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Building Our Home: Lessons Learned Along the Way

      It is a privilege to share with you my Presidential Address delivered at the combined American Orthopaedic Society for Sports Medicine (AOSSM)–Arthroscopic Association of North America (AANA) Annual Meeting in Nashville, Tennessee, on July 9, 2021. When I was younger, I remember thinking, “When I am successful, I will finally take time for myself and family and take advantage of the fruits of my years of labor.” I see the consequences of that earlier decision when I go back and look at photos of myself over the years. They tell a story in and of themselves. Today, I try to view balance in the context of days and weeks, rather than something achieved over decades that gets reconciled in the end.
      I am frequently reminded that I am far from perfect as it relates to balance in family and work. Work is like a ball...you drop it and it bounces back. However, family, health, friends, and spirit, are far more fragile than a ball, and once dropped, they can shatter irreversibly like a glass. The opportunity to share these thoughts at moments like this is always a reminder that I can do better.
      Achieving work–life balance is analogous to building a house. It has a foundation, it is framed floor by floor, and finally, it delivers a final structure completed with all the finishing touches.

      Family Is the Foundation

      A foundation, the start of any good home, is the base upon which everything else is built. It provides a stable platform for sustainable growth. My wife, Emily, a career prosecutor and the CEO of our home and family, tends to nearly every responsibility. She is full of positive energy and balance. I am fortunate to have her love, patience, and unconditional support, which has enabled me to balance family with my passion for education, research, and notably, to answer my calling and the fulfillment that comes from caring for patients.
      Our children, Ethan, Adam, and Ava, are our gift of life, love, and future vision. They are my greatest source of pride and happiness. Emily and I are so proud of what they have become. They bring us great pleasure, even when we get angry or frustrated.
      My parents were married for more than 65 years. My 2 brothers, Russ and Mike, are in business. My dad is 87. He is a former commercial real estate broker and for the past 11 years has run my Sports Medicine Weekly podcast with self-taught digital skills better than most 20-year-olds.
      My mom passed away peacefully last August at 84 years of age. She loved to golf and was an interior decorator. All the activities I enjoyed with own my family growing up, such as skiing and sailing, are what I enjoy with my own children today. My parents’ unconditional love and support was the foundation that enabled me to pursue my wish to become a doctor—a dream that began as early as the 8th grade. Like most of us in this room, I chose medicine to make a difference in peoples’ lives. I was not born to be an orthopaedic surgeon by any means. As Mike Simon, the then Chairman of the Department of Orthopaedics at the University of Chicago, wrote in my letter of recommendation for residency, after first considering pediatrics and infertility, I was “late to the game.”

      Rush: My Second Family

      A particularly important part of my foundation is my Midwest Orthopedics at Rush family—my life blood at work includes my physician assistants Kyle, Paige, and Kailey; my administrators Sam, Val, and Val; and my dedicated research assistants. These individuals exude loyalty, compassion, patience, a tireless work ethic, and an amazing tolerance for my last-minute changes. On a daily basis, I make sure they know how much I value them. My partners in the Section of Sports Medicine—under the leadership of Nikhil Verma, one of our program chairs and my friend—are an enormous part of this second family.
      As a 5th year resident at the Hospital for Special Surgery, Bernie Bach, affectionately known as “BRB,” called me from Chicago and said, “If you are not going to train with us at Rush for Sports and Arthroscopy, then at least consider joining us when you are done.” And so, I did. BRB has been my mentor and friend for 26 years. He has always reinforced the concept of “life being a marathon and not a sprint.” One of his greatest strengths is his ability to remember everyone’s name, and a not-so-irrelevant fact such as your birthday, your kid’s names, and the colleges that they attend. He is a savant in that way.
      Our fellowship has been functioning for more than 30 years. We have trained more than 100 sports, 33 primary care sports, and 10 shoulder and elbow fellows since its inception. From this legacy, 60% of our graduates have pursued academics. Many are taking care of professional or college teams, are chairmen of their departments, and have assumed leadership positions in specialty societies. We are very proud of these individuals.

      AANA: A Finishing Touch to my Home

      The framing of my allegorical home includes my connection to my other family, AANA, and our many accomplishments over the last year. Those of you who had the privilege of knowing the late Howard Sweeney will always equate AANA and the Orthopedic Learning Center with selfless commitment to teaching and education otherwise what I call “academic philanthropy.” I remember the first course I taught in 1997 as a junior instructor...I thought I had arrived.
      AANA embodies meritocracy and mentorship. There is something for anyone who wishes to contribute, and advancement is based on merit, not ego. AANA provides a level playing field for those who have common interests and to unconditionally share ideas, foster innovation, education, and research.
      Recently, I was reminded that, “No is a complete sentence. Every time I say yes, I am saying no to something else.” In reality, we do not pay for things with money, but rather we pay with time. After my run on the board more than 10 years ago, AANA Past President Rick Ryu asked me if I would be interested in moving up the AANA leadership ladder. As health care providers, we all seek affirmation. In part, our validity comes from the impact we have on our patients and peers. We have trouble saying no because we need that feedback loop. Over time I have learned to ask myself, “Will the obligation enhance my career? Will the commitment take me away from my family and friends? Can I deliver with excellence? Will this obligation take me out of balance?”
      At that time, I said no to Rick because I believed I could not deliver with excellence, although I feared that I might never have this privilege again. Six years later, when I was in a much better position to say yes, I found myself on the board as Treasurer. I learned it was ok to initially say no.
      I have enjoyed my more than 10-year run on the board with AANA. I observed many leadership styles along the way from incredible mentors. I paid attention to what they said, how they said it, and most importantly, to how they built consensus to do work on behalf of this great organization. There are so many individuals who deserve thanks for their tireless commitment to AANA. One cannot lead without an excellent team in front of them. The AANA mentality is a “can do” attitude; we dig in and get it done with excellence. Thank you for making my year easy and productive, especially in the midst of a global pandemic.

      The Pandemic’s Silver Lining

      Taking office exactly when the pandemic started and finishing at a time when we can all see the other side was, as we frequently say, “unprecedented.” I swear I thought I contracted COVID on a weekly basis. I tested when I could so I could protect my family and patients. I washed our groceries with surgical precision at times using bathroom cleaner, the only cleaning solution available at that time. In the early days, there was seemingly no good information to rely upon.
      I know many of you lost family members, became sick, and may have residual symptoms from this crazy disease. It still amazes me that this massive public health issue became a contested political narrative at the expense of so many. I hope that all of you are vaccinated or are considering doing so. The vaccine has opened the door to allow us to be here safely today.
      The silver lining of the pandemic included the opportunity to spend time with our families in ways we never thought possible. While most Americans raced to purchase their first Peloton, my kids acquired Felix, the most amazing, yet inappropriate dog a busy family could ever have—a Border Collie.
      This year was a time of reflection. After a nearly 2-month hiatus from clinical activities, many of us felt the palpable absence of the gratification that comes with seeing and treating patients. The pandemic reinvigorated our core values and reinforced why we do what we do with passion and relentless commitment. And then there were the perpetual Zoom calls. I think the most common expression over the year was “your mic is muted.” We have all missed the personal interactions that we are fortunate to experience this week. Despite the pandemic, AANA membership grew more than 10% with more than 6,000 members with representation in more than 80 countries.

      AANA Thrives

      AANA continues to thrive. The Arthroscopy family of journals has earned a high impact factor under the oversight of its Editor-in-Chief and my friend, Jim Lubowitz, with more than 2,000 submissions last year. We also owe a debt of gratitude to all of the reviewers who contribute their time to make sure what we read is always excellent and contributes to our ability to manage our patients better.
      AANA’s commitment to skills and performance-based training continued throughout the year. Many of us hope this will become an integral part of the board-certification process. In terms of advocacy, Eric Steifel has worked tirelessly on several initiatives in collaboration with other specialty societies to protect us from the economic impact of reimbursement and coding changes.
      Under the oversight of Jim Stone and Joanne Halbrecht, we initiated the Practice Service Organization (PSO) to provide additional value to AANA members by offering many services such as curriculum to help Arthroscopy and Sports Medicine programs meet the needs of the Accreditation Council for Graduate Medical Education process in addition to several platforms for practice management. And, because of the generosity of many AANA members, our industry partners, as well as a favorable economic climate related to investment opportunities, AANA’s endowment remains strong, allowing us to deliver value to our members well into the future.
      Finally, in recognition of AANA’s 40th Anniversary, we initiated a Legacy Giving campaign to ensure AANA’s future. We are grateful for the 100% participation of the AANA board and the generosity of many of our past presidents and members. We have raised more than $1,500,000 of our $4,000,000 goal for the next year, which will culminate at Mark Getelman’s meeting in San Francisco in May of 2022.

      Strength in Diversity

      This year, we also focused on diversity. Two minority groups, women and non-white medical students, are essentially equally represented in medical school. However, practicing orthopaedic surgeons are 94% men and 70% White. Bright, talented non-White and non-male medical students are choosing specialties other than orthopaedics. As a profession, we are missing the innovation, competency, and unique perspectives that a wide range of individuals would otherwise provide.
      In an effort to do something meaningful, in 2020, I activated the Diversity and Inclusion Task Force led by Julie Dodds and Don Buford. We supported the committee members who contributed to the development of several initiatives: An annual AANA diversity lecture delivered this year by Rick Ryu; the Diversity Research Award for the best paper authored by an individual who is under-represented in medicine; and a yearly Orthopedic Learning Center course introducing minority medical students to orthopaedics in a welcoming, supportive environment and connecting them with mentors. I am learning that diversity and inclusion is not an end point or demographic percentage, but rather an ongoing “practice,” just like we practice medicine and surgery.
      I would like to bring your attention to a recent publication by Lisa Cannada and her co-authors presenting #SpeakUpOrtho.
      • Cannada L.K.
      • O’Connor M.I.
      Equity360: Gender, race, and ethnicity—Harassment in orthopaedics and #SpeakUpOrtho.
      As many of you may know, #SpeakUpOrtho is a social media platform and campaign that provides the opportunity for individuals to share actual experiences of bias, inequities, and harassment within orthopaedic surgery. I want to thank those who have shared their stories and provided awareness to so many.
      While not always related to diversity, under-represented groups are often the targets of harassment and unfair treatment in our White, male-dominated specialty. Reading posts on #SpeakUpOrtho made me cringe. I felt uncomfortable, and likely most of you will feel the same way. As uncomfortable as I feel, I cannot imagine how uncomfortable it must feel to be on the receiving end. Over the last 12 months, I have recognized my own blind spots, some of which made me part of the problem for not seeing or redirecting when I had the opportunity to do so. In addressing this topic today, I worried about saying the wrong thing, or that I could not possibly say the right thing because of my station as a White male. I certainly do not want to preach or make others feel uncomfortable, but I do feel comfortable today saying I can do better. I will do better. We can do better together.

      AANA-AOSSM Collaboration

      Our presence at this combined annual meeting reflects true collaboration. As an active member of AANA and AOSSM, this partnership was especially meaningful to me. When it became clear that our annual meeting in April was threatened by the pandemic, on a Saturday morning in August of 2020, I called AOSSM President Michael Ciccotti and asked him if he would contemplate working with his board and presidential line to collaborate on the idea of a joint conference. Mike agreed that a combined meeting made sense, and that organizational differences could be effectively blended to deliver on our respective missions. As time was short, we quickly and efficiently built consensus among our leadership and constituents.
      Interpersonally, getting to know Michael was particularly rewarding. We spoke frequently and exchanged weekly text messages even until the last moment. Michael was insightful, thoughtful and an impeccable communicator. I also wish to thank the program chairs, Nik Verma, Kevin Bonner, Steve Cohen, and Brett Owens, for successfully creating a blended program. We navigated challenges with compromise and by putting our egos aside. I also want to acknowledge the two organizations’ CEOs, Greg Dummer and Laura Downes, for assuring that our unique event was truly a blended collaborative effort. We can all acknowledge we delivered with excellence!

      The Home’s Finishing Touches: 10 Lessons I have Learned Along the Way

      Generally, I am most comfortable sharing what I have learned about research, treating patients, or decision-making. However, as I put the final touches on my proverbial home, I would like to now share perhaps what is harder, but more meaningful: Ten lessons that I have learned that transcend my medical knowledge.

      Lesson 10: Managing Time

      I am frequently asked “How I do it all? How do I manage my time?” I have found that I can achieve more success by ceding control to the right people and accepting that perfection is not always the goal. Here are a few points that have proven particularly helpful along the way.
      First, I surround myself with people better than me, and I regularly let them know that they are valued. Second, I have learned to delegate responsibly. Theodore Roosevelt said, “The best executive is the one who has the sense enough to pick enough good people to do what needs to be done and the self-restraint to keep from meddling while they do it.”
      A quote by Warren Buffet recently hit home, as it emphasized the point about the value of extra effort for marginal return. “The interesting thing about business, it’s not like the Olympics. You don’t get any extra points for the fact that something’s very hard to do, so you might as well just step over one-foot bars, instead of trying to jump over seven-foot bars.” In an effort to achieve perfection, I was often overprepared for things like tests and lectures, and because of the sheer volume of opportunities coming my way, I came to realize that there is a sweet spot that balances perfection and efficiency. Colin Powell once said that it is okay to make a decision if the probability of success is between 40 and 70. It is also okay to be wrong sometimes. We are by design, human and not flawless.

      Lesson 9: The Importance of Mentors

      I have spent much time contemplating exactly what it is to become a good mentor. I have learned from many of you in this room. I am thankful to those I have met along the way who have provided a menu of character traits to emulate. In addition to many of the individuals I have already recognized, there are many others who go back more than 20 years and who have had an enormous impact on who I am today. Thank you all for teaching me to be thoughtful, resilient, patient, fair, respectful, and collegial.

      Lesson 8: Preserve Our Roles to Deliver the Best Care

      Early on, Neal ElAttrache taught me something very important about our role as team physicians. While building friendships with our athlete patients is gratifying, in the end, maintaining proper boundaries is important so as to provide them someone to believe in when the time comes where they really need our help. This advice has served me well in providing the best care I can when athletes need us most.

      Lesson 7: To Be a Good Leader, Put Yourself in Others’ Shoes

      I think Mark Twain said it well, “Really great people make you feel that you too can become great.” I have learned that an essential aspect of leadership is focusing on perspectives other than your own. The military is replete with excellent lessons on leadership. These points are adapted from Colin Powell’s thoughts on leadership:
      • 1.
        Being a leader sometimes means pissing people off.
      • 2.
        Build consensus with pre-emptive communication.
      • 3.
        The day your team stops bringing you their problems is the day you stopped leading.
      • 4.
        Look below the surface even if you are afraid of what you might find.
      • 5.
        Never let your ego get so close to your position that when you position goes, so does your ego.
      • 6.
        Great leaders are also great simplifiers.
      • 7.
        Surround yourself with people who take their work seriously, but not themselves...have fun as a leader.
      • 8.
        If you are successful, you will be criticized.
      When I am criticized, I look for at least a grain of truth in that criticism, and I try to make necessary changes to show a sincere commitment to teamwork and collaboration. Validating others’ concerns rather than dismissing them has helped me immensely to understand differing viewpoints and solve problems. Finally, showing remorse, not just regret, for mistakes has been an important avenue for my growth and effectively made me a stronger leader.

      Lesson 6: Be a Good Listener

      I was not a good listener early in my career. In fact, I think, like some of us here, it took me an average of about 7 seconds before I routinely interrupted my patients while speaking. Over time, I have learned that patients are quite complex with lots of concerns. Disarming patients who catastrophize their problem by helping them effectively reframe has also been particularly effective once I took the time to really understand their concerns. Ultimately, I learned to sit down, ask targeted questions such as, “why are you here?” or “what are you hoping for from our visit today?”
      An editorial by Lisa Rosenbaum entitled “The Art of Doing Nothing” speaks to the preoccupation our society has with technology even to the extent that it supersedes the importance of listening, examining our patients, and drawing from our knowledge base.
      • Rosenbaum L.
      The art of doing nothing.
      We need to do a better job of resisting the temptation to accept technology over medical judgment.

      Lesson 5: Voltaire

      Directly related to this is my favorite quote by Voltaire: “The art of medicine consists of amusing the patient while nature cures the disease.” It took me some time to figure out that mostly patients have concerns and want reassurance. My patients often ask, “If I do nothing now, will I end up in a different place later on that could otherwise be avoided?” Or “can I remain active without making my condition worse?”
      In reality, our jobs are pretty simple. Have a firm understanding of the natural history of disease, maximize skillful neglect, and add a strong dose of reassurance by being kind, a good listener, and validating your patients’ concerns. And if necessary, performing a well-indicated orthopaedic procedure will likely avoid the most common complication: a failure to deliver and meet patient expectations.

      Lesson 4: Take Off the Blinders

      I once practiced that whenever I was overwhelmed with challenges, I would just put my head down and get it done. I have since learned that this compromise lacks self-awareness and risks the alienation of those closest to me. I learned to take off the blinders. Mercedes Lackey said it well, “Once the blinders are off, it is hard to go back to seeing the way you used to.” Acknowledging my surroundings while I do my job has helped to ease this burden.

      Lesson 3: Show Gratitude

      I recall an amazing NPR episode where an 85-year-old former kindergarten teacher came upon a student from 60 years earlier. He told her that “she was the most influential person in his life and that he simply wanted to thank her.” This teacher responded that no one had ever taken the time to pay her a compliment or acknowledge her teaching skills. I have learned that showing gratitude is time sensitive. If you think it, just say it right then and there.
      I recently counted that 32 people were involved with initiating and delivering the care to a single patient undergoing an anterior cruciate ligament reconstruction from the time of the initial appointment to the point of return to play clearance. My role was quite small in the total delivery of care. Data support that people value being appreciated even more than their salary. While I am terrible at remembering names, I will routinely recognize people for their efforts and simply say thank you for doing what you do.

      Lesson 2: Humility and Self-Awareness

      C.S. Lewis once said, Humility is not thinking less of yourself but thinking of yourself less.” I recognize that humility is not something we are born with, but rather, something that we learn and acquire after experiencing life. I experienced my first impactful lesson in humility in my early 40s. My career and family felt on track, I was happy with where I was. Then, my family and I were hit with 2 personal crises. I felt helpless, vulnerable and even embarrassed. I felt ill-prepared to manage that time in my life as I had little to borrow from my earlier life lessons. Eventually I got through it, I found the other side, and I learned humility in the process. More than anything, this lesson in humility taught me to look outside of myself. I now embrace the fact that my own humility and self-awareness are interconnected and critical character skills to improve upon over time. Of course, now I have learned that no one really knows humility until they have a teenage daughter…which brings me to my final point.

      Lesson 1: Family and Friends Matter Most

      An abundance of research suggests that shared experiences, not things, are what makes us happy. If you look at the marginal utility of a dollar versus our happiness factor, philosophers have long argued that it will plateau at a surprising low value. It is often said that youth is wasted on the young. And in the end, money has no value at all. Dr. Barbara Fredrickson recently determined that we have a “forward looking” immune system. Having meaningful social interactions as we age has a positive impact on happiness, overall health, and meaning in life.
      Some of my happiest moments have been with my family. Beyond that, I can safely say that the times that many of us in this room have shared together face-to-face have been particularly meaningful. I think this last year is a true reminder of what is and what is not important. The pandemic provided the opportunity for us to “re-boot” in a meaningful way. Because we are always learning, we can always do better.
      At this time, I welcome Dr. Mark Getelman as AANA’s 41st President as I transition to Immediate Past-President. We are all confident that with Mark’s vision, energy and thoughtfulness, AANA’s mission will be heard and felt as we continue to foster innovation, research, education.
      Thank you for the privilege to share, and I wish you all well on your own personal journeys.

      Acknowledgments

      I thank Annemarie Tilton, M.D., for her insights and for helping me better understand the critical importance of how we can do better as a profession to improve our commitment to reshape diversity, inclusion, inequities, and harassment.

      Supplementary Data

      References

        • Cannada L.K.
        • O’Connor M.I.
        Equity360: Gender, race, and ethnicity—Harassment in orthopaedics and #SpeakUpOrtho.
        Clin Orthop Relat Res. 2021; 479: 1674-1676
        • Rosenbaum L.
        The art of doing nothing.
        N Engl J Med. 2011; 365: 782-785