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Presidential address: American shoulder and elbow surgeons closed meeting
SOCIETY NEWS
Presidential Address: American Shoulder and Elbow Surgeons Closed Meeting La Quinta, California, October 20, 1995 I have drunk from wells I did not dig, and been warmed by fires I did not light. W e , who have traveled here by many paths, have had our thirsts quenched from the wells of accumulated knowledge. Each of us has been warmed and enlightened by men of genius who have taught us well. In my address today I will consider the state of our Society as it is today and the forces that will influence our direction in the future. Although treatises on shoulder disorders date back to Hippocrates and much of great value had been published earlier this century, the 1970s marked the beginning of an explosion of interest and new knowledge of the shoulder. The literature became abundant, and educational opportunities increased. Major centers of shoulder excellence developed, and a cadre of disciples, many of whom were trained or influenced by the teachings of men like Charles Neer, Carter Rowe, Anthony DePalma, Julius Neviaser, Charlie Rockwood, and others, began to establish shoulder clinics and fellowship programs throughout this and other countries. Kessel and DeBeyre come to mind as comparable leaders in Europe. In 1982 the American Shoulder and Elbow Surgeons was founded. Led by Charles Neer, the Founding Members of this Society represented the outstanding shoulder surgeons in America. Each of them was also in the forefront of shoulder education. They established the goals of the Society and its bylaws by which we are governed to this day. Once these were established, they set out to implement the membership by nominating additional ,~ SHOULDERELBOWS@RG] 996;5:157 60. Copyright @ 1996 by Journal of Shoulder and Elbow Surgery Board o{ Trustees.
3218171199
individuals whose shoulder-related activities up to that time met their qualifications for membership. I was among that group that was honored to be accepted in 1983. Within a few years, the membership ranks had swelled to 34. Today we number 148, in various categories of membership. Most of our newer members are now selected from among those who have been fortunate enough to have completed the few shoulder or sports medicine fellowships available and have demonstrated their continued dedication to shoulder research and education. Our role among the constellation of musculoskeletal societies is well established. The American Academy of Orthopaedic Surgeons (AAOS) looks to our membership to act as chairmen and faculty for every major shoulder course. The author of every contemporary textbook on the shoulder, from Bateman and Post in the 1970s to Neer, Rockwood, and Matsen in the 1990s, is a member of this Society. This holds true even for the most recent texts on shoulder arthroscopy. Today this Society can be compared to a spaceship that has achieved orbit. Only a short blast of power is required to correct or change course. Are we satisfied to circle the earth endlessly? Are we prepared to travel boldly into the future? The new wave of interest in shoulder disorders spawned by our founders has gained momentum and grown. When will it crest? How long will it be before a wide spectrum of orthopaedic generalists are able to deal proficiently with most shoulder disorders? Let us look at the knee for an analogy. A widening interest in the treatment of knee disorders began more than 10 years before interest in shoulder disorders developed. Knee joint replacement with the technology learned from hip arthroplasty 157
158
EIIman
was developed by a group of pioneers. More or less concurrently, the giants in sports medicine led the way in evaluating and treating knee injuries. Then arthroscopy was thrown into the broth! By the time our society was formed, most generalists were capable of performing knee replacements and arthroscopic knee surgery, and today that even includes cruciate repairs. The passage of time has barely dampened the attendance at the various subspecialty meetings dealing with the kneet This generation of graduating orthopaedic surgeons has no lack of mentors skilled in the ways of shoulder surgery, compared with the relative vacuum that existed when I completed my residency 40 years ago. This background has created an interest among many orthopaedic surgeons to expand their knowledge of the shoulder into a subspecialty. This tendency to develop subspecialty skills extends into every anatomic area today. In the most recent AAOS survey, 36% of the members identified themselves as generalists, 38% indicated they were generalists with special subspecialty interests, and 26% were specialists who worked at least 75% in one area. In 1988, 25% of the graduating orthopaedic residents entered fellowship programs. In 1994, 60% continued fellowship training after completing their residency. What's going on? I believe two factors are at play. One is technologic, and the other is economic. First, we are surgeons and predominately procedure-oriented. It has become increasingly difficult, if not impossible, for the generalist to keep up with everything that is happening in every anatomic area. The literature is overwhelming. The jigs, bells, and whistles that must be mastered to perform a hip or knee arthroplasty are far different from those required to perform spinal instrumentation. No wonder few perform both! It also follows that the surgeon with the most training and experience will perform a given operation best. Now enters the second factor--ECONOMICS. The current Medicare Reform Act advocates a $270 billion dollar reduction in funds, coinciding with a plan to reduce taxes by $240 billion. Both numbers will probably be somewhat less in the final version, but in any case the "health care providers" (doctors and hospitals) will take the biggest hit. Now notice, we are no longer referred to as "physicians and surgeons," we are "health care providers." Why? The answer is simple. As the result of past scientific and technologic advances, we have be-
J. Shoulder Elbow Surg. March/April 1996 come procedure-dependent. During the same period, other providers have moved into "musculoskeletal care" with nonsurgical techniques. A great many groups provide musculoskeletal care today. Although our physical therapists are our greatest allies and assets, many competitors exist. Physiatrists, osteopaths, chiropractors specializing in "Sports Medicine," podiatrists, and acupuncturists. In Los Angeles there are still advertisements extolling the virtues of a "High Colonic" for what ails you! Currently we orthopaedists are less interested in nonsurgical care. As managed care programs proliferate, diminished referrals are likely to occur. The general orthopaedist will be obliged to provide both nonsurgical as well as surgical care. The basis for our current problems is purely economic. Our government spends an inordinate amount of the Gross National Product for health care. Resources are increasingly limited, and the marketplace will eventually respond to the laws of supply and demand. The number of managed care patients increases daily, as does the number of physician networks offering reduced fees. Doug jackson, the Second Vice President of the Academy, has reported a substantial reduction in his income in the past few years. He poses an interesting question. How do we keep the fee-for-surgery surgeon from doing too much, or the salaried surgeon from doing too little? The small businessperson/physician may find the escalating cost of rent, malpractice insurance, employee salaries, and perks is simply not worth it in the face of declining reimbursements and opt br a salaried post (if a position is open!). How will the quality and the cost balance out? The market will decide. In the competitive economy ahead, we are at risk of losing our collegiality. I believe there is an alternative to this bleak scenario. More and more orthopaedic surgeons have signed on to one or more programs in which they agree to accept a reduced fee for service. As these managed care programs grow and consolidate, the number of orthopaedists on any panel increases. Inevitably the subspecialty interests within the panel will vary. Often established groups of orthopaedists, with members already identified as being proficient in one or more subspecialties, will join these organizations. The AAOS has stressed the importance of offering "point of service" contracts to managed care enrollees (permitting specialist referral). This, along with legislation that will prohibit financial incen-
J. Shoulder Elbow Surg. Volume 5, Number 2, Part 1 tives for nonreferral, will go a long way to allow patients in these programs access to quality health care. Both of these concepts are being considered in present legislation, but at this time passage is not certain. Under these circumstances I envision that most referrals to orthopaedic surgeons within the managed care program will be triaged to the surgeon with the most appropriate subspecialty skills. Referrals to the super-specialist will be reserved for the failed cuff repair or instability case or for the redo arthroplasty case. Otherwise the welfare of the patient is in jeopardy. The two factors I have been discussing, technologic overload and Economics 101, have already been discovered by the orthopaedic surgeons in America! Why else the dramatic interest in subspecialization among our Academy members and the phenomenal increase in fellowship applicants? There are now 18 subspecialty societies in the AAOS Council of Musculo-Skeletal Societies. The total membership in these societies is more than 10,000. We are a mere 102 shoulder/elbow practitioners when our corresponding, affiliate, and honorary members are subtracted. When the year of subspecialty fellowship ends, some of these men and women will enter a large orthopaedic specialty group or academic institution and receive all of the referrals in their specialty from other members. (If really fortunate, they will also have facilities for research.) Spine and shoulder are good examples. Most graduate fellows will enter a small, two- to four-person group, participate in the office triage, and share the call schedule. They will gain additional subspecialty experience quite gradually. They will actually use their generalist training well. When fellowship-trained orthopaedists enter private practice in the present economy, it will not be a question of being either a generalist or a specialist; both are necessary! They will do what they have to do. The market will decide! What will be the role of the American Shoulder and Elbow Surgeons when our educational crusade succeeds? When the wave splashes onto the beach and begins to ebb? The time will inevitably arrive when the generalist with subspecialty interest in the shoulder can ably evaluate and treat the painful shoulder at a far higher level of competence than even 10 years ago. I cannot conceive that at that point our Society will have served its purpose and will become obsolete or disband. Rather, we will continue our leadership role into the yet unknown advances of the future. Before we
EIIman
159
leave this subject, let us consider for a moment what opportunity the generalists who have gained proficiency in the shoulder will have to express their interest by joining some type of shoulder association. Clearly, many orthopaedic surgeons with skills and interests in shoulder surgery will lack the dedication to writing and teaching that would qualify them for this Society. Indeed, the completion of a fellowship by no means ensures subsequent admission to the American Shoulder and Elbow Surgeons. I propose that we begin consideration of a category of membership, or perhaps an affiliated association, that will encompass these clinically qualified individuals. The Hip Society and the Knee Society, both elite teaching societies, have helped develop an "Association of Hip and Knee Surgeons" numbering nearly 600 members. The ranks of the American Orthopedic Society of Sports Medicine have swelled to more than 1000 while retaining the elite Herodicus Society as the enclave of leadership. The Arthroscopy Association of North America approaches that number. With fewer than 100 members present, our Shoulder Specialty Day has enjoyed 600 to 900 attendees in recent years. We members are vastly outnumbered. The other specialty groups have a 50% ratio of members to attendees at their meetings. This augurs well for the development of an annual open meeting for our Society. I have no desire to destroy the intimacy and intellectual stimulation that accompanies this Closed Meeting of the American Shoulder and Elbow Surgeons. I have no specific suggestions on the methods or merits for developing some form of affiliated organization that will encompass the growing number of orthopaedic surgeons who share our interest in the shoulder. Today I am asking the Planning and Development Committee, composed of all of our past presidents, to deliberate on this subject and advise us on this matter. We must exert our leadership or abrogate the formation of such an association to others! Now, a few words about the aging of America and the impact on our subspecialty. Currently 12.8% of our population is age 65 years or older. By the year 2030, 28% of our population will be 65 years or older. The fastest growing segment of our population today is older than 85 years. We are all becoming geriatricians. More elderly patients will visit our offices, and the percentage of our time spent treating the elderly will increase.
160
EIIman
The AAOS is studying the effects of aging. As shoulder surgeons, we must develop outcome studies to confirm the most appropriate method of dealing with the inevitable increase of rotator cuff tears, arthritis, and proximal humeral fractures in an aging population. We will need to work closely with geriatricians and a variety of nonsurgical providers to meet the needs of the aged. The AAOS has asked our Society to include offerings on shoulder and elbow issues related to an aging population in our Instructional Course Lectures and in our Specialty Day and Annual Meetings. i want to end this address on a personal note. Elite societies and members of the establishment have been accused, at times, of hindering the introduction of progressive ideas. That can never be said of the American Shoulder and Elbow Surgeons. I was invited to join in 1983 because of my work on open shoulder surgery, yet I was allowed a forum 2 years later, at the First Annual Specialty Day Meeting, to present a preliminary report based on 10 cases of anterior acromioplasty with a highly controversial instrument--the arthroscope. Later, when I reported a follow-up study on 50 cases of arthroscopic acromioplasty in
J. Shoulder Elbow Surg. March/April 1996 Arthroscopy, the Editor, Ward Cassell, added the comment, "this paper appears to push the frontiers of arthroscopic surgery beyond anything that was dreamed of just a few years ago." For better or worse, arthroscopy is being integrated into the practice of shoulder surgery within the glenohumeral joint as well as the subacromial space. Some of you use it barely or not at all; others find that more than 50% of their shoulder operations involve the arthroscope. The success of any surgical intervention ultimately depends on the proper indications for, and execution of, the procedure--not what instrumentation is used! The quintessential value of the American Shoulder and Elbow Surgeons has been the establishment of a forum for new ideas. Codman expressed this challenge best when he wrote, "Give me something different, as there is a chance of it being better."l am honored to have served as your President. Thank you. Harvard EIIman, MD President American Shoulder and Elbow Surgeons Marina Del Rey, California
Presidential Address: American Shoulder and Elbow Surgeons Closed Meeting La Quinta, California, October 20, 1995 I have drunk from wells I did not dig, and been warmed by fires I did not light. W e , who have traveled here by many paths, have had our thirsts quenched from the wells of accumulated knowledge. Each of us has been warmed and enlightened by men of genius who have taught us well. In my address today I will consider the state of our Society as it is today and the forces that will influence our direction in the future. Although treatises on shoulder disorders date back to Hippocrates and much of great value had been published earlier this century, the 1970s marked the beginning of an explosion of interest and new knowledge of the shoulder. The literature became abundant, and educational opportunities increased. Major centers of shoulder excellence developed, and a cadre of disciples, many of whom were trained or influenced by the teachings of men like Charles Neer, Carter Rowe, Anthony DePalma, Julius Neviaser, Charlie Rockwood, and others, began to establish shoulder clinics and fellowship programs throughout this and other countries. Kessel and DeBeyre come to mind as comparable leaders in Europe. In 1982 the American Shoulder and Elbow Surgeons was founded. Led by Charles Neer, the Founding Members of this Society represented the outstanding shoulder surgeons in America. Each of them was also in the forefront of shoulder education. They established the goals of the Society and its bylaws by which we are governed to this day. Once these were established, they set out to implement the membership by nominating additional ,~ SHOULDERELBOWS@RG] 996;5:157 60. Copyright @ 1996 by Journal of Shoulder and Elbow Surgery Board o{ Trustees.
3218171199
individuals whose shoulder-related activities up to that time met their qualifications for membership. I was among that group that was honored to be accepted in 1983. Within a few years, the membership ranks had swelled to 34. Today we number 148, in various categories of membership. Most of our newer members are now selected from among those who have been fortunate enough to have completed the few shoulder or sports medicine fellowships available and have demonstrated their continued dedication to shoulder research and education. Our role among the constellation of musculoskeletal societies is well established. The American Academy of Orthopaedic Surgeons (AAOS) looks to our membership to act as chairmen and faculty for every major shoulder course. The author of every contemporary textbook on the shoulder, from Bateman and Post in the 1970s to Neer, Rockwood, and Matsen in the 1990s, is a member of this Society. This holds true even for the most recent texts on shoulder arthroscopy. Today this Society can be compared to a spaceship that has achieved orbit. Only a short blast of power is required to correct or change course. Are we satisfied to circle the earth endlessly? Are we prepared to travel boldly into the future? The new wave of interest in shoulder disorders spawned by our founders has gained momentum and grown. When will it crest? How long will it be before a wide spectrum of orthopaedic generalists are able to deal proficiently with most shoulder disorders? Let us look at the knee for an analogy. A widening interest in the treatment of knee disorders began more than 10 years before interest in shoulder disorders developed. Knee joint replacement with the technology learned from hip arthroplasty 157
158
EIIman
was developed by a group of pioneers. More or less concurrently, the giants in sports medicine led the way in evaluating and treating knee injuries. Then arthroscopy was thrown into the broth! By the time our society was formed, most generalists were capable of performing knee replacements and arthroscopic knee surgery, and today that even includes cruciate repairs. The passage of time has barely dampened the attendance at the various subspecialty meetings dealing with the kneet This generation of graduating orthopaedic surgeons has no lack of mentors skilled in the ways of shoulder surgery, compared with the relative vacuum that existed when I completed my residency 40 years ago. This background has created an interest among many orthopaedic surgeons to expand their knowledge of the shoulder into a subspecialty. This tendency to develop subspecialty skills extends into every anatomic area today. In the most recent AAOS survey, 36% of the members identified themselves as generalists, 38% indicated they were generalists with special subspecialty interests, and 26% were specialists who worked at least 75% in one area. In 1988, 25% of the graduating orthopaedic residents entered fellowship programs. In 1994, 60% continued fellowship training after completing their residency. What's going on? I believe two factors are at play. One is technologic, and the other is economic. First, we are surgeons and predominately procedure-oriented. It has become increasingly difficult, if not impossible, for the generalist to keep up with everything that is happening in every anatomic area. The literature is overwhelming. The jigs, bells, and whistles that must be mastered to perform a hip or knee arthroplasty are far different from those required to perform spinal instrumentation. No wonder few perform both! It also follows that the surgeon with the most training and experience will perform a given operation best. Now enters the second factor--ECONOMICS. The current Medicare Reform Act advocates a $270 billion dollar reduction in funds, coinciding with a plan to reduce taxes by $240 billion. Both numbers will probably be somewhat less in the final version, but in any case the "health care providers" (doctors and hospitals) will take the biggest hit. Now notice, we are no longer referred to as "physicians and surgeons," we are "health care providers." Why? The answer is simple. As the result of past scientific and technologic advances, we have be-
J. Shoulder Elbow Surg. March/April 1996 come procedure-dependent. During the same period, other providers have moved into "musculoskeletal care" with nonsurgical techniques. A great many groups provide musculoskeletal care today. Although our physical therapists are our greatest allies and assets, many competitors exist. Physiatrists, osteopaths, chiropractors specializing in "Sports Medicine," podiatrists, and acupuncturists. In Los Angeles there are still advertisements extolling the virtues of a "High Colonic" for what ails you! Currently we orthopaedists are less interested in nonsurgical care. As managed care programs proliferate, diminished referrals are likely to occur. The general orthopaedist will be obliged to provide both nonsurgical as well as surgical care. The basis for our current problems is purely economic. Our government spends an inordinate amount of the Gross National Product for health care. Resources are increasingly limited, and the marketplace will eventually respond to the laws of supply and demand. The number of managed care patients increases daily, as does the number of physician networks offering reduced fees. Doug jackson, the Second Vice President of the Academy, has reported a substantial reduction in his income in the past few years. He poses an interesting question. How do we keep the fee-for-surgery surgeon from doing too much, or the salaried surgeon from doing too little? The small businessperson/physician may find the escalating cost of rent, malpractice insurance, employee salaries, and perks is simply not worth it in the face of declining reimbursements and opt br a salaried post (if a position is open!). How will the quality and the cost balance out? The market will decide. In the competitive economy ahead, we are at risk of losing our collegiality. I believe there is an alternative to this bleak scenario. More and more orthopaedic surgeons have signed on to one or more programs in which they agree to accept a reduced fee for service. As these managed care programs grow and consolidate, the number of orthopaedists on any panel increases. Inevitably the subspecialty interests within the panel will vary. Often established groups of orthopaedists, with members already identified as being proficient in one or more subspecialties, will join these organizations. The AAOS has stressed the importance of offering "point of service" contracts to managed care enrollees (permitting specialist referral). This, along with legislation that will prohibit financial incen-
J. Shoulder Elbow Surg. Volume 5, Number 2, Part 1 tives for nonreferral, will go a long way to allow patients in these programs access to quality health care. Both of these concepts are being considered in present legislation, but at this time passage is not certain. Under these circumstances I envision that most referrals to orthopaedic surgeons within the managed care program will be triaged to the surgeon with the most appropriate subspecialty skills. Referrals to the super-specialist will be reserved for the failed cuff repair or instability case or for the redo arthroplasty case. Otherwise the welfare of the patient is in jeopardy. The two factors I have been discussing, technologic overload and Economics 101, have already been discovered by the orthopaedic surgeons in America! Why else the dramatic interest in subspecialization among our Academy members and the phenomenal increase in fellowship applicants? There are now 18 subspecialty societies in the AAOS Council of Musculo-Skeletal Societies. The total membership in these societies is more than 10,000. We are a mere 102 shoulder/elbow practitioners when our corresponding, affiliate, and honorary members are subtracted. When the year of subspecialty fellowship ends, some of these men and women will enter a large orthopaedic specialty group or academic institution and receive all of the referrals in their specialty from other members. (If really fortunate, they will also have facilities for research.) Spine and shoulder are good examples. Most graduate fellows will enter a small, two- to four-person group, participate in the office triage, and share the call schedule. They will gain additional subspecialty experience quite gradually. They will actually use their generalist training well. When fellowship-trained orthopaedists enter private practice in the present economy, it will not be a question of being either a generalist or a specialist; both are necessary! They will do what they have to do. The market will decide! What will be the role of the American Shoulder and Elbow Surgeons when our educational crusade succeeds? When the wave splashes onto the beach and begins to ebb? The time will inevitably arrive when the generalist with subspecialty interest in the shoulder can ably evaluate and treat the painful shoulder at a far higher level of competence than even 10 years ago. I cannot conceive that at that point our Society will have served its purpose and will become obsolete or disband. Rather, we will continue our leadership role into the yet unknown advances of the future. Before we
EIIman
159
leave this subject, let us consider for a moment what opportunity the generalists who have gained proficiency in the shoulder will have to express their interest by joining some type of shoulder association. Clearly, many orthopaedic surgeons with skills and interests in shoulder surgery will lack the dedication to writing and teaching that would qualify them for this Society. Indeed, the completion of a fellowship by no means ensures subsequent admission to the American Shoulder and Elbow Surgeons. I propose that we begin consideration of a category of membership, or perhaps an affiliated association, that will encompass these clinically qualified individuals. The Hip Society and the Knee Society, both elite teaching societies, have helped develop an "Association of Hip and Knee Surgeons" numbering nearly 600 members. The ranks of the American Orthopedic Society of Sports Medicine have swelled to more than 1000 while retaining the elite Herodicus Society as the enclave of leadership. The Arthroscopy Association of North America approaches that number. With fewer than 100 members present, our Shoulder Specialty Day has enjoyed 600 to 900 attendees in recent years. We members are vastly outnumbered. The other specialty groups have a 50% ratio of members to attendees at their meetings. This augurs well for the development of an annual open meeting for our Society. I have no desire to destroy the intimacy and intellectual stimulation that accompanies this Closed Meeting of the American Shoulder and Elbow Surgeons. I have no specific suggestions on the methods or merits for developing some form of affiliated organization that will encompass the growing number of orthopaedic surgeons who share our interest in the shoulder. Today I am asking the Planning and Development Committee, composed of all of our past presidents, to deliberate on this subject and advise us on this matter. We must exert our leadership or abrogate the formation of such an association to others! Now, a few words about the aging of America and the impact on our subspecialty. Currently 12.8% of our population is age 65 years or older. By the year 2030, 28% of our population will be 65 years or older. The fastest growing segment of our population today is older than 85 years. We are all becoming geriatricians. More elderly patients will visit our offices, and the percentage of our time spent treating the elderly will increase.
160
EIIman
The AAOS is studying the effects of aging. As shoulder surgeons, we must develop outcome studies to confirm the most appropriate method of dealing with the inevitable increase of rotator cuff tears, arthritis, and proximal humeral fractures in an aging population. We will need to work closely with geriatricians and a variety of nonsurgical providers to meet the needs of the aged. The AAOS has asked our Society to include offerings on shoulder and elbow issues related to an aging population in our Instructional Course Lectures and in our Specialty Day and Annual Meetings. i want to end this address on a personal note. Elite societies and members of the establishment have been accused, at times, of hindering the introduction of progressive ideas. That can never be said of the American Shoulder and Elbow Surgeons. I was invited to join in 1983 because of my work on open shoulder surgery, yet I was allowed a forum 2 years later, at the First Annual Specialty Day Meeting, to present a preliminary report based on 10 cases of anterior acromioplasty with a highly controversial instrument--the arthroscope. Later, when I reported a follow-up study on 50 cases of arthroscopic acromioplasty in
J. Shoulder Elbow Surg. March/April 1996 Arthroscopy, the Editor, Ward Cassell, added the comment, "this paper appears to push the frontiers of arthroscopic surgery beyond anything that was dreamed of just a few years ago." For better or worse, arthroscopy is being integrated into the practice of shoulder surgery within the glenohumeral joint as well as the subacromial space. Some of you use it barely or not at all; others find that more than 50% of their shoulder operations involve the arthroscope. The success of any surgical intervention ultimately depends on the proper indications for, and execution of, the procedure--not what instrumentation is used! The quintessential value of the American Shoulder and Elbow Surgeons has been the establishment of a forum for new ideas. Codman expressed this challenge best when he wrote, "Give me something different, as there is a chance of it being better."l am honored to have served as your President. Thank you. Harvard EIIman, MD President American Shoulder and Elbow Surgeons Marina Del Rey, California