Advertisement

Legacies

      A couple of months ago, Holly contacted me and said, ‘I need the title of your presidential address.’ I thought ‘a WHAT?’ I thought it was just called the Presidential Address. I hadn't begun to figure out what I was going to speak about, much less give it a title.
      While I've kicked around several, I may have to let you decide. ‘It's my job’ is a term occasionally heard around our office. It's usually heard from me as I'm exiting a patient's room. Every now and then, we will have a patient who's actually happy and expresses appreciation for the care they received and how they are feeling. My mother taught me a long time ago to never turn down a compliment. It is probably a supreme insult. But mostly, I just say, ‘that's my job. That's what we're here for.’
      About two months ago, we were sitting at home watching ESPN and John Gruden was talking about Gruden's Grinders, and my daughter, Ellen, asked ‘what's a grinder?’ Well, grinders, by definition, are individuals who succeed through hard work and determination rather than exceptional skill. Well, if I've accomplished anything, it certainly wasn't through exceptional skill. Through AANA, I have been around some remarkably talented people, and I can at least tell the difference. But hard work and determination can help you to accomplish a lot.
      Legacies are as much about those that got you to where you are as they are about what you leave behind. So which of these is this next 30 minutes all about? I guess I'll have to let you decide.
      On that note, I do hope you are enjoying this 33rd Annual Meeting of the Arthroscopy Association of North America here in beautiful South Florida. For many of you, I suspect it is a long needed respite from the harsh winter that is just behind us.
      We are being treated to a magnificent program thanks to the guidance of our program chair, CDR Matt Provencher, and the hard work of his entire committee. He has been ably assisted by Ben Shaffer, chair of the Education Committee, and his entire team as well. And, of course, we can't forget the entire AANA staff, which is definitely the glue that holds this whole thing together.
      We enjoy and benefit from the presence of all of our international colleagues, and this year are especially pleased to have Italy as a guest nation. Our international guests and Italian faculty certainly enliven the entire meeting, but perhaps more importantly you help to make this one of the strongest educational programs, ever. There is so much happening in Europe and other parts of the world that are sometimes slower to make their way to U.S. soil. These few days in May offer an excellent opportunity to escalate some of this knowledge exchange. On a personal note, we have certainly enjoyed Raul Zini's visits to Nashville.
      Just to provide you with a quick health report on AANA, the organization is strong and healthy. Membership continues to grow. By next year, we will likely broach the 4,000 mark; AANA is the largest of all the orthopaedic subspecialty societies. Of course, this is good news, but why is it important? Well, nearly 1,000 orthopaedic surgeons are in attendance at this meeting where the latest scientific data is being disseminated, arming surgeons with the most current knowledge in a world of increasingly evidence-based medicine. An equal number attended Specialty Day and nearly 500 surgeons attended the 32nd Annual Fall Course last November in Las Vegas, learning the most up-to-date techniques for arthroscopy of the knee, shoulder, wrist, elbow, ankle, and even the hip; 350 attended the Metcalf/AANA Winter Course in Snowbird this past January, and 2013 saw an all-time high attendance of 740 among the 14 weekend-long AANA Masters Experience Courses at the Learning Center in Chicago.
      Our membership is the engine that powers AANA. From within our ranks come the talent pool and resources that allow us to accomplish everything that we do. However, AANA is about much more than just education. Perhaps you have noticed that health care reform is in our midst. Although this may be needed, some is good and some is not.
      In a country that is blessed with all of the latest science and the most current technology imaginable with which to provide patient care, AANA has been very busy on two fronts.
      First, AANA has served as an advocate preserving patients' rights to access for appropriate medical and surgical care. Often we serve as a voice for those who otherwise have none. Most recently this came to light in Oregon where it was determined that government employees, Medicaid recipients, and those entrusted to the state's penal system should not be allowed treatment for femoroacetabular impingement. Through the collaborative work of AANA and others, this decision was reversed. You may ask, ‘why should AANA be involved in health care policy?’ I would ask, ‘if not us, then who?’ And the problem is just beginning, which brings us to a second important area of AANA activity.
      In this world of evidence-based medicine, we need to make sure that we keep our heads about us when it comes to the practical aspects of simply taking care of folks. We cannot ignore science for instinct, but we have to keep a balanced perspective on interpreting the science that is often before us. Not everything we do is based on Level I evidence, and sometimes the best treatment does not necessarily mean that you have the best science. AANA has been working feverishly to make sure that a sense of perspective is maintained in a world increasingly drawn to the highest levels of evidence. There are more than a few examples where science has been misused to draw convenient conclusions, solely for the purpose of reducing health care costs. Reducing health care costs is admirable and important, but not at the deliberate detriment of those for whom these institutions are responsible. Sometimes, even with the best of intentions, some organizations have leaned too heavily on levels of evidence as a sole decision maker in providing proper care. Again, AANA has fought, and sometimes successfully, to maintain balance and practical application in how best to treat patients, sometimes at direct odds with organizations with whom we otherwise collaborate.
      It takes the energy and talent pool of the AANA membership to make these things happen. The battle has just begun.
      If the membership is the engine that drives AANA, then our industry relationships are the fuel that powers the engine. We strive to continually provide the latest state-of-the-art methods of surgeon education. In fact, AANA has been the long-proven leader in surgical skills training. Naturally, as an educational organization, it is a given that all of this is carried out in an unbiased, CME-friendly environment. Still, these take resources far beyond our membership and registration fees alone. Additionally, our other advocacy roles, looking after the rights of those patients for whom we receive the honor to serve, consume lots of resources. Little of this would be possible without the generous support of our industry partners. Industry understands the importance of surgeon education and patient advocacy. And, yes, they are also motivated to make a profit. To express anything different would be silly in a democratic, free enterprise system. Thus, transparency and a system of checks and balances are essential to a healthy relationship, but one that has and can successfully exist toward our collective end purpose of bettering patient care.
      There are many meaningful and exciting things happening within AANA. In the interest of time, I will limit my comments to only as they relate to the current Presidential line.
      Rick Angelo's Magellan Project, which began long before his presidency, has now been distilled down to the Copernicus Project, which will revolutionize surgical skills training for years to come.
      It was remarkable to watch Nick Sgaglione last year as President, as he deftly handled numerous challenges that would suddenly arise. For Nick who, as we know, has been no stranger to adversity, it was definitely the right man at the right time. Now Nick serves as our principal liaison with AAOS in the construction of the new headquarters in Rosemont. We are very excited about this new facility that will house the new state-of-the-art Orthopaedic Learning Center. Nick also serves as the AANA representative for the newly formed triumvirate with AAOS and AOSSM overseeing the Learning Center.
      I know that all of AANA takes comfort in knowing that Bill Beach is poised to take over the helm as President in just a couple of hours. Bill has redefined the meaning of health policy and everyone here owes part of their livelihood to Bill and now Lou McIntyre's ongoing efforts before the AMA's RUC Committee.
      Second Vice President is normally a pretty cushy job, but Jeff Abrams has taken on several immense responsibilities for AANA. He is actively involved in making sure that our new state-of-the-art Orthopaedic Learning Center will be fully funded. Additionally, he has chaired an ad hoc committee working closely with industry to enhance the educational experience at our meetings. We are just starting to scratch the surface with ideas such as the Theater Sessions in the technical exhibit area here. Stay tuned for much more to come.
      This year AANA approved funding from the Education Foundation to the tune of $794,000 for research, scholarships, and support of numerous pioneering educational projects. There are so many great things happening, it's hard to keep track.
      President Truman said “It's amazing how much you can accomplish when you don't care who gets the credit,” and this clearly exemplifies an AANA mantra. As an organization, AANA truly is a meritocracy. It is an association where individuals are acknowledged or singled out based on their contributions and not their connections or where they come from. Otherwise, how do you think an old boy from Nashville, who is a solo practitioner, could be standing before this auspicious gathering?
      To give you a personal perspective, in 2003, I decided I was going to slow down and not travel as much. I had resigned my position with the Tennessee Titans; although that didn't last long. I didn't submit anything for the AANA Annual Meeting, and didn't even plan to attend. In fact, I had bought a new set of clubs and was taking more golf lessons, thinking I would focus more on my game. However, Ron Sparks asked if I would come out and do an evening program at AANA so, at the last minute, I went. I didn't even arrive until late Thursday afternoon. This was the year the new Marriott in Phoenix had just opened, and we were one of the first meetings to be held there. Registering at the hotel, I had two different people stop to congratulate me. In return, I just said thanks and nodded, having no idea on earth what they were talking about. Walter Shelton was the third person who stopped me to offer congratulations and, finally, I had to ask him what he was congratulating me for. It turns out I had been voted onto the AANA Board of Directors. I was certainly very honored, although I didn't really feel like I knew why. I did my three years on the board, shook hands, said thanks, and parted ways.
      And then I remember in 2006 when the Academy meeting was in Chicago, having been moved there from New Orleans because of Hurricane Katrina, I attended the AANA faculty reception following Specialty Day. I found myself approached by two of the AANA Past Presidents, who said they thought I should pursue the AANA presidency. My immediate thought was that that was the stupidest thing I had ever heard. It took a while for me to figure out that maybe AANA saw more in me than I saw in myself. I think it is very true that AANA can bring out the best in people and provide them opportunities to make use of their talents and interests in education, research, and patient advocacy.
      Frankly, I would have to say that, on a selfish level, I have had so many things working for me that if I were to fail at this point, I would really have had to go out of my way. Newton said, “If I have seen further, it is because I stood on the shoulders of giants.” Well, man, I’ve stood on some big ones.
      As an aside, I have to qualify my statements by saying that I am the worst person on earth for someone to ask for career advice. That is because there is nothing in my career that I set out or planned to do. I didn't plan to go to medical school. I didn't plan to be an orthopaedic surgeon. I didn't plan to have a special interest in hip arthroscopy, and I certainly didn't plan to be President of the Arthroscopy Association of North America. Basically my life and my career have just evolved based on the circumstances in which I found myself at the time. And I have been incredibly blessed by the Lord through all of this.
      My mother still chuckles about all the different jobs I would hold down at once, none of which amounted to much, and usually paid nothing more than minimum wage. The only steady job I ever had was teaching scuba diving through college and medical school. I guess it's good to know that I have a fallback position if this doctor stuff doesn't work out.
      I say that there is nothing I have done and nothing I have accomplished that I set out to do. That is, except this. When I was an intern in Louisville—Louisville wasn't exactly the strongest program around at the time and, trust me, I was lucky to have even had a spot there. One of the chief residents, Darrell “DogMeat” Lowery, got a fellowship with Dr. Andrews and was always talking about Dr. Andrews this and Dr. Andrews that. Well, I had no idea what a Dr. Andrews was, but it certainly sounded like the thing for me. I also knew that there was nothing to separate an also-ran from Louisville from anyone else. So, starting with my first year of residency, I would take my vacation time and go visit Dr. Andrews in Columbus. After about three years of this, I think he said, “I guess we’re just going to have to give you a fellowship.” There is no way that Dr. Andrews could bestow upon me his God-given surgical skills, but hopefully I learned something. Perhaps more importantly, through his example, I saw how to treat special people like they were regular folks and how to treat regular folks like they were special.
      Like many of you, I have stood on the shoulders of my greatest giant, my father. He was a general surgeon who began his medical career in the military, serving in the Stonewall Jackson Brigade of the 29th Infantry. During World War II, he oversaw the medical evacuation of Normandy Beach, an action in which they lost 75% of their officers in the first 24 hours. Fortunately, he was part of the 25%. During his time in the European Theater, he earned two Purple Hearts and was awarded the Bronze Star with two oak leaf clusters and the Silver Star. He dedicated his career to fighting cancer, which is a much more admirable pursuit than anything I will accomplish. In the 1940s and 50s, the cause of cancer was largely unknown, and there was always a stigma associated with it. It was felt that, if you contracted cancer, you must have done something wrong. His main focus was breast cancer, and he spent decades debunking myths. In the 1960s, he completed a landmark longitudinal study that showed the single greatest factor in survival from breast cancer was early detection. In the 1960s and 70s, he traveled extensively to places like China and Egypt and Russia where Americans didn't go. But these governments understood the destructive power of cancer, and he led delegations to educate their medical communities. He was a solo practitioner for over 50 years. Along the way, he was President of the American Cancer Society, the Chamber of Commerce, the Nashville Academy of Medicine, the Exchange Club, Leadership Nashville, and on the Medical Staff of the Junior League Home for Crippled Children. He was Chairman of the Board of Overseers of the Vanderbilt Ingram Cancer Center. He was Chairman of the Board of Cheekwood, our most recognized museum, and the Board of Trustees for the Hermitage, the home of President Andrew Jackson. He served on the board of a major bank and an insurance corporation. He was also the Sunday School Director, a Deacon, and Elder for First Presbyterian Church. I think you get the picture.
      The 1960s and 70s was a time of social revolt and rebellion, and we kids weren't any different. Still, among many of my brothers' friends, my father's nickname was God, and they meant it with reverence. Anything good I have accomplished, I credit to my father and Dr. Andrews. The bad stuff I figured out on my own. Basically, I am just a cheap imitation of my father and I don't mean this in a self-deprecating way, it is just the truth.
      In so many ways, I was probably even more influenced by my mother. She was a child of the Depression. They were certainly among the more fortunate, but it was a time that affected the haves and the have-nots alike. My mother's home was near the railroad tracks, and they always set an extra place at the dinner table in case someone arrived unexpectedly. This often happened, and they always felt their home was probably marked by the hobos, knowing that friendly people lived there and food could be had. My mother can easily be described as generous and frugal in the same sentence. I remember her saying “I don't mind spending money, but I hate wasting it.” That's a concept I have a used a lot in this last year during our financial discussions for AANA. She would give you anything you needed, but would not leave the light on in the room when she left because she didn't want to waste the electricity.
      I won't bore you with anecdotes, but any project that we would work on, she would insist that we had to have the right tools for the job, and they had to be good quality. Trying to do it with anything less was nonsense. Boy, if you think that doesn't spill over into my operating room today, then you need to visit Nashville.
      My mother is a powerful woman who detests attention. For the last 50 years, our family has gathered for lunch every Sunday at our country club. With six siblings and extras, it is usually a pretty busy occasion, but my mother never goes. She finds it to be too much of a spectacle. With that, maybe Kevin Plancher can understand why I just couldn't seem to make it to the faculty entertainment at his meeting this last December.
      Although not deliberate, I believe my mother instilled in me some of what has been affectionately referred to as the Caldwell temper. I hide it pretty well but, more than occasionally, it comes out, and there are at least a few people in this auditorium who can attest to it.
      We have been around Nashville a while. I have some relatives who still live on land deeded to the family by the King of England. My great-great grandfather, Major John W. Thomas, was long-rumored to have run guns for the South during the War Between the States. After the war, he became President of the railroad and worked feverishly to rebuild Nashville as a cultural center. Nashville became known as the Athens of the South because of its many colleges and universities. He was known as a man of great character and remembered those around him. No veteran ever had to pay for passage on his railroad.
      Another great-grandfather moved to Nashville as a child when his widowed mother was chased off their property on the Yazoo River in Mississippi by Grant's gunboats when they laid siege to Vicksburg. He became one of Nashville's business leaders and took particular pride in hiring talented young men that he knew would leave and develop their own success stories. I think this is a lot like mentoring that is nurtured through AANA. We try to identify and nurture talented young surgeons and then watch them flourish into new thought leaders.
      During the first part of the last century, my great uncle was described as the most powerful man in the South. He built his career betting on the South's economic recovery. Even in the 1950s and 60s, up until his death, the major power brokers would gather for lunch at his home. The newspaper said you could tell the day of the week by who was eating lunch on his porch. Occasionally, my father would take me along for visits. Through his career, Uncle Rogers always had a sign displayed prominently in his home. It said, “When in this house, please do not say anything unkind about anyone, bearing in mind that what you think of others is nothing like as important as what others might think of you.” I always wanted to put this in my office, but I knew that I could never live up to its message.
      In some circles, I have to be quick to point out to people that I am not a hip preservation surgeon. I am just a sports medicine doc who happens to have taken an interest in hip problems. Like most arthroscopists and sports medicine physicians, my career centered more on the knee and the shoulder. I have always enjoyed elbow arthroscopy because Dr. Andrews taught me how to do it, and it was something different than what most people were doing. Thus, I probably wrote more about elbow at a time that I was doing tons more knees and shoulders.
      Did I mention that there is nothing in my career that I set out to do? Nothing except stalk Dr. Andrews. Well that is also true of hip arthroscopy. This is just something that evolved and eventually took on a life of its own.
      In 1990, one of my partners had a 16-year-old kid with a bunch of loose bodies in his hip two years following closed treatment of an acetabular fracture. She was planning to do an arthrotomy to remove the fragments and asked me if I thought I could do anything arthroscopically. Actually, Dr. Andrews had envisioned this for me years before, but at this point I had never heard of one being done, never seen one, and certainly had never done one, but I thought as long as we didn't do something dumb, like cut the femoral nerve, we could try and, when it didn't work, she could flip him over and do a formal arthrotomy.
      The bottom line is, it worked, and we were able to remove the loose bodies. Basically we just used the principles and techniques that Dr. Andrews had taught me for dealing with the shoulder and knee. We used a large shaver to remove some, and some we flushed out through the largest diameter cannula we could find. Some were still too big, and these we just had to free-hand with pituitaries we grabbed from the spine surgeons.
      After that, about once a year, someone would land on my doorstep with loose bodies to be removed. So, after two years, we had done 3 loose bodies and that is when one of our therapists came to me and said, “I have been rehabbing these hips with loose bodies, and I think my brother has loose bodies in his hip.” He had been in a motorcycle accident 14 years before and had hip problems ever since. He used to work framing houses, but had to give up his job because he never knew when his hip would go out on him. We did x-rays, MRI and a CT scan, all of which were normal, keeping in mind that MRIs weren't very reliable back then anyway. I thought, well maybe you have some type of radiolucent loose bodies that we just can't see on the studies. After 14 years of symptoms, it did not seem premature to consider the role of arthroscopy. I fully expected it to be a normal hip scope and I thought if I'm going to scope a normal hip, I might as well make a good educational video out of it. So we set it up to film the case inside and out.
      When we put the scope in the hip, what we found was a displaced bucket-handle tear of the labrum, which we excised, and after 14 years, his symptoms were gone. That is when a light went off in my head that there were other things besides loose bodies in the hip that we just weren't good at detecting. Ultimately, that is what set me on this journey as we’ve been trying to better define hip problems ever since. By the way, 20-something years later, radiographically, his hips are still normal and he is pain free.
      I tell people I have only done two smart things in my life. One was marrying my wife, and the other was in 1993 when I had no idea where this hip arthroscopy stuff was going, but I didn't want to get years down the road and be trying to guess back on how these patients had been doing. So we started collecting data on our outcomes. This has subsequently become the foundation for much of the work that we have done. So, for the young surgeons in the audience, I encourage you to start following your data early in your career. There may be unique aspects of your practice that may turn out to be especially meaningful to others, but you may not know it for a long time to come.
      In 1994, we published the technique that we had developed on performing hip arthroscopy in the supine position. This was based on our vast experience with 12 cases. There is an important message here. For the young people, or really for any of you in small practices, you do not have to have had experience with thousands of something before you may have something meaningful to share. Each of you may have unique aspects of your practice and your experiences that may bring to light a meaningful nugget of knowledge that could be beneficial to many. The key is observation. Pay attention to what you see and constantly be trying to put it together.
      Speaking of observations, how many of you perform hip arthroscopy? How many of you are familiar with the C-sign? How many of you know that I described it? Well, you are wrong.
      I said the smartest thing that I ever did was keeping track of our data early on. Well, that's not really true. The smartest thing I ever did was hiring this scrappy young nurse, Kay Jones, back in 1993 who has been keeping track of the patients and me ever since. One day Kay commented to me, “You know, have you ever noticed how these patients with hip problems tend to cup their hand above the greater trochanter gripping their fingers down into the groin forming their hand like a C?” So really it should be called the Kay sign. The point is that observation is a powerful tool and not necessarily possessed by some of the most brilliant people. It is amazing how much you can learn if you just pay attention to what is in front of you. Kay came on board partnering with my secretary Sharon Simmons, who was a seasoned veteran of four years which seemed like an awfully long time back then. I think Sharon and I just sort of inherited each other. The two of them have been telling me what to do ever since, and I do acknowledge that following instructions is a skill worth possessing. More importantly, I strongly believe that you need to surround yourself with good people. Don't accept mediocrity. It will drag you down. But, also don't expect of others what you might expect of yourself. We sometimes do unreasonable things.
      I remember one time with a paper I had written that the reviewers wanted to know who were the other authors that I had left off because the methodology referred to what WE did although I was the only author. I explained to them that there isn't anything that I do or accomplish truly by myself but I made the grammatical correction anyway. This is true for everyone in this room. If you have accomplished something meaningful and feel it was the results of your own ability, you'd better look closely to see who you are leaving out.
      Our center, Nashville Sports Medicine, is not about Thomas Byrd and it is not about Kay Jones or Sharon Simmons. It is about the patients that we have the privilege to treat. It takes all of us. We are each a unique and essential element to the comprehensive approach that we are blessed to be able to provide to our patients.
      Karen Griffin was Karen Middleton when I first met her in Columbus, Georgia, where she was Dr. Andrews' right hand person in physical therapy. She is unquestionably one of the most remarkable physical therapists that I have ever met. Frankly, I am not sufficiently qualified to make that judgment but I have had so many other therapists tell me the same thing that I know it to be true. Karen went with Dr. Andrews when he moved to Birmingham. Fortunately, she fell in love with a guy from Nashville and moved here. Karen and I have worked together and known each other now for over 30 years. Karen helped to train and handpicked Erica Elsasser to be our go-to hip therapist. At this point, I would put Erica up against anyone in the world with her ability to assess and manage hip disorders.
      Beth Potts, our nurse practitioner, is the newest member of the team. Just a baby, she has been with us the last four years. Among her many skills, she is the master of ultrasonography and I would put her up against anyone in the world with her ability to visualize and inject anything and everything around the hip.
      Loraine has been manning the front desk for 22 years, and I can't tell you what it means for a patient who hasn't been in the office for 10 years and when they come in, they are greeted by the same face that was there 10 years ago. And most times, Loraine remembers their name. And Linda has been shooting our x-rays for 21 years. So did I mention that I think it is important to surround yourself with good people?
      Now back to this paper. When the supine position manuscript was accepted for publication, the Editor-in-Chief of the Arthroscopy Journal, provided some personal comments on how to improve my practice. Not how to improve the paper, but how I could improve the care that I provided my patients.
      By this time, labral tears were the most common problem we were encountering. There were only three articles in the literature, and they all described posterior labral tears. In my practice, I was seeing anterior labral tears. Why was my experience so different? In fact, the tears were more around where my portals were coming in anteriorly. Was I creating these tears? I had lots of questions, and I didn't like some of the potential answers. So what'd I do? I wrote a paper about it. In 1996, we submitted a paper to Arthroscopy on labral tears. The Editor-in-Chief said this is a good paper, but you can make it better. They converted it to a current concepts article.
      The next thing I knew, I was on the Editorial Board and eventually the Editor-in-Chief appointed me an Associate Editor. As a reviewer, I felt like I had stole something. I wasn't a good author. Not that I am a good author now, but I am a whole lot better than I was. By reviewing articles, I got to learn immensely through others' experiences. I could emulate manuscript preparation strategies that I found appealing, and I would also see things that I learned that I wouldn't do.
      Like Forrest Gump said about shrimpin', being an Associate Editor is tough. It's a lot of work. It was then, and it is especially so now. My hat's off to those in the trenches today. But, when I became an Associate Editor, that's when I really lit it up. Like a voyeur, I got to peer at how a legion of talented reviewers would dissect the labor of other authors. I really got to learn vicariously through the toils of others. I could adopt writing styles and methodologies and learned a lot of things that could be a death sentence to even the best work. I wrote an editorial about this one time entitled “How to Become a Better Author Without Really Trying.” However, it was years before it really dawned on me what this experience really meant. It finally registered that it is amazing how much you can gain personally through service to others.
      I am bringing closure to a year at the helm of AANA. I am humbled by those who preceded me as well as those who will follow. But, of much greater significance, Gary Poehling is bringing closure to his 29 years with the Arthroscopy Journal, the last 24 as its Editor-in-Chief. This is a milestone worth commemorating. If you want to look for a role model, Gary is it. He has been an innovator, pioneering techniques in wrist and elbow arthroscopy in addition to his vast experience in knee. In addition to that, he is a true scientist in both clinical and laboratory research, serving as author on over 200 journal articles. He is the consummate educator and thought-leader. He served as Chairman of the Department of Orthopaedic Surgery at Wake Forest University Bowman-Gray School of Medicine for 18 years and has been President of ISAKOS. In his spare time, he has served as Editor-in-Chief of the Arthroscopy Journal which, to steal a phrase from Rick Ryu, is the crown jewel of AANA. Under Gary's guidance, the Journal has grown from 91 submissions and 331 printed pages in 1991 to 951 submissions and more than 2,300 pages this last year. Amidst all of these accomplishments, Gary is a strong Christian and consummate family man as a loving and beloved husband, father, and grandfather. If you want a role model, this is it. In terms of professional and personal accomplishment, I couldn't carry Gary's jock strap.
      I should speak about my favorite subject for just a moment—me. Anything I have accomplished has only been through the gracious support and understanding of a loving family—my wife Donna, who has put up with me this last 34 years of marriage, and our two lovely daughters, Allison and Ellen. They are as different as night and day but somehow they have always been able to hold a warm spot in their hearts for their broken-down, sometimes cantankerous old father. As for Allison, they say when you marry someone, you are marrying the whole family, so I definitely have to acknowledge the courage, if not the insanity of a great son-in-law, Scott Freeman. He and Allison have also blessed us with a very special pair in young Thomas and Eloise.
      So, as I start to wrap this up, in health care we do have challenges before us. Last year, Nick was definitely the right person at the right time, and I am supremely confident that we are poised to once again have the right person at the right time when Bill Beach takes over as President. No one possesses a superior skill set for helping AANA and its nearly 4,000 members navigate through the poorly chartered waters of health care reform.
      So where are we in closing this last 30 minutes of ruminations? Well, we each have a job and we should try to do it the best that we can. Grinders are good. And, with regards to legacy, it doesn't have to be about bricks and mortar or a legion of fellows. Just look in the mirror. Each of us has an opportunity to leave our own legacy. Whether it is the influence we have on colleagues or other health care providers, junior partners, or senior partners, and, of course, most importantly, the patients we treat. It is all about how we influence the lives around us.
      I'll just close by saying Greetings from Nashville; or as we sometimes say, Bye Bye.
      Thank you.