer in Massachusetts. They reported 54 patients with 61 retained foreign bodies (31 percent instruments and 69 percent sponges). Sixty-nine percent of patients required another operation and 77 percent resulted in litigation.

I calculated the incidence of retained instruments and sponges for all cases done in the United States each year using the incidence from this study. It turns out that approximately 1,500 cases in 28.4 million surgeries done annually would have a retained instrument or sponge. The percent is 0.05 or a level of excellence of 6 SIGMA; something we should achieve with all of healthcare. In other words, if Dr. Gawande’s data can be expanded to include all operations done in the Unites States, surgeons are performing at a very high level of excellence.

However, no one wants to leave a sponge or instrument in a patient just as we don’t want to operate on the wrong site. Both errors are very uncommon, but find their way to the front page of the local press when they occur.

Dr. Gawande and his co-authors made three observations of increased risk of retention of a foreign body:

They made the following recommendations: insure an accurate sponge count at each operation and an instrument count in larger cases, especially with an open cavity. For the above selected high-risk situations consider an X-ray at the end of the case to avoid that rare foreign body inadvertently left behind.

Each of us can "turn the wrench" one more time by such action.

James H. Herndon, MD, MBA

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