Published 2/1/2015
Frederick M. Azar, MD

My Top Ten

If you read AAOS Now on a regular basis, you know that Editor-in-Chief S. Terry Canale, MD, frequently releases his “Top 10” lists—from things to do and see in Annual Meeting cities to issues he thinks are important. But Dr. Canale isn’t the only one who makes lists. I started my presidential year with a list of “What Keeps Me Awake at Night,” so it seems only fitting to end it with “My Top Ten,” my list of the changes and challenges we, as orthopaedic surgeons, face.

10. Hey ya’ll, look over here! Setting priorities
We are practicing medicine in a historic time in health care, and particularly, orthopaedics.

Although all eyes are on the Affordable Care Act, transformative changes and paradigm shifts are occurring in core areas, including education, quality, advocacy, and communications. We cannot neglect them.

9. Education, our foundation
In a typical day, we seek orthopaedic information either because we “need” it or because we “want” it. We “need” information for a patient with a complicated diagnosis in clinic, for the next patient in surgery, for the Orthopaedic In-Training Exam, for our Boards, or for Maintenance of Certification. We “want” information for lifelong learning, which is a fundamental tenant of our profession.

Education is a fundamental tenet of the Academy; it is critical that we keep pace with the learning needs and patterns of our members. We are transitioning to that type of learning. We are also expanding our electronic media platform of mobile apps, ebooks, webinars, and webcasts.

The Academy is consistently seen as a trusted source for information, with content that meets the “gold standards” of accuracy, reliability, and peer review. But the message is no longer enough.

Those who seek education from the AAOS can be divided into two categories: “digital natives” and “digital immigrants.” Digital natives demand robust search engines, easy navigation, and targeted information. According to them, “You should be able to get to anything on the web in three clicks or less.” Digital immigrants may not be as comfortable with iPads and web-based information, but they are gradually assimilating.

As a result, the AAOS is updating our education and publishing programs to meet the challenges posed by these shifts in learning styles and expectations. Rather than simply developing “products,” we are now actively developing “content.”

What does all this mean to you? Primarily, it means a better learning experience as you customize and individualize a learning portfolio geared to your particular learning needs and wants.

8. The Affordable Care Act and Quality
As physicians, we do not make a single decision about a patient without first thinking about quality. However, we are now being asked to measure that quality. During any discussion about health care in the United States, you will hear the words “quality” and “value.” The “value equation” calls for high-quality, low-cost health care and is likely a euphemism for lower reimbursement.

For some time, the AAOS has been investing heavily in quality initiatives, such as evidence-based clinical practice guidelines, appropriate use criteria, patient safety initiatives, registries, the Orthopaedic Quality Institute, and, most recently, performance measures. We must continue these efforts, because they are directly linked to both delivery and payment reforms.

We need to be the ones developing quality initiatives. For too long, we have been held to proprietary measures that lack evidence. We must adhere to the Institute of Medicine standards, which identify the pursuit of quality with care that is safe, effective, patient-centered, timely, and equitable.

It is frustrating to put forth Academy resources to find that evidence to support a quality topic is lacking. We need to select topics with sufficient evidence to support our quality initiatives. We need to play to our strengths in evidence.

It is also important to note that it is inappropriate to use quality initiatives for coverage decisions and malpractice cases, and we will continue to fight the misuse of any guidelines on all fronts. Additionally, all evidence-based medicine efforts recognize that myriad factors—including clinician experience, patient preferences and values, and comorbid conditions—will affect the very complex clinical decision-making process.

AAOS and specialty societies are working together on many quality initiatives. These joint efforts will result in the most effective quality-related instruments to help us provide the highest quality care to our patients. At the same time, we hope to develop tools to enable compliance with healthcare delivery and payment reform models using just a few clicks in the electronic health record.

Just as politics are local, so is healthcare delivery. As the needs of orthopaedic practices continue to evolve, our Academy must continue to be responsive to ALL members, including those who are moving to a hospital-employed model.

7. Advocacy, a seat at the table
Did you know that the Orthopaedic Political Action Committee (PAC) is the number one health professional PAC for dollars donated? Under the leadership of Stuart M. Weinstein, MD, our PAC set an all time record, with 31 percent of our members contributing during the last election cycle. (See “
Orthopaedic PAC Continues to Set Records.”) But that still means more than two thirds of AAOS members are not contributors—we’ve got a way to go. Please take a minute right now and go to www.aaos.org/pac to find out how you can support advocacy efforts.

6. Communications—Getting the message
Your Academy speaks to many audiences: to you as members, to policymakers and regulators, to payers and device manufacturers, to media representatives, and to patients and members of the public. This year we have looked at how we currently communicate, both internally to you and externally to everyone else, and how we could communicate better.

With all the “noise” out there, it is difficult to know what is important to read. Going forward, the Academy will be looking to fine-tune our messages to help you distinguish “must reads” from “might reads.”

As diverse as the AAOS fellowship is, our external audiences are even more varied. Although our outreach efforts extend to all stakeholders, including policymakers, payers, industry, and the media, the largest audience is the American public, including our patients.

For this reason, external communications must operate on two levels. When we advocate in Washington, D.C., we need both the tallies—how many Americans are affected by musculoskeletal disorders and conditions—and the tales—the patient stories of the difference orthopaedic surgery has made.

One of our key goals has been to identify ways to engage patients as advocates, just as we physicians are their advocates. For example, the A Nation in Motion campaign provides powerful patient stories that can help improve the image of orthopaedic surgeons and underscore the value of the services we provide. The campaign highlights personal stories from both surgeons and patients that capture the best of what orthopaedic care can do.

We can spread that information and understanding by capitalizing on the audience we have in our offices each day. From patient education brochures to public service announcements and videos, we can educate our patients about injury prevention, treatment alternatives, and advocacy-related issues designed to preserve their access to our services.

Of course the greatest potential vehicle to inform our patients about musculoskeletal issues and how to effectively communicate with their Congressional representatives is through the AAOS website. Updates to AAOS.org and Orthoinfo.org to make them more appealing and user-friendly are underway. In addition, the AAOS uses Twitter, podcasts, Facebook, and YouTube to deliver our message to the appropriate audience.

To be effective, communication must be credible, authentic, and sincere. Whether the communication is a 1,400-word comment letter to a regulatory agency or a 140-character Tweet, the most important goal is that the recipient “gets” the message.

5. “YOUnity”—Please check your hat at the door!
My mother taught me to never wear a hat inside the house. Although we all may wear various “hats” from time to time, we should aspire to not wear hats while inside “the house of orthopaedics,” particularly when deliberating on orthopaedic issues that affect our patients’ access to our care.

At the Board level, we accomplish this by beginning every conversation with “what is best for our patients,” because we believe this gets us to “what is best for our members and our profession.”

The house of orthopaedics is diverse, enabling us to focus on the anatomic area, research arena, or patient population that interests us most. The 22 member societies of the Board of Specialty Societies (BOS) exemplify our wide-ranging interests.

As orthopaedic surgeons, we recognize and prize that diversity. It is a source of strength because it certainly serves to improve the care of our patients. But although specialization is good, fragmentation of our ranks is not. Orthopaedic surgeons represent less than 3 percent of all physicians. Of all the challenges that we currently face, I believe the need to maintain our unity is the greatest of them. We must stand together on strategic issues, especially on advocacy-related issues, to have an impact.

Abraham Lincoln once famously noted, “A house divided against itself cannot stand.” For the house of orthopaedics to achieve its goals, I believe that we must be able to work together—to listen and to compromise. This means putting the good of our profession ahead of personal wants.

4. New orthopaedic headquarters
We moved into a new AAOS headquarters in December on time and under budget. It houses a state-of-the-art Orthopaedic Learning Center with modular capabilities and all the latest technologies that will enable us to conduct distance learning, hold simultaneous courses, and provide objective, peer-reviewed, nonbiased skills training. All of these things will contribute to the lifelong learning of our members.

With any new building comes the opportunity to conduct a capital campaign. We have been fortunate to surpass our initial goal of $7 million and are now closing in on our new goal of $10 million. It is not too late to contribute!

3. Professionalism
Look around. We stand on the shoulders of distinguished predecessors who built our profession. We have the responsibility to give back to our profession. It is up to us to carry the torch forward and to pass it on, burning brightly.

It is easy to succeed in times of calm but we will be judged individually, and collectively as a profession, by how we respond to these unprecedented times of uncertainty and vast change. We need to continue the professionalism in our profession.

2. Don’t stand in the kudzu too long!
The invasive kudzu plant can grow up to one foot per day. With all the challenges facing orthopaedics today, we are metaphorically standing in the kudzu. If we are complacent, even for a short time, we risk missing out on big opportunities.

Even if 20 percent of the people do 80 percent of the work, 100 percent of us are kept awake at night by the same concerns. We need a more consistent and sustained effort from those members who are not currently engaged in giving back to our profession. Consider your own talents, strengths, and interests; and then consider using them to make our profession better. In return, your Academy will endeavor to support our mission-critical efforts on all fronts.

We are certainly fortunate and blessed to be orthopaedic surgeons, even with the challenges before us. We need to meet these challenges and the other paradigm shifts occurring today, and not simply look upon them in wonderment or dismay. As orthopaedic surgeons we have the desire, the ability, the resources, and the fortitude to determine our destinies. What is at stake here is worth fighting for.

1. Peeling back the layers
I still consider medicine to be a vocation, a calling. I chose to become an orthopaedic surgeon because of the ability to restore function and improve lives. I would make the same choice again in a heartbeat. Nothing else in medicine comes remotely close to what we do.

After we peel back the Affordable Care Act,

After we peel back Meaningful Use,

After we peel back pending ICD-10,

After we peel back the medico-legal threats,

After we peel back the MAC/RAC audits,

After we peel back the coverage decision issues,

After we peel back all of the unfunded mandates,

After we peel back all of the regulations,

After we peel back all the passwords we have to keep track of just to get through a workday,

After we peel back everything else, we are left with the patient–doctor relationship; and we should do everything we can to preserve that bond!

After all this, I am left with a heart full of gratitude for the faith, trust, and responsibility you have entrusted to me as AAOS president. Although I do not want to start another list—and it would be a long one, indeed—I do want to thank all those who have served over the years with me, both volunteers and staff, for their support.