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Orthopaedic forum The Renewal of Excellence Mohamad J. Halawi, MD

Excellence in orthopaedic surgery has been a long time in the making. What we currently enjoy reflects over a century of innovation, leadership, and consummate professionalism. Today, our practice faces monumental challenges that have never been more demanding, and our commitment to the preservation and advancement of excellence has never been more pressing. Away from the scientific tone but without romanticizing our proud heritage, this article seeks to revitalize the values that have defined our practice, drawing on the wisdom and experiences of leaders in our field. Collectively, it aims to stimulate our enlightened understanding, to reignite our hopes, and to reaffirm our commitment to the highest standards of excellence.

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

The history of orthopaedic surgery is full of invigorating achievements that have not only propelled patient care to higher levels of quality, but also have transformed modern medicine. Total hip replacement is now recognized as the operation of the century1. We have gained tremendous public trust, and with it came societal privileges, including self-governance2. Today, in renewing our commitment to excellence, we stand at the crossroads. We are faced with challenges of historic proportions, and our direction will determine our fate and the fate of the future generations of orthopaedic surgeons. What are the pinnacles of excellence? To answer this question, this article delves into the presidential addresses of the American Orthopaedic Association (AOA) since the turn of the twenty-first century. The AOA is the oldest and arguably the most distinguished orthopaedic association in the world. The presidential addresses are invaluable lessons in the history of

orthopaedics and they demonstrate the wisdom distilled by decades of experience of some of the most accomplished individuals in our profession. History serves witness that our rich heritage was built upon insatiable scholarship, inspiring innovation, and unwavering service. In this article, these fundamental beacons are dissected into their most basic elements: education, mentorship, leadership, and professionalism. Education In its simplest sense, education is the first and foremost prerequisite for scholarship. Joseph Buckwalter has used the term ‘‘the science and art of orthopaedics’’ to describe this educational process3. It is the science of understanding the pathophysiology and the natural history of musculoskeletal disorders, and the art of taking a history and performing an examination in favor of

Disclosure: The author received no payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. Neither the author nor his institution has had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, the author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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reliance on imaging techniques3. Unfortunately, this critical principle is often lost in today’s highly productive and highly efficient practices. The boundaries between education and training have blurred and become indistinguishable. Michael Simon has lamented the deterioration in the quality of orthopaedic education as the resident becomes an employee4. Simon has warned: ‘‘We should not profit from our students. Residents are not trainees, employees, surgical assistants, physician extenders, or professional assistants. Residents are not for covering operative cases, clinics, and emergency rooms. They are students, like postdoctoral candidates. Resident education is not the by-product of patient care.’’4 Terry Light has outlined a number of precepts for resident education that include respect for individuals of all walks of life, ensuring adequate exposure and supervision, and nurturing the development of residents as teachers5. Other worrisome trends have emerged in recent years. Buckwalter has pointed to an increasing reliance on abstracts and presentations from scientific meetings at the expense of peer-reviewed literature. He also has identified an increasing emphasis on technology and implant design at the expense of basic science research3. Joseph Lister, one of the most celebrated physicians of the nineteenth century, is the quintessential example of the shortcomings of a technology-driven approach. Lister’s staunch commitment to refining the antiseptic applications of carbolic acid, despite contrary findings by his contemporaries, demonstrated ‘‘how commitment to technology. . .can compromise the ability of a talented individual to appreciate that scientific advances will make that technology obsolete.’’3 Technology is vital to our success, but it should be guided by scientific research. Today, we are reminded that our commitment to the highest quality of orthopaedic education should be unwavering. We are charged with the responsibility to advance the science and the art of orthopaedics in medical school, residency, and fellowship curricula. Scholarship and excellence are two faces of the same coin. Light has reminded us that ‘‘we have received the gift of robust orthopaedic education and love of our specialty. . .I believe it has created the obligation to educate and inspire the next generation of leaders.’’5 Mentorship Vincent Pellegrini has eloquently defined mentorship as ‘‘the act of nurturing the emotional and intellectual growth of another person to the point that, and here comes the hard part, he or she is your peer and equal and, ideally, has eclipsed your own accomplishments with the tools and opportunities that you have provided.’’6 This active bidirectional process is unfortunately all too foreign today, a victim of egocentric personalities. Effective mentorship requires flexibility, setting aside egos, providing constructive criticism, and being available for support along the way. Mentorship is not an option; it is an obligation and a prerequisite for the advancement of our profession. Leadership The past decade has witnessed dramatic complexities in our health-care system. We are challenged with increasing govern-

mental regulations, depreciating insurance reimbursements, rising lawsuits, changing patient expectations, and expanding relationships between physicians and industry. In the face of these challenges, our profession, now more than ever, needs to reposition itself, not as a premier organization of highly accomplished professionals, but as an alliance of highly committed and visionary leaders. Edward Hanley has cautioned that ‘‘success requires more than sheer professionalism. . . .Under normal conditions, fidelity to the technicalities of the craft will see you through. But in an exceptional trial, it needs to be supplemented by human qualities that may have nothing to do with professional skills.’’7 This ‘‘human surplus’’ is leadership, the fundamental catalyst of the orthopaedic community to higher levels of achievement. Effective leadership requires respect, integrity, trust, responsibility, service, commitment, teamwork, and willingness to change7. An effective leader is one who listens first and talks later, one who is good at delegation, and most importantly, one who is able to resist the temptation to make a decision when one is not needed7. Douglas Dirschl has added another dimension to leadership: the ability to transform adversity into triumph8. This ‘‘creative leadership’’ is particularly needed today. In the face of criticism and pressure, our natural tendency is to resist and to hold onto our familiar practices. Alternatively, we can seek creative opportunities for growth. This is not a break with the past, but rather a widening of potential and a leap of courage to take on risks and be innovative to create our own ‘‘good news.’’ While doing so, we must never accept mediocrity. As Dan Spengler has stated, ‘‘We are a group of committed team-playing academicians who embrace constructive change but who steadfastly refuse to succumb to mediocrity in the name of a paradigm shift.’’9 Leadership is part of our tradition, and in reaffirming our tradition, we need to remain strongly committed to identifying, developing, engaging, and recognizing leaders in our field10. Professionalism Professionalism is the foundation of our contract with society. It is about upholding integrity and honesty, safeguarding the public’s trust, and delivering an unbiased care that is in the best interest of patients. Marc Swiontkowski has warned that the values of professionalism are increasingly being devalued and replaced by materialistic interests2. We appear to have swayed from our true calling. By doing so, not only are we sending the wrong message to future generations of orthopaedic surgeons, but we also are risking our autonomy and our privileges2. Perhaps the most pressing professional challenge confronting our specialty today is conflict of interest. Financial relationships with industry (e.g., consulting fees, ownership or stock holdings in private companies, and corporate sponsorship of academic research) are increasingly coming under scrutiny and threatening our credibility. While our patients have immensely benefited from technological advances that only were made possible through collaborations with industry, disproportionate and potentially questionable relationships can provoke bias and distrust. We need industry to promote our practice, but

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our professional primacy should remain the welfare of our patients and the advancement of medical knowledge. Conflict of interest is a monumental problem facing us today, and it will never go away. Our obligation is to eliminate conflict of interest whenever possible.

mitment to our patients, our society, and our heritage. Over half a century ago, Frank Stinchfield perfectly stated: ‘‘We orthopaedists have problems—many problems. . .but let us consider them. . .and take care of them, because to survey our problems is to behold our promise.’’11 n

Conclusions We cherish this profession thanks to the contributions of great educators, mentors, and leaders whose unwavering passion and consummate professionalism have made it a pinnacle of excellence. The spirit of excellence should continue to animate our practice and transcend to the future generations of orthopaedic surgeons. Excellence is the very fabric of our heritage, and today we are presented with a unique opportunity to renew our com-

Mohamad J. Halawi, MD Department of Orthopaedic Surgery, Duke University Medical Center, Box 3000, Durham, NC 27710. E-mail address: [email protected]

References 1. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet. 2007 Oct 27;370(9597):1508-19. 2. Swiontkowski MF. Orthopaedic leadership: W2 or WMD? J Bone Joint Surg Am. 2005 Oct;87(10):2349-52. 3. Buckwalter JA. Advancing the science and art of orthopaedics. Lessons from history. J Bone Joint Surg Am. 2000 Dec;82(12):1782-803. 4. Simon MA. The education of future orthopaedists—d`ej´a vu. J Bone Joint Surg Am. 2001 Sep;83(9):1416-23. 5. Light TR. Orthopaedic gifts: opportunities and obligations. J Bone Joint Surg Am. 2006 Nov;88(11):2521-6. 6. Pellegrini VD Jr. Mentoring: our obligation ... our heritage. J Bone Joint Surg Am. 2009 Oct;91(10):2511-9.

7. Hanley EN Jr. Leading beyond the shadow-line. J Bone Joint Surg Am. 2004 Nov;86(11):2554-9. 8. Dirschl DR. Creative leadership: making good news. J Bone Joint Surg Am. 2012 May 2;94(9):e58. 9. Spengler DM. Great to greater: opportunities and challenges for the American Orthopaedic Association in the early twenty-first century. Challenges in our academic mission. J Bone Joint Surg Am. 2003 Dec;85(12): 2471-6. 10. Morrey BF. Dancing with who brung us: reaffirming our tradition, redefining our trajectory. J Bone Joint Surg Am. 2002 Dec;84(12):2301-4. 11. Bigliani LU. Stand up and be counted 2008. J Bone Joint Surg Am. 2009 Jun;91(6):1531-3.

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The renewal of excellence.

Excellence in orthopaedic surgery has been a long time in the making. What we currently enjoy reflects over a century of innovation, leadership, and c...
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