In delivering his address as incoming president during the 2017 AAOS Annual Meeting, William J. Maloney, MD, spoke to the AAOS membership about the challenges the Academy and the profession must address as orthopaedic surgeons navigate what he called today's “disruptive times in health care.”

William J. Maloney, MD

Describing the recent presidential contest as “the most unusual U.S. presidential election in our lifetime and maybe of all time,” with implications yet unknown for health care and the practice of medicine, Dr. Maloney said, “in times of uncertainty, it is helpful to keep our mission and core values—excellence, professionalism, leadership, collegiality, and lifelong learning—as guideposts moving forward. Our Board is committed to these values, as we know you are.” 

The making of a leader
Dr. Maloney, who specializes in joint replacement, is the Elsbach-Richards Professor in Surgery and professor and chairman of the Department of Orthopaedic Surgery at the Stanford University School of Medicine. He also is a team physician for the Golden State Warriors and San Francisco 49ers.

Dr. Maloney earned his undergraduate degree at Stanford and his medical degree from the Columbia College of Physicians and Surgeons in New York. He was chief resident in orthopaedic surgery at Stanford University Medical Center and completed a fellowship in hip reconstruction surgery at Harvard Medical School and Massachusetts General Hospital. Dr. Maloney was on the faculty at the Washington University School of Medicine Department of Orthopaedic Surgery and was chief of orthopaedics at Barnes-Jewish Hospital in St. Louis, Mo.

Dr. Maloney has served on several AAOS committees, including the Council on Education. He championed the formation of the American Joint Replacement Registry (AJRR), and chaired its board of directors. Additionally, Dr. Maloney has been a part of board leadership for the Knee Society, the Hip Society, the Western Orthopaedic Association, and the American Association of Hip and Knee Surgeons. He is a past president of the Hip Society and a recipient of numerous research awards.

Embracing the challenge
Reviewing the major events and milestones that have reshaped the healthcare landscape over the past decade—including the Physician Quality Reporting System, the Medicare Improvements for Patient and Providers Act, the seminal Affordable Care Act, and MACRA (the Medicare Access and CHIP Reauthorization Act)—Dr. Maloney said, “It is clear that the ever-expanding regulatory requirements that we all have faced have increased the administrative burden and cost of providing care, resulting in doctors spending less time with patients.” These and other measures, while “designed by well-meaning people,” have had an impact on medical practice that has been significant and, many feel, counter-productive,” contributing, many believe, “to increasing physician burnout without significantly improving patient outcomes.” 

He identified two major imperatives that the Academy and its members must address. The first is “failure to engage,” which means, he said, “If we want to play a role in what happens next, we need to have a seat at the table in Washington.” To this end, he said, “The American Association of Orthopaedic Surgeons provides that seat through the Office of Government Relations and our Political Action Committee (PAC), chaired by John Gill. We are fortunate to have colleagues like Paul Collins and Stuart Weinstein who had the foresight to start the PAC almost 30 years ago, long before I ever thought to use the words 'advocacy' and 'medicine' in the same sentence.  The Orthopaedic PAC is the second largest medical PAC and we should be the largest. I encourage you to contribute before you leave San Diego. To be effective, we need everyone's support.”

The second major challenge, Dr. Maloney said, is the impact of subspecialization on unity. He noted that in contrast to the trend in industries such as airlines, banking, and, pertinently, orthopaedic device makers and healthcare companies, where consolidation is the watchword, orthopaedics is on a path that is “just the opposite.”

He elaborated, “The number of subspecialty societies continues to grow. We now have 23 in the Board of Specialty Societies. The natural history of a subspecialty society goes something like this: A subspecialty society forms, often with the help of our Academy, with the idea of providing focused education and discussion around a specific topic. Sounds reasonable, right? A board forms and a presidential line is elected. Initially and sometimes indefinitely, our Academy may provide administrative and financial support. If the societies get big enough, they hire their own executive director. Naturally, that executive director wants something to direct. If membership continues to grow, the staff expands, annual meetings are planned, and a new journal emerges. Missions and goals specific to that subgroup of orthopaedic surgeons are established, and the subspecialty society might even hire its own lobbyist in Washington, D.C.”

This recurring phenomenon, he said, is an important issue because “the fragmentation that comes with sub-specialization impacts unity and our ability to deliver a clear, concise message will negatively impact our effectiveness.” He invoked the Benjamin Franklin admonition that “we must indeed all hang together or most assuredly we shall all hang separately.”

Priorities: MOC, alternative fellowship accreditation
Outlining the priorities he foresees as he begins his presidential term, Dr. Maloney said he intends to follow the example of responsiveness set by his immediate predecessor, Gerald R. Williams Jr, MD. “Instead of identifying a specific project to focus on during his year as president, Jerry made the conscious decision to address the needs of our members as they arose. We want this to be a member-driven organization where membership provides value.” 

Among specific member concerns that he will address, he said, is Maintenance of Certification (MOC) as brought forth by the Board of Councilors. “We heard loud and clear your frustration with MOC. Our members feel strongly that the process is overly burdensome and not reflective of individual practices,” Dr. Maloney said, to applause “The high-stakes exam every 10 years is especially unpopular. As a Board, we were asked to explore alternative pathways for MOC and we are doing just that with the expectation of a formal report to the Board in June. The American Board of Orthopaedic Surgery has participated in collegial discussions, hears our concerns, and is considering several new options. Specialty-specific exams are on the way. I am confident that as a result of our engagement, new pathways for MOC will be available in the relatively near future.”

An initiative that warrants continued attention is evaluation of alternative pathways for fellowship accreditation. “It was felt that the Accreditation Council for Graduate Medical Education (ACGME) process as applied to residency programs was overly regulated for fellowships and was biased against the standalone programs,” Dr. Maloney said, noting that in conjunction with the Board of Specialty Societies, a template is being developed for the AAOS and related specialty societies to accredit fellowships. “The ability to speak with a single voice in discussions with the ACGME has, I believe, lent significant credibility to the effort and impacted their willingness to review the topic and consider change.”

Two priorities that the Board of Directors will address at an upcoming workshop are advocacy efforts—with a focus on “how to improve on what is already a good operation”—and registries. Dr. Maloney said the AJRR is now flourishing, and the Board will seek to build on its success by including representatives from the American Academy of Ophthalmology and the American College of Cardiology to explore ways to use registries in the office to meet reporting requirements, document quality, “and, perhaps, meet MOC requirements.”

In closing, Dr. Maloney made four requests of his audience and the membership:

1. Be leaders in the community. “Be inclusive, commit to diversity, and support your colleagues.”
2. Provide feedback. “We want to focus our priorities as a Board on your priorities as orthopaedic surgeons, but can only do that with your good input,” including, at the Annual Meeting, sharing feedback through the My Academy app and at kiosks located throughout the Convention Center.
3. Commit to lifelong learning. “For the senior members of our group, [we do] very little of what we did as residents. You have to stay current in order to deliver the best patient care.”
4. Get engaged in the process. “Most of us don't have the time or inclination to get directly involved in politics … but we should contribute to the PAC.”

Dr. Maloney expressed his gratitude for the opportunity to serve as president. “I appreciate your support and will do my best to represent our profession as effectively as possible,” he said.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org