Showing the Way

Abstract

Ladies and gentlemen, members, guests, family, and friends. First of all, thank you Jim, for that kind introduction. The theme of this morning’s presentation is “Showing the Way.” I would like to illustrate how AANA has shown the way, and then offer some of my personal insights into showing the way. I want to thank everyone who has helped me over the past year. This has been the highlight of my career, and a great way to paddle off into the sunset!Specifically, I would like to thank the staff of AANA: Whit and Ed, who gave me advice and direction during the year; Holly and Leah, for their meeting planning, and especially for pulling off the Whistler meeting; Donna, for her assistance with the committees; Pam, for her organization of the many courses at the Learning Center; Tiffany, for her outstanding job on the Web site; Beatrice and Marge, for their dedicated and loyal work over this past year; and the audio-visual group of Phil, Mark, and Julie have always made the task of electronic presentation easy.I also want to thank the staff of our journal, Arthroscopy—Gary Poehling, Charles Jenkins, and Debbie VanNoy for their continued success with the Journal, and to Gary for his many valuable croquet lessons.I especially want to thank my family for their encouragement and support. Carole, my wife of 40 years, my best friend and advisor, who has followed me on my many adventures. Our children, Mike and Jane, Chris and Maria with grandson Ryely, and Paul and Susan with granddaughter Sarah-Elizabeth. My brother David, and his wife Lorraine, thanks for coming today. And my many friends from around the world who have made this such a wonderful journey.Particularly I want to thank all the past leaders of AANA who were the visionaries in showing the way, and who have contributed to the success of AANA. There are 3 milestones that illustrate that ideal. First, their initial vision resulted in the formation of the Arthroscopy Association 25 years ago, then the establishment of the Learning Center in Chicago 10 years ago, and 5 years ago the initiation of the “Building on Excellence” program, that raised 5 million dollars to further support our educational endeavors. Our next challenge is to explore how technology can deliver our educational message. Leaders make things possible, but exceptional leaders make things inevitable. I think that everyone should be extremely proud of the accomplishments of this organization.Showing the wayI want to emphasize how AANA has been showing the way in arthroscopic education. To paraphrase the mission statement, AANA exists to promote, encourage, support, and foster the development of the knowledge of arthroscopic surgery.I would like to use the symbol of the Inukshuk, to compare it to AANA: Showing the Way. The Inukshuk shows the physical path and AANA shows the educational path.First of all, what is an Inukshuk? This is literally translated as “in the image of man.” They are beacons, somewhat like a lighthouse, that are erected in the Artic by the Inuit, not only to show the way, but as symbols of leadership and friendship. They act as a guide for a safe journey and they point the direction of the path across the frozen tundra. Each one is different and conveys a specific message. They could be at the location of a good fishing spot, a caribou pathway, or a food cache for travelers in need. They represent the cooperative effects of many to build this statue that will help guide others in the future.AANA is also unique in showing the way in providing education of arthroscopy. The association is built on the strong foundation of the dedicated office staff members who are the heart and soul of the organization. The Arthroscopy journal is our scientific journal to disseminate new information in our field. The Learning Center in Chicago, and the fall course are the basic building blocks for the hands-on teaching of arthroscopic procedures.The annual meeting is the core of our educational efforts. The committees are the essential components of the planning and development of new, and innovative programs. All of this activity is overseen by the board of directors, who will continue to make sound judgments on the future direction of our organization.The building of the statue is unique, in that each stone is dependent on another; if one is removed, the Inukshuk collapses. Thus the Inukshuk conveys the importance of the team, with each component relying on the other. The we is always stronger than the me!I feel that this ancient symbolism applies to the mission of AANA. We are all dedicated to providing the best possible arthroscopic education, but one person can only be successful if he is a part of the team. To attest to the success of the teaching mission, AANA has been granted by the ACCME 6 years of CME approval with a commendation for excellence. Thanks to all those who made that possible.Life is an orthopaedic odysseyNow I would like to make a few personal observations on ‘Showing the Way’ using some ancient Greek analogies. In Homer’s poem “The Odyssey,” Odysseus experienced numerous adventures on his way home from the Trojan wars. Most orthopaedic surgeons will never encounter a Hydra, and will have a more sedate journey as they travel through 3 major stages of their career. •The rookie years•The productive years•The mature yearsThe Rookie YearsThis is the time to find the path, to gain surgical experience, and find out what works best for you. Learn the secrets of success! They will be mentioned throughout this presentation, and when you hear them 3 times, you know they must be important.In these early years you leave behind the altruistic mindset of residency, and phase into the realism of practice. The rookies are also called Gen X and were born between 1961 and 1981. They are 30% of the workforce. They view medicine as a career, rather than a life. They are generally proactive to have a balanced life style; they recognize stress and usually control it. They are techno literate, and information savvy. They are flexible, independent, entrepreneurial, and self confident. They almost sound too good to be true!In AANA we are fortunate that 25% of our members are under 40 years of age. We are listening to this group. We have formed a young members’ development task force to gather information about how these young surgeons can be identified and encouraged to participate in our teaching programs. We are looking to them for our future leadership, and will help develop these leaders with mentorship. The education committee and the young members task force are working together to develop the mentor program.We will continue to be sensitive to gender equality. The young person must find a routine to keep up to date with medicine. AANA is there to provide the best CME opportunities, as well as providing a family of like-minded people. Going to an AANA meeting has always been very stimulating for me, and I come home with many new and interesting ideas. More often than not, it is “Why didn’t I think of that?”I would encourage young members to volunteer to teach courses at the Learning Center in Chicago. This is one of the best ways to keep up to date and to give back some of your recent experience. There are 3 resident courses held each year that are hands-on and labor-intensive courses, requiring more than the usual number of instructors. Your assistance at these courses would be greatly appreciated. During this time you will also have opportunity to try out new techniques and fixation devices for yourself.I also suggest that young members get involved with AANA committees, especially technology, and the Learning Center. By doing so, you can influence how AANA will provide education and CME in the future.Finally, develop a relationship with a mentor. Bob Jackson taught me arthroscopy in 1972. He later taught me the value of digital image documentation of the arthroscopic procedure.What Worked for Me in the Rookie Years?Becoming a team physician was a wonderful experience. This is one of the ways that you can begin to gain knowledge, and also give back in your rookie years. You spend many nonremunerative hours on the sidelines and traveling. You really have to enjoy the involvement with the athletes to do this. I loved jogging around Europe with all the famous athletes. It also puts your clinical judgment and your surgery on display. My career started at the university, and I went on to become an Olympic team physician, and eventually a professional team doctor for hockey and football. Sometimes being a team physician had its downside, like the time that I had to run onto the ice to attend to a player, and forgot that I was wearing cowboy boots.In order to set the stage for the rest of your life, the balance of family, work, and play is extremely important in these early years. This is a time when more weight of the balance has to go the family. It has always been difficult for me, as I tend to be slightly excessive in everything that I do. In fact, I was sometimes referred to as “Doc Holiday” due to the extensive team travel.Why Arthroscopy and Sports Medicine?Originally I wanted to be a trauma surgeon. I know that some of you who know me now would find that hard to believe. Sports medicine was not a recognized subspecialty at that time. I was introduced to sports medicine by providing care for the university hockey and football teams. Early on, this was a part-time hobby. I never really felt that it would amount to much, especially when doing joint replacement was so much fun!Arthroscopy during this period evolved from the fringes of medicine, that is, the jock doc looking through a keyhole, to an accepted and widely practiced specialty. This may have been largely patient driven, and the Arthroscopy Association responded to provide the much needed education. Most of all for me it was the realization that the arthroscopist pushed the envelope. But, to be practical, there was an opportunity open in Ottawa.Sports Medicine allowed me to combine my vocation and avocation. The avocation consisted of the challenge of outdoor adventure, mountain climbing, x-c ski racing in the winter, and triathlons and marathons in the summer. It gets your teenagers’ attention to hang them off the end of a rope on a glacier! The ultimate experience was being the team doctor on a trek to the north face of Everest.Arthroscopy the VocationThink about the progress that has been made over the past 25 years and consider how you can continue this evolution. Recall that Dick Caspari developed an arthroscopically assisted unicompartmental knee arthroplasty more than 10 years ago. At that time, industry didn’t think that it had much potential, and now minimally invasive arthroplasty is all the rage. The message is, don’t give up on that outrageous idea that you have been thinking about.To me, one of the appealing aspects of the arthroscopist was that he was always pushing the envelope; from the traditional open procedure to mini-open, and eventually to the all-arthroscopic. They embraced technology; the first to use a television camera on the scope, and the first to record still images, and the first to record digital video. Digital documentation and archiving quickly followed. As always, they were improving the instrumentation.Burkhart said that one of the major attractions for him was that he recognized that arthroscopists were a major group of cowboys. And cowboys were his heroes. This is not the cowboy of reckless abandon, but is the one known for hard work, independence, and tenacity. Let us not lose sight of this theme.It is interesting that these qualities are similar to what I have seen in the Inuit who create the Inukshuks. There is no question that, in my experience, I felt more at home with the family of AANA, which was innovative, provocative, and always expanding the limits of arthroscopy. Now, we can even scope the tendon sheaths around the ankle!Early arthroscopy involved putting your eye on the scope and no one else in the room knew what you were doing. The articulated teaching arm allowed the fellow to actually see what was going on. Now that was a real teaching experience!Bob Jackson was taking 35-mm slide photos with the arthroscope and made early attempts at videotaping the operation. Bob scoped my knee in 1979 for a torn PCL. He even took pictures through the posteromedial portal, which was quite an advanced technique at the time. But even the master has his moments—the camera didn’t have any film in it. The progress was amazing; the open procedures quickly gave way to keyhole surgery. The large extra-articular ACL reconstruction of Macintosh evolved to the 2-cm hamstring harvest for ACL reconstruction.The Old and the NewI don’t perform any of the procedures that I was taught as a resident. Yes, granted, I was a resident in the days of black and white TV! In addition, I regard most of them as barbaric. Just imagine what the future surgeon will think about us ripping out the patellar tendon just to reconstruct your ACL. The posterolateral corner is the last of the big open operations. The message for the young surgeons is to think of this as an arthroscopic procedure. Could this be done as a popliteus tenodesis, posterolateral capsular plication, and LCL subcutaneous reconstruction with an allograft?Thanks to Bob Jackson and others, arthroscopy has evolved from the days of skepticism and ridicule—I was told by one of my senior surgeons when I was struggling to do an arthroscopy, “Why don’t you just open that knee like a man?”Arthroscopy became 1 of the 3 important advances this past century: Arthroscopic surgery, joint arthroplasty, and open reduction and internal fixation.Success is not a one-time destination, but a life-long journey. What makes someone successful? A sports psychologist, and friend of mine in Ottawa, Dr. Terry Orlick, studied Canadian Olympic athletes, and found there were a number of basic values that correlated with their athletic success. He published this as the “Theory of Human Excellence”.1Mental readiness in surgeons and its link to performance excellence in surgery.J Pediatr Orthop. 1995; 15: 691Crossref PubMed Scopus (59) Google Scholar We felt that many of these attributes were also present in the successful orthopaedic surgeon. The same survey that was used on the Olympic athletes was applied to 33 surgeons in Ottawa. In the interview, the OR was substituted for the playing field.The 2 core principles of success are commitment and belief: •Commitment means a dedicated lifestyle, having high standards, feeling responsible for your actions, and having compassion.•Belief means self confidence with control of the environment, mentor support, and religious or spiritual belief. There are important secondary traits: •Full focus means total concentration, with anticipation of the next step, and a rhythm to make surgery look effortless.•Positive imaging means closing your eyes and visualizing the perfect notchplasty, and maybe even the perfect subacromial decompression!•Mental readiness is psyching yourself, positive thinking, and putting the imagery to use.•Distraction control means to shut out the distractions, and control the inattention to detail.•Constructive evaluation is reviewing the videos of your surgical procedure to try and improve your technique.The superstars, or the high-performance surgeons, were all experienced, with a high level of refinement in all 7 elements of success. Their expertise was unmistakable and their dedication very powerful. They had a high level of commitment and, usually, spiritual or religious beliefs. They were bored with the routine or delays in surgery, but they realized the potential to become inattentive to details and took focus very seriously.In summary, the authors recommended mental training for surgery, as this has proven to be successful in sports performance. Role modeling is an effective way to teach the elements of success.The Productive Years: Work, Work, WorkThis is the time when you are the busiest with your practice. During this hectic time, you should focus on finding your niche, what is it that you do best? Saint Francis of Assisi said, “Do only a few things, but do them well.” I decided that I don’t do hardware removal. You can never look good. If it comes out easily, it is expected. If you spend an hour digging out a screw, you get the look from the nurse!Maintain a passion for what you do, and keep a positive attitude. Danforth said “Catch a passion for helping others and a richer life will come back to you.”Listen, listen, listen. In an Academy instructional course, it was stated that the average time that an orthopaedic surgeon interrupted his patient’s dialogue was after 14 seconds. No wonder, when our interview process is something like this, “Does your knee catch, lock, and give way? How long has it been locked?” This is often followed by “When did you eat last?” Read to be well rounded, go to meetings to be prepared, and write to become exact.The Arthroscopy JournalVolunteer to review for Arthroscopy, our premiere scientific journal. This process helps with your critical evaluation of the literature, and it improves your own writing.Develop an Outside InterestFor me, photography worked. Learn to balance work, family, and recreation. In these busy years, more time will have to be spent in practice. By this time, your children will have become more independent, and regular vacation time will continue the connection with them. Learn to accept the continuing changes in medicine. Don’t be the first, but don’t be the last to accept a new idea or technique.Maintain a high energy level with regular physical fitness. Be a good role model for your patients. Exercise calms the soul. The endorphins stimulate the creative mental juices, which allow you to solve that difficult problem that was troubling you. Maintain your focus to eliminate the many potential bad choices that will present themselves to you, and stay the path.Giving BackA physician should continually consider how he can give back. To be a physician is a very satisfying and privileged position in the community. We all went into medicine for a variety of altruistic reasons, but sometimes we have become jaded by the realities of practice. Emerson said that “No man can sincerely try to help another, without helping himself.” Giving back can help revitalize the passion, and can be done in many ways. By doing clinical research and reviewing the results of your surgery you improve the quality of care for your patients. You can give back by working with professional organizations such as AANA. You can perform community work to broaden your outside interests. If really disenchanted, volunteer for overseas professional work.Reach Out and Teach SomeoneMedicine has evolved from a paternalistic art to evidence-based medicine. The randomized clinical trial has become the standard to accept new techniques and treatment. This is not the perfect method as bias can still be introduced into the trials; however, it is great improvement over the retrospective review of cases that we did in the past.TeachingWe can give back during the middle years by teaching. It is through teaching that we ourselves learn. You don’t have to be associated with a university to teach with AANA, just committed. This is a particularly good time to teach practice management to younger members. I hope that teaching has evolved from the antiquated style to a more modern mentorship. Teaching is now a kinder gentler experience, for both the student and for the teacher. For through teaching you learn.Why Teach? To Show the WayOne of the most gratifying things that you can do is to lead someone through the process of an arthroscopic procedure, and then watch them eventually become proficient on their own. There is enormous satisfaction in watching the fellows develop their skills. And sometimes enormous frustration! This is similar to watching the development of your own children. Teaching helps to keep you up-to-date and stimulated by young people, who will question your treatment protocols. Most of all, you make and continue wonderful life-long friendships with your fellows. The fellows will eventually surpass the teacher, and they will become the future.Acceptance of New TechnologyWhere do you fall on the bell curve of acceptance of new technology? Are you an early adapter or a late laggard? The early adapter has the risk of doing a procedure before the results are well known. Don’t be the first to try something new, as I did with Gore-Tex synthetic ligaments. Those early results looked very promising. I was even subsequently seduced by a French synthetic ligament that turned out to have similar results.Thermal capsular shrinking is another example that comes to mind. This was one procedure that was accepted very quickly, and perhaps disappeared a little too quickly. Early results often look good, but nothing spoils good results like follow-up. But, don’t be the laggard on the other end of the bell curve who is the last one on the bandwagon, and even resists using PowerPoint or e-mail. Being a late adapter is not in the best interest of your patients. You must find your comfort level of acceptance of new technology.Autogenous chondrocyte implantation is, I believe, a procedure for which it has been good to wait for further developments. Now, instead of an open arthrotomy and eversion of the patella, we can arthroscopically patch the defect with the MACI and Hylagraft membranes. Now this is getting my attention. This is similar to the progress from open meniscectomy to the arthroscopic meniscal repair.The current accepted teaching methods are textbooks, CDs, and DVDs, didactic presentations with embedded video clips of surgical techniques, live surgical presentations, hands on plastic models, hands on cadaver labs. But most important—practice makes perfect.Jim Esch has emphasized that, after golf the golf pro practices golf… But, after surgery the surgeon practices golf. So the story goes that a young man was walking down the streets of New York and stopped to ask directions. “How do I get to Carnegie Hall?” A woman replied, “Practice practice, practice.”Our challenge for the future is to find new and innovative ways to train a technically excellent surgeon. This may be through online education, remote transmission of surgery, or computer simulators. I will leave this decision to the younger surgeons.But, no longer do you have to see one, do one, then teach one. There is a natural progression from learning the steps on the plastic model, to perfecting the steps on a cadaver, and finally performing the operation in the OR. The Learning Center in Chicago has taught many people to convert from the open meniscectomy to the arthroscopic meniscectomy, and now to perform meniscal repair. It is the only place where you can learn to do a meniscal repair, and compare the various fixation devices from all the companies, and then select the one that works best for you.AANA has been a leader in our relations with industry, probably in part due to our mutual respect. We all have enjoyed, and benefited, from our partnerships with industry. In fact, AANA meetings are critically dependent on industry support. But this has been a contentious issue over the past few years. The Academy has ethical guidelines on their Web site to assist you in your relationships with industry. AdvaMed has similar guidelines for industry dealing with physicians. Arthroscopic surgeons have by and large followed these rules and have avoided the current problems plaguing the arthroplasty and spine surgeons.What Were Some of the Predictions?“Predictions are tricky, especially for the future.”Dan QuayleWe are all familiar with the predictions of who needs more than 64K of computer memory, and who would want a computer in the home. No one will walk on the moon.In our field, Jack Kennedy often said that torn ACL was the end of your athletic career. (For some it still is.) No one will do an arthroscopic meniscectomy, or an arthroscopic rotator cuff repair. And so on… .What predictions can I make? •Biology will surpass biomechanics in orthopaedics in the near future. The ACL of the future will be off the shelf, made of synthetic collagen, and embedded with growth factors, and maybe even the patient’s own fibroblasts.•A meniscectomy will be followed by the implantation of a synthetic meniscal implant to restore the volume of the meniscus and, hopefully, its normal function.•Complex procedures will be done with computer assistance and image guidance.•Teaching will be done on a realistic plastic model with computer documentation of the accuracy of the learning process.The only downside of all this wonderful new technology is that, here in Canada, we won’t be able to afford it!The Inukshuk—Now we come to the sunset years, orThe Mature Reflective YearsThis is the best period to share your time and experience. Giving back should be a high priority at this stage of your career. This is also the period with the highest physician burn out. Why the dissatisfaction with medicine? Is it because of decreasing reimbursement, increasing bureaucracy, and the resulting frustration with the daily practice of medicine?What makes one person disenchanted, and another still enjoying what he does? I don’t know the answer to that. It may be that, like an athlete, you only have so many years that you can be on your game. I can, however, tell you what worked for me. I think that the most important message is to have a life!! In a society that judges us by what we do and what we have, it is important to realize that happiness is not in things, it is in us.This is also a time to cut back on your clinical work so that you have time to reflect, review, and do something creative. Take time out to recharge your batteries. This can be a stressful time for older physicians, and some thought may have to given to changing your practice situation. Volunteer for Orthopaedic Overseas, Médecins Sans Frontières, do a locum up north. Develop the hobby, and nurture and cultivate the outside interest. Help develop new arthroscopy products. Communicate and disseminate arthroscopic information through traditional publishing, the Internet, and by presenting the results of your techniques.Patient CareMedicine has been good to us. One of the most rewarding things that you can do is to perform a procedure, improve the patient’s function, and then have him thank you after he has returned to sports. What could be more gratifying?We should strive to provide excellent patient care. Dedicate yourself to lifelong learning in order to provide state-of-the art care. This means keeping up-to-date, and reviewing your clinical results.Keeping Up-to-DateA recent study in the Annals of Internal Medicine, February 2005, showed that older physicians are not keeping up to date. Almost three quarters of the studies reviewed showed that the average physician’s performance declined over time. There is definite evidence that the number of years in practice is inversely proportional to quality of care provided. You can reverse this trend by going to regular AANA CME meetings and courses.The EpiphanyA sabbatical in 1995 allowed me time to refocus, a time to recharge the batteries, a time to smell the roses, a time to develop an outside interest in computers and photography, a time to confront my vulnerability, and a time to find that there was life after orthopaedics. During this period, I attacked the computer just like everything else in life, with full fury. Nothing is ever done in moderation. The “command center” used to be part of my wife’s kitchen. And I have a swivel chair so I can turn around and communicate, “yes dear.”But in the end, I did learn how to communicate, publish, present, and keep databases. I became interested in the digital documentation of arthroscopy images, as well as the use of databases to document the arthroscopic procedures.And this was at a time when most orthopaedic surgeons didn’t know what a Palm Pilot was. Older orthopaedic surgeons may not be particularly facile with a keyboard, and thus not well suited to the computer. Remember, the computer is just a tool, not a religion.Get involved with AANA. Once again to paraphrase, ask not what your association can do for you, but what you can do for your association. This is great family of like-minded individuals who will continue to stimulate and inspire you. “This is our thing.” Just like another family, “it is a respect thing,” once you become part of the family, you won’t want to leave!AANA is on the leading edge of teaching arthroscopy with the fall course, the Learning Center courses, the resident courses, and the scientific spring meeting. There is a strong committee structure to bring innovative ideas to the board to implement. There is an emphasis on talent, not status. Young members are encouraged and will be mentored.Aana showing the wayRemember the AANA/Inukshuk symbolism to show the way. AANA is a family of like-minded people who will encourage and motive you in your educational pursuits.In conclusion, learn how to enjoy the sunsets… There are only so many left. There are some folks out there trying to make 60 years of age look bad, so here is some of my sage advice to those of you in the sunset years: Take care of yourself, exercise regularly. Eat in moderation. No white at night! Make friends inside and outside of medicine. Have a buddy; remember that wives can fill that role! Give back to medicine; it has been good to you.Learn how to say NO. Remember the rule that says that when you are over 50 years of age you don’t have to do anything that you don’t want to do. Have fun, smell the roses. Savor the Kodak moment; that is, those moments when you were happy, creative, and having fun. The key to happiness lies within us, not in our possessions. Electron