Presidential Address| Volume 28, ISSUE 7, P993-997, July 2012

A Lady, an Explorer, and the Golden Orb

      Ladies and Gentlemen, Distinguished Guests, Friends.
      Before sharing some thoughts this morning about a Lady, an Explorer, and the Golden Orb, I would like to begin by expressing my gratitude. I thank God for his unmerited graces, one of which is the opportunity to participate as a member in our outstanding organization, The Arthroscopy Association of North America, for the past 25 years. My wonderful wife Marguerite deserves ebullient accolades for her undying support, but more importantly for me, her cherished love. As the demands on my time have increased, so too hers. Marguerite, you are an incredible lady—I simply could not have taken on the responsibilities of this position without you—my heartfelt appreciation! I also want to thank our three sons, Dom, Sam, and Ben, for their patience and understanding and for enriching our lives beyond measure. What more can a man ask for than a full quiver of fine, young sons? I am grateful for my parents, Louis and Francis—the opportunities I've had have been paid for by their sacrifices, too numerous to count, too heavy to weigh. Though my father passed away a year and a half ago and my mother was unable to attend for health reasons, I know they are both sitting in the front row this morning.
      I would like to commend the Executive Committee and the Board of Directors. They are bright, insightful, and totally committed to the success of AANA, and you and I as members are the beneficiaries of their efforts. Their deliberations were thorough, decisions prudent, and counsel wise.

      The Lady

      As is recently in vogue, the lady I'm speaking of is known by her first name only. She is vibrant, intelligent, industrious, multitalented, has great character, and is well-respected. I realize that those of you who know my wife probably assume that I'm speaking of her; I could be, but I'm not. There is no purpose served in being cryptic. I'm referring to your AANA, the Arthroscopy Association of North America! The purpose for our organization is to be relevant to the needs and goals of our membership in their quest to provide the best possible care for their patients. I would like to offer an abbreviated “State of the Association.” Time does not permit me to mention all of the achievements that you, our membership, have realized this past year.
      Under the direction of Education Chairman, Dr. Larry Field and his committee, spectacular meetings and programs have been crafted to address the expressed needs of our members. The Fall Meeting in Palm Desert met with rave reviews. During this past AAOS Specialty Day in San Francisco, AANA partnered with SOMOS (The Society of Military Orthopaedic Surgeons) and in the afternoon with ASES (American Shoulder and Elbow Society). AANA enjoyed the largest registration of all specialty societies for the day-long event. Those of you sitting in the audience today are part of a record-setting attendance for any AANA event.
      In the past year, we have seen the greatest single-year increase in our membership due to the enthusiastic efforts of the Membership Committee chaired by Dr. Bill Stetson. Many creative initiatives have been introduced to encourage individuals to join AANA. In the past 2 years, there has been a 63% increase in new members overall, and a 90% increase in new resident/fellow members. AANA's total membership now approaches 3,500.
      The Research Committee led by Dr. Jon Ticker has seen an explosion of applications for research grants. Both the quality and number of requests have increased substantially. In the past decade, an annual average of 26 applications has been submitted. In the past year, 41 applications were received. The quality of the proposals was so strong that additional funds for this year were made available by the Board of Directors. In addition, the Research Fund budget for this important and valid need has been increased for subsequent years. We must recognize the diligence and perseverance of past Research Committee chairwoman, Dr. Julie Dodds, in managing the Complications Project pioneered by Immediate Past President, Dr. Felix (Buddy) Savoie III.
      Building on the solid foundation established by past Fellowship Chairman, Dr. Pat St. Pierre, current chairman Dr. Mark Getelman and his committee have made great efforts to enrich the AANA Traveling Fellowship Program and, in doing so, have seen the applications nearly double from 8 to 15 for this fellowship class. A fourth fellowship position was added due to the demand and quality of the applicants. Past president Dr. Walter Shelton served as this year's Godfather. The Fellows Day Program during the annual meeting has grown to over 50 participants in each of the last several years.
      Essential to our educational initiatives is Continuing Medical Education accreditation. Due to the tireless work of Dr. Alan Barber, Education Overview Committee Chairman, Dr. Whit Ewing, Ed Goss, Holly Albert, and staff, AANA has earned reaccreditation for a period of 4 years. Dr. Barber has also overseen the development of a comprehensive Conflict of Interest policy that applies to all of our educational programming.
      One of AANA's major strengths is surgical skills training. Under the expert leadership of Chairman Dr. Alan Curtis, the Master's Series of Surgical Skills courses conducted at the Orthopaedic Learning Center continues to thrive. He has overseen an updating of the curriculum that incorporates new teaching methods to enrich the learning experience for the registrants. Three resident courses are offered each year with all participants receiving scholarships from the AANA Education Foundation to cover tuition.
      Due to the superb stewardship of Arthroscopy Journal Editor-in-Chief Dr. Gary Poehling, Assistant Editor-in-Chief Dr. Jim Lubowitz, Deputy Editor Dr. Matt Provencher, and Managing Editor Hank Hackett, the Journal enjoys its largest worldwide circulation to date. The work of the Associate Editors, Editorial Board, reviewers, and staff has significantly enhanced the quality of the Journal. The impact factor, a measure of how often articles in the Journal have recently been referenced, has leapt to 3.3. This rating has raised the Journal ranking from 16th to 3rd out of 61 periodicals with orthopaedic content. Article submissions could top 1,000 this coming year. The business affairs of the Journal have been managed admirably by Dr. Walter Shelton.
      The energy, enthusiasm, and productivity of your membership has led to such broad and far-reaching initiatives that the Association felt the need to publish our first Annual Report documenting AANA's stewardship of the resources entrusted to it. The generosity of the contributors to the AANA Education Foundation, including our vendor partners as well as individual member donors, has enabled our organization to launch innovative new programs that will help insure that the Arthroscopy Association remains the leader in arthroscopic education.
      Any healthy organization must be able to respond prudently and expeditiously to changing needs. Our primary need is to offer our membership the finest in arthroscopic surgery education and training. A realization has grown that, in order to accomplish that goal, we needed to draw on the collective experience of the world-wide medical community. As a result, AANA has welcomed and embraced requests to co-venture and co-brand courses internationally. As insights and new, effective techniques are gained, they are introduced into our AANA programming. Partnering with SLARD (The Society for Latin American Arthroscopy, Knee and Sports Medicine) and President Mauricio Gutierrez, M.D., to conduct a “North Meets South” one-day pre-course prior to this meeting is the most recent example. This stellar program, designed to share insights and preferred treatment strategies, was created by Dr. Larry Field and Dr. Guillermo Arce from Buenos Aires, Argentina, and recorded an attendance of over 400 surgeons.
      Changes in the health care policies in our country are occurring at a staggering pace. We need to take an active role in these discussions and remain informed. Among important current issues are Clinical Practice Guidelines, Appropriate Use Criteria, coding and reimbursement, and most importantly, patient access to care. Dr. Bill Beach and Dr. Louis McIntyre have done a phenomenal job of keeping AANA at the forefront of health policy and advocacy issues. In addition, due to their efforts, AANA will offer a new 2-year Health Policy Fellowship with the first fellow beginning at close of this meeting.
      In attempting to paint a characterization of an organization, an example of AANA's responsiveness to need will be helpful. Past President Dr. Rick Ryu was participating in a course with Commander Matt Provencher, M.D., and Colonel John Tokish, M.D., both Past Presidents of the Society of Military Orthopaedic Surgeons (SOMOS). Dr. Provencher described the challenges that military surgeons face with regard to the complexity of the injuries they see, and the limited opportunities they have for specialty training in surgery. In direct response to that need, the three of them orchestrated a special course at the Orthopaedic Learning Center solely for young military orthopaedic surgeons. This course was completely underwritten by our incredibly generous industry partners. In addition to telling you that the course was extremely successful, permit me read you an excerpt from a letter written by one of the Master Instructors to Dr. Ryu: Rick,I have had the great pleasure of doing quite a number of AANA Courses at the OCL—this course was different. These men and women were different. They behaved with true humility and integrity while showing the utmost respect for each other and the AANA members there to help. Their commitment to country and their desire to advance their skills, not so much for their own good but rather so they could serve those for whom they are responsible was transparent. It made dedicating a weekend to be with them seem very trivial. I have truly loved being an AANA member for many years and expect to enjoy our association for many years to come. That said, I have never been so proud to be associated with AANA and its membership.Robert E. Hunter, M.D.
      [Colonel John Tokish, M.D., was asked to stand as a representative of our servicemen and women and received an extremely enthusiastic and sustained applause from the audience!]

      An Explorer

      Ferdinand Magellan was born in Portugal in 1480. Following his parents' death when he was 10, he became a page at the Portuguese royal court. After many colorful expeditions and conquests, he fell out of favor with the Portuguese crown. Undaunted, Magellan convinced the Spanish King Charles V to support an exploration for a westward route to the Spice Islands. Magellan and his fleet of 5 ships west set sail in 1519. Despite an arduous journey, 3 ships circled the tip of South America and reached waters that Ferdinand named, “Mar Pacifico,” the Pacific Ocean because of the tranquility of its waters. In the Philippines, Magellan perished at the hands of the Lapu Lapu natives who refused to be converted to Christianity. Eventually, one ship, the Victoria, returned to Spain 3 years after departing. Magellan's expedition was thus the first to be credited with circumnavigation of the globe. I will return to Magellan in a moment.
      It is not infrequent to hear a speaker begin a presentation by stating, “There is a significant learning curve with this procedure, but the outcomes justify the effort to master the technique.” Figure 1 shows a graph of the learning curve for a particular procedure. We could say that the area under the curve is made up of patient morbidity, cost, suboptimal outcomes, and the like. Imagine the impact on those parameters if we could lower the learning curve by only 10% to 15%, as shown, by improving our training methods. The benefits would be extraordinary. Traditionally, we have looked at our educational programming and said, “What is working well, and what could we be doing better?” This has led to an incremental improvement in our educational initiatives. Two years ago, a group of thought leaders from AANA convened and asked a different question, “What if we went out into the entire world and searched across all businesses, industries, and disciplines that are involved in the education and training of highly-skilled professionals and asked what they are doing much better than we, that we could adapt for our purposes?” Thus, six subcommittees were formed including Didactic, Surgical Skills, Simulation, Electronics, Metrics, and Health Policy. It was the intent of these groups to “sail the world” if you will, looking not for trinkets but true treasures that would enrich our ability to educate and train those interested in mastering arthroscopic and minimally invasive surgical techniques. As Magellan was credited with being the first to “sail around the world,” these efforts became known as the Magellan Project.
      Figure thumbnail gr1
      Figure 1A significant improvement can be made to the learning curve using new methods of training.
      Although time doesn't permit a charting of the entire voyage, I'll share one specific example. Dr. Buddy and Amy Savoie's son, Chris is an aerospace engineer for NASA, and he was able to provide us with several contacts involved in training programs. We inquired, “How do you decide which of the astronauts to spend millions of dollars on to teach how to successfully dock the lunar landing module; they must not all have the same skills and ability?” They returned with an exhaustive document, “The Development and Implementation of an Extravehicular Activity Skills Program for Astronauts.” We were able to adapt their evaluation and scoring methodology to the performance of an arthroscopic suture anchor repair for anterior instability using a shoulder model.
      Numerous additional treasures were gained from the Magellan voyage. Adult learning theories emphasize the value of priming, targeting, and visual enhancement of cognitive retention. Employing these principles, major improvements to the Orthopaedic Learning Center curriculum were developed by Dr. Joe Tauro, Dr. Keith Nord, and Dr. Vic Goradia, under the direction of Dr. Alan Curtis. An array of over 30 on-line video learning modules has been painstakingly created for the shoulder. These videos are available to the registrants 6 weeks prior to a course to assist them in their preparation. Modules have also been created for the associate master instructors to help standardize the learning experience for those in the lab. Additional videos are planned for the knee, hip, and elbow.
      Educational psychologists have documented the superior learning experience for those who participate in small-group interactions in which “engagement, relevance, and problem-solving” concepts are incorporated into the learning sessions. Dr. Larry Field has brought these concepts to life at this Annual Meeting by creating “Roundtables” arranged around a specific topic. A small group of registrants (15 to 18) gather with 2 recognized authorities to discuss and digest real clinical cases; refining key historical clues, determining appropriate use of imaging modalities, and detailing specific surgical indications and techniques to optimize patient outcomes.
      The pace of development of new technologies is staggering and affords the opportunity to enhance the learning experience. The F.A.S.T. program (Fundamentals of Arthroscopic Surgery Training) is the brainchild of Dr. Robert Pedowitz. Rob and his task force are in the process of harnessing relatively inexpensive technology to create an affordable workstation that, along with a laptop computer and a $69 USB camera, promises to enable learners to repeatedly practice and master basic arthroscopic skills in the convenience of their own home.
      Lastly, a paradigm shift is occurring in the manner in which surgeons will be trained. For the past century, the “apprenticeship” method created by Dr. William Halsted has remained the model for surgeon education. An evolution in proficiency-based training strategies promises to enable the surgeon to acquire and demonstrate the mastery of progressively complex operative skills. By employing the concepts of objective standards (performance metrics), proximate feedback, and “deliberate” practice, skill acquisition will be more effective and efficient. The Copernicus Initiative is a study currently under way and is designed to document the superior results of proficiency-based training over the apprenticeship method. Nicolai Copernicus is credited with being most responsible for the paradigm shift from the belief that the earth was the center of the universe to the appreciation that the sun is the center. Thus, the study investigating the paradigm shift in surgical training is termed, the Copernicus Initiative.

      The Golden Orb

      AANA is a very unique organization that enjoys a culture noted for its collegiality, recognized for the engagement and contributions of its membership, and defined by its passion for the advancement of arthroscopic and minimally invasive surgical therapies. This culture is not an accident. We owe a debt of gratitude to our past leadership and members, for they chose to share, rather than protect their knowledge; to educate, rather than lecture; to advise, instead of direct; to contribute, rather than criticize; and most importantly, to provide opportunities, not obstacles for our young members. Our culture may be represented by a golden orb. The knowledge, wisdom, and experience it contains cannot be assertively tapped or taken, they can only be freely given. It is our responsibility to transfer this tradition to those who follow us in this society. We, you and I, have a problem though—the orb cannot be padded, packaged, crated, or shipped. It is too delicate! It must be hand-carried to the next generation of orthopaedic surgeons one selfless contribution at a time. How so, you say? From serving on committees to delivering didactic presentations, from participating as an associate master instructor at the OLC to reviewing for the Journal, from providing “Pearls” to submitting original scientific abstracts … the list is endless. Every one of our members has something valuable to share. Our legacy must be that we left an even stronger, more vibrant and healthy organization than we found. I am supremely confident that 10 to 15 years from now the history of this organization will reflect that you accepted the responsibility to transfer the orb with passion and determination, ensuring an even brighter and stronger future for those that follow.
      I'll share a few final thoughts in closing. A number of individuals have come up to me and stated with confidence that, “one of the best days of your life is the day you become immediate past president!” With one exception, nothing could be further from the truth for me. This has been the most enjoyable and rewarding year of my professional career. The opportunity to work with colleagues of great talent and a desire to genuinely contribute to the betterment of the organization has been truly inspiring. What more could one ask for than to roll up your sleeves daily with friends who want nothing more than to serve our organization well? I mentioned one exception—my stepping down means that Dr. Nick Sgaglione assumes the presidency of The Arthroscopy Association of North America. I could not be more excited for his tenure. He is a man of immense talent, great character, and is one of the most outstanding natural leaders I have ever met. Dr. Thomas Byrd will follow Nick and is a man wise beyond his years, respected throughout the world for his contributions to hip arthroscopy, and is the epitome of a “Southern Gentlemen.” This organization could not be in better hands.
      So, I am able to stand before you today and make three statements with great certainty. First, the Lady AANA is in robust and radiant health. Secondly, the trade winds are fair for the continued exploration for educational treasures. Finally, there is no finer group of individuals to transfer the golden orb of AANA's culture to the next generation of young orthopaedic surgeons than those of you sitting in this audience today!
      I offer my sincere thanks to you for the opportunity to serve as your president this past year.