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© 1998 The Journal of Bone and Joint Surgery, Inc. Let's Keep Our Eye on the Sparrow* , SAN ANTONIO, TEXAS*First Vice-President's Address. Read at the Annual Meeting of the American Academy of Orthopaedic Surgeons, New Orleans, Louisiana, March 21, 1998.
President Jackson, fellows of the American Academy of Orthopaedic Surgeons, family, and friends: I am honored beyond description to serve as the next President of this, the greatest professional society in the world, and I shall do everything in my power to uphold the confidence that you have vested in me.
It was Sir Isaac Newton who said: "If I have seen further, it is by standing on the shoulders of giants." Certainly, that is where I am standing today. Before I begin my formal remarks, I want to express my appreciation to all of those giants in orthopaedics who have preceded me in this office. I hope to emulate the standards set by them. I want to thank four in particular who have strongly influenced my career. Dr. John Gartland: my teacher when I was a third-year medical student at Jefferson Medical College in Philadelphia. I will never forget the day he showed me a prototype Charnley total hip prosthesis and said: "This is going to revolutionize the practice of orthopaedic surgery." Dr. Roby Thompson: who, along with Dr. Warren Stamp and the faculty at the University of Virginia, taught me to be an orthopaedic surgeon—often a formidable task for them. Dr. John Hinchey: my close friend and adviser who has taught me much about the traditions and values of this organization. Dr. Charles Rockwood: my predecessor in the chairmanship in San Antonio and perhaps the most creative orthopaedic surgeon whom I have ever met. I want also to thank my parents, James A. and Virginia M. Heckman, for standing shoulder to shoulder in support of my career at every turn. It certainly was through his example that my father taught me to be a good doctor and through his satisfaction that I learned how much fun it is to be an orthopaedic surgeon. As I get more involved with this job, it becomes very apparent that one really needs more than the shoulders of giants to stand on. Not infrequently, one also needs a shoulder to cry on. For all the love and support that they have given me throughout the years, let me publicly say thanks to my immediate family: our children, Coleman and Betsy, and especially my dear wife, Susan. I love you guys. The work at home must go on while the Heckmans are traveling around the world representing this great organization. My thanks also goes to my partners, faculty, and staff in the Department of Orthopaedics in San Antonio for keeping their shoulders to the wheel, particularly during this coming year. Finally, thanks would not be complete without acknowledging the superb staff in the Academy's office in Chicago or, as Carl Sandburg called it, the "City of the Big Shoulders." Led by our Executive Vice-President, Bill Tipton, the Academy staff is world-class and simply wonderful. I will conclude my thank-yous by reminding everyone of this quote from Sir F. M. R. Walsh who, in his address as President of the Canadian Medical Association in 1952, said: "Medicine is the oldest learned profession in the world, and it is rooted in its past. Each successive generation of doctors stands, as it were, upon the shoulders of its predecessors, and the fair perspectives that are now opening before you are largely the creation of those who have gone before you." As I stand proudly on the shoulders of the great individuals who have preceded me in this office, the direction in which this Academy is going is very clear. Guided by a strong strategic plan that keeps us focused on the important issues and working in collaboration with an incredibly talented Board of Directors, it is my promise to you that over the next year a lot of very important and positive events will occur. In each and every case, the steps that we as an Academy Board take will have one primary motivating factor: the welfare of our patients will always be our highest consideration. Here in New Orleans, home of Dixieland jazz, many great songs have been spawned. One of the greatest of those and one that you will hear sung frequently, whether in bars or churches, is entitled "His Eye is on the Sparrow." I have chosen as the theme for this talk the phrase "Let's keep our eye on the sparrow," to remind us that whatever we do in our professional lives must be focused on the welfare of our patients. All other considerations, whether they be political benefit, personal achievement, or economic satisfaction, must be secondary. An obligation that one has when preparing this speech is to read the talks of one's predecessors. Over the years, many hot political, socioeconomic, health-care, and educational issues have arisen and temporarily taken front stage. However, one enduring theme overall began with Willis Campbell's speech in 1934 when he said: "The main objective [of the Academy] is an unselfish one, that is, the development of the specialty for the best interest of the patient and not for personal or collective aggrandizement." This absolute imperative to keep our patients' welfare in the forefront has been a part of every First Vice-President's speech since that time. As we set the agenda for the coming year, let's keep our eye on the sparrow and always do that which is in the best interests of our patients.
One overarching theme that can accomplish this objective and that can be developed within the Academy structure, among orthopaedic societies, and even in our local orthopaedic communities is that of unity. This year, we will strive to further unify orthopaedics in several ways. The Academy has three major focuses of activity represented by the three Councils: Education, Research and Scientific Affairs, and Health Policy and Practice. When these three Councils were created ten years ago, it was hoped that these related, but fairly independent, activities would thrive in an organization structured to support their individual growth and development. That certainly has been the case, but an interesting phenomenon has occurred over the last couple of years: we can see a real fusion of all three of these endeavors occurring, with the patient as the common element that unites them. When I was Chairman of the Council on Education, we were quite proud of the continuing-education activities that the Academy produced. It was our goal to convey contemporary orthopaedic knowledge by as wide an array of media and opportunities as possible. This plan has generated a vast bonanza of well produced continuing-education courses, publications, and audiovisual materials. What was lacking, however, was a common thread directing our educational programs. Over the last two years, the Council on Education has taken a critical look at the educational needs of the practicing orthopaedist. It has correctly and clearly identified the importance of increasing the emphasis on value generation when planning the content of all of our continuing-education activity. Applying this principle will greatly enhance the value of the educational experience to each and every one of us and in turn make it that much more relevant to our patients. One way to enhance the value of the continuing-education experience lies in our ability to assess outcomes data generated by large numbers of patients receiving orthopaedic care. These outcomes data provide the basis for the development of practice guidelines, algorithms, and clinical pathways. Generation of outcomes data has become the most important task of the Council on Research and Scientific Affairs. Specifically, the Task Force on Data Management has been responsible for the development of the Academy's forward-thinking, standard-setting clinical outcomes research program, which is now affectionately known as MODEMS. What could be more patient-oriented than the development of a continuing-education program that is based in great part on the patient's perception of the benefit of our intervention? This example shows how the educational and research endeavors of the Academy have become very much intertwined. The third major focus of the Academy is on health policy and practice. Often, pocketbook issues push to the forefront of our concerns in Washington. While the Academy will continue to provide as much relevant, objective data as we can to the health-policy-makers to support the economic interests of the practicing orthopaedic surgeon, our greatest advances in Washington continue to be those that focus on the welfare of the patient. Our most notable example of success in this area has been the Access to Specialty Care Coalition. Under the able direction of Nick Cavarocchi, this coalition has enrolled more than 100 physician and patient-advocacy groups and has lobbied very effectively to maintain a direct and open pathway for our patients to the specialist of their choice. The coalition has been successful because its primary purpose resonates positively with the desires of our patients. These examples clearly reflect how well integrated and interdependent all three of our major Academy initiatives are. As we move forward in the era of evidence-based disease management2, further horizontal integration and interdependence of the various Academy endeavors will be essential. Unity has been and will continue to be a strong characteristic of your Academy leadership as well. One concern that I commonly hear voiced by the fellowship is that there is a preponderance of academic orthopaedists running the day-to-day affairs of the Academy, somehow leading us away from the right course of action. Having spent my career there, I will agree that there are some individuals in academic orthopaedics who find a safe harbor from the rigors of private practice in the academic environment, but I can assure you that very few, if any, of those individuals are in leadership positions in academic orthopaedics or our Academy today. The typical academic orthopaedist today is faced with severe demands to be efficient and productive in the clinical environment. Most of our departments receive minuscule amounts of financial support from our parent institutions. Indeed, for the most part, academic orthopaedic departments are expected to contribute positively to the bottom line of the universities in this country. In order to be successful, academic leaders must be astute businesspeople who not only can deal with the vagaries of the private practice of medicine but also must do so within the convoluted bureaucracies of academic institutions, usually in a complex multispecialty group-practice setting. It is from these ranks of academic orthopaedists that a substantial portion of the leadership of this organization is derived. I can assure the fellowship that these leaders are extremely savvy about the issues of workforce and health-care reimbursement as well as other practice issues. Furthermore, overall, your Board of Directors is very representative of practicing orthopaedic surgeons. This past year, nine of the sixteen members of the Board characterized their activity primarily as the private practice of orthopaedic surgery. The close relationship that has developed between the Academy leadership and the Board of Councillors has further enhanced a sensitive and clear understanding of the current circumstances of the practicing orthopaedic surgeon. Every fellow can rest assured that the decisions arrived at by the Board of Directors have not been and will not be made in a vacuum. Rather, the Board will solicit grassroots input and rely on consensus-building to make unified decisions that serve best most of the fellowship. Unity is not just important within the organizational structure of the Academy. As we move forward to advance the care of our patients, we must do so with a united front across all of orthopaedics. Dr. Rockwood, in his landmark First Vice-President's Address in 1984, urged us to "keep the orthopaedic family together." As a consequence of that initiative, the Council of Musculoskeletal Specialty Societies was formed, and over the last decade we have seen substantial unification of purpose among the orthopaedic societies. Through the inspiration of Jim Strickland and under the guidance of Ken DeHaven and Doug Jackson, we have done much to build bridges within the orthopaedic community. Currently, our relationships with the American Orthopaedic Association, the regional orthopaedic societies, the Orthopaedic Research and Education Foundation, and the Orthopaedic Research Society are stronger than they have been in many years. We will continue to strengthen those bridges in very real ways over the next year. In addition to organizational unification, I hope that during the coming year we can place a higher priority on establishing and maintaining unified and collegial relationships with our fellow orthopaedists in our local communities. The pressures of the marketplace often strain collegial relationships within the local orthopaedic community. We must strive to overcome our urges to make the fellow down the street the target of our anger and concern as managed care encroaches on our practices and our incomes. We must realize that our fellow orthopaedists are not the enemy. Indeed, in this fight to protect the quality of care given to our patients, they our best allies. I sometimes wonder if we could learn a lesson from our colleagues in the legal profession. After completing a rather contentious deposition for one of my patients, I am always amazed at the lawyers' behavior. During the deposition, they aggressively and sometimes malignantly attack each other, but as soon as the court reporter turns off the machine the two are discussing where to go to lunch or to play golf! Despite the competitive nature of their encounter, the two maintain a degree of professional respect toward one another. If even lawyers can do this, perhaps we can learn something from their example. Let's not make snide or demeaning comments about our orthopaedic colleagues in an offhand way in public or in front of patients. Rather, let's use the proper forums of peer review and quality assurance within our local professional organizations to criticize constructively when we believe that the best possible care has not been provided. Let's join together in our local communities to share continuing-education experiences, treat our fellow orthopaedists with collegiality and respect, and focus together to counteract the egregious behavior of the industries and institutions that threaten the quality of care given to our patients. To summarize my emphasis on unity: we must stand united within the Academy, among orthopaedic organizations, and even in our own communities as we keep our eye on the sparrow, doing what is best for our patients.
Now I would like to address some of the initiatives that will characterize the activity of your Academy during the coming year. In this setting of dramatic changes in the practice of orthopaedic surgery, as I indicated before, the Presidents who have preceded me have reached out to the other national orthopaedic organizations in positive ways. One of the important joint initiatives supported by the Academy, the American Orthopaedic Association, and many of our specialty societies over the last two years has been a study of the orthopaedic workforce that was conducted by the RAND Corporation3 and was published in our official scientific journal, The Journal of Bone and Joint Surgery. The issues of workforce will be of paramount concern during the next year. In this country, there are almost 20,000 orthopaedic surgeons—the physicians who are most expert at providing care for all aspects of the musculoskeletal system. With the advent of managed care, we are now hearing more and more that there are too many orthopaedists for the American population. Indeed, according to managed-care models, there are 50 per cent too many orthopaedic surgeons. According to the RAND study3, which was based on a demand model, there are 20 per cent too many of us and this oversupply could continue for at least the next twenty to thirty years. Needless to say, these statistics are distressing and they represent the most common cause of concern raised by you, the fellowship. In particular, there is the abiding concern that this oversupply will increase the competition for the existing orthopaedic patient-population base. These concerns have had unfortunate consequences, leading to an increase in competition and a decrease in collegiality and even in professional respect among fellow orthopaedic surgeons. We need to address this problem. While the problem is real, some of the simple solutions that have been proposed will have little effect on workforce numbers: 1. Many individuals have recommended a mandatory decrease in residency positions in orthopaedics. While the marketplace is moving in this direction, it is moving very slowly. Today, the Residency Review Committee for Orthopaedic Surgery has seen a decrease of only twelve graduates per year, from 617 to 605, through formal requests by program directors to reduce their resident complement4. Such a small decrease caused by voluntary cutbacks and market forces alone certainly will not be enough to have a substantial impact. Even massive cutbacks now will have no appreciable effect for at least a decade. We have heard the question frequently: "Why doesn't the Academy cut the number of residency positions?" Because the members stand to gain a direct financial benefit from any steps that the Academy would take to influence the number of residency positions, this is not a practical solution for this Academy or any similar association. The Academy can, however, provide useful information to decision-makers who can influence the number of residency positions. This spring, at the meeting of the American Orthopaedic Association, we will present a symposium in which we will bring together the leadership from the Residency Review Committee for Orthopaedic Surgery, the American Board of Orthopaedic Surgery, the Academic Orthopaedic Society, and other interested groups to discuss in an open forum the issue of workforce and how the number of orthopaedic residents being trained in this country can be influenced without raising the concerns of the Federal Trade Commission. 2. Another approach to addressing the oversupply of orthopaedic surgeons is for each of us to cut back voluntarily on our clinical activity. Some have said that orthopaedists work too hard and that if we only cut back from eighty hours a week to sixty hours a week the workforce issue would be resolved immediately. Unfortunately, this is not such a simple solution either. Most of us like our current work style. Furthermore, voluntary reduction of our activity in the marketplace will only create an opportunity for non-orthopaedic surgeons to fill the void. A decade or two ago, when we were fat and sassy, we decided to limit our practices to those aspects that were fun and well remunerated. We chose not to counsel elderly women about the prevention and treatment of osteoporosis, we chose not to provide foot-care services in our offices, and often we did not get up in the middle of the night and go to the emergency room to treat a simple fracture. The void created by our absence was immediately filled by internists, podiatrists, emergency-medicine physicians, and others hungrier than we and willing to perform the more mundane, less glamorous tasks of musculoskeletal care. I am sure that if we were to voluntarily cut back further on our scope of practice, other providers, often with fewer qualifications, would step in and provide those services. 3. Early retirement represents a third option for us to cut back the provision of our services. For some, given the vicissitudes of the marketplace during the last decade, this is becoming a more attractive alternative. However, of those who have tried it, many are unhappy and their wives are miserable. You must remember, she married you for better or worse, but not for lunch every day! Given these options, I do not think that the answer to the workforce problem will be found by truncating the amount of musculoskeletal care provided by orthopaedic surgeons. Rather than attacking the supply side of this equation, I suggest that a better approach can be made on the demand side. Why not expand the practice of orthopaedics, expand our horizons, and take the expert education and training that we have been provided both through our residency programs and through the continuing-education programs of our Academy and deliver it in a broader context, to more patients, in more venues? The RAND study3 clearly shows that one key element in the workforce equation is the demand for orthopaedic services that are reasonably priced. Who is better educated and trained to provide musculoskeletal care than we? Why do we need to sit and whine about podiatry and chiropractic encroaching on our practices? Why not turn the tables and aggressively pursue that part of the market by promoting ourselves to primary-care providers and the public as the best providers of care in these arenas? There are several ways in which we can accomplish this objective: 1. We should continue to work through the Patient Access to Specialty Care Coalition in Washington and similar state coalitions to ensure that our patients continue to have wide-open and direct access to our services, without going through intermediary steps. 2. We should explore attractive alternative forms of orthopaedic practice to provide options for those fellows who wish to leave a surgical practice. During the past eighteen months, we have seen a resurgence of interest in alternative forms of orthopaedic practice among a fairly substantial segment of our fellowship. In particular, there has been a strong interest in enhancing and developing further the office practice of orthopaedics. As we see our surgical load decreasing for one reason or another, many of us find that we have more time to spend in the office with our patients. Since we know that patient satisfaction is one of the key elements of the successful clinical practice of orthopaedics, spending more time in the office with our patients certainly cannot hurt us. More importantly, however, with more time being available to us in the office, we need to look to expand the actual scope of what we do there. To that end, we are creating a Board of Directors task force this week to explore the expansion of the scope of orthopaedic practice. One focus of this task force will be on the office practice of orthopaedics. In no way will this endeavor compromise our commitment to the practice of orthopaedic surgery, but it will enhance the quality of office practice both for the orthopaedic surgeon and for his or her patients. 3. In the several symposia and courses that the Academy has held over the last eighteen months to explore the subject of alternative forms of orthopaedic practice, a surprising array of alternative interests has been presented. This year, we plan to explore the creation of a Shared Interest Group within the Academy to include all fellows who wish to investigate new and alternative pathways in the delivery of musculoskeletal care. 4. Those of us who remain actively involved in the traditional practice of orthopaedic surgery need to reclaim some of the areas in which we have defaulted in years past. Perhaps we should get out of bed at night and come back to the emergency room to treat the patients who are now being managed by others in primary-care and emergency medicine. Perhaps we should train our cast technician or office nurse to trim corns, calluses, and toenails, and maybe we should take the time personally to instruct our patients in rehabilitation principles after shoulder and knee surgery rather than delegating all of that responsibility to physical therapists. Whatever avenue we take, our efforts should be directed at expanding our scope of practice and enhancing our presence in the marketplace, always with the goal of providing the very best care to patients who have musculoskeletal problems, anytime, anywhere. It is in this way that we can take some very positive steps to address the workforce issues that will continue to face us over the next two decades. This year, I will assign the Board of Directors the task of creating a menu of viable, reasonable, attractive, and patient-care-directed methods of expanding the scope of orthopaedic practice. 1. We will work in collaboration with orthopaedic industry through our newly created Corporate Advisory Council and with the Federal Drug Administration through our Device Forum to bring new, safe, and effective orthopaedic technologies to the marketplace in a more timely manner. 2. We will work through our International Committee to explore additional opportunities to deliver high-quality orthopaedic care to underserved areas of the world. 3. Through the newly created Task Force on Volunteerism, we will look for ways in which we can enhance, in a meaningful way, the delivery of high-quality musculoskeletal care to underserved populations here at home. 4. Through our outcomes research initiatives, we will demonstrate once and for all that most things that we do enhance our patients' quality of life and sense of well-being. Armed with that information, the Academy will continue to ensure that all of our patients have access to our services through our interactions with the policy-makers, both in Washington and at the state level. 5. We need to emphasize not that there should be limits to the scope of practice of primary-care practitioners or to the number of licensed practitioners but rather that the scope of practice of orthopaedics should include the entire field of musculoskeletal care. We must be ready and willing providers of that care and then there will be no need to grant an extended scope of practice to individuals who are neither as well educated nor as well trained to perform those services. 6. Finally, through our Council on Research and in collaboration with industry and the Orthopaedic Research and Education Foundation, we are going to redouble our commitment to clinical and basic research. We cannot afford to let happen what has occurred in other countries when financial resources became so tight that no dollars were left for basic, innovative research initiatives. What would orthopaedics be today if research funding provided by industry and clinical-practice dollars as well as granting agencies, such as the Orthopaedic Research and Education Foundation, the National Institutes of Health, and the Veterans Administration, had not supported the development of total joint arthroplasty and arthroscopy as well as the tremendous advances in techniques of fracture care? We would probably still be treating fractures with casts, torn ligaments with crutches, and arthritis with drugs. What would our scope of practice be today without those initiatives? Who knows what the next set of advances in the delivery of orthopaedic care will be? As we move into the era of biological solutions to biological problems, we will have an artificial meniscus, we will be able to reconstitute articular cartilage, and we will be able to further enhance the fracture repair process. But we will be able to do these things only if we continue to allocate a certain proportion of our time, energy, and resources to both basic and applied research. Over this next year, we are going to focus on methods to incubate and promote the development and clinical application of new orthopaedic surgical technologies that will make the practice of orthopaedics twenty-five years from now as different as the current practice of orthopaedics is from what it was twenty-five years ago. The combination of all of these efforts should expand the scope of practice to such a degree that in twenty-five years there will be a demand for more, not fewer, orthopaedic surgeons.
In this discussion of the directions for the coming year, I have addressed major health-care policy and research issues and left for last my most abiding and fervent interest in the Academy's role in orthopaedics: education. Having spent my career as an educator, I want to reassure everyone that, despite the dramatic changes that are taking place in the health-care arena, despite the apparently monumental restructuring of our organization itself, despite our apparently myopic focus on health-care policy issues, and despite the horrible distractions caused by our litigious environment, the major endeavors of your Academy over the next year will be focused on enhancing our already rich and robust educational offerings. This endeavor will take many forms. The Council on Education is continually reassessing and reevaluating our educational programs. Through its initiative entitled CME-2001, the Council will incorporate the concept of value generation into each of its offerings. We receive feedback from our outcomes research initiatives that demonstrates the effectiveness or ineffectiveness of specific orthopaedic interventions for specific diseases. This information will be put directly into our continuing-education programs so that the clinician will be able to identify the interventions that are of value to the patient and those that provide little or no enhancement of the patient's quality of life. In order to achieve this objective, we need to nurture and vigorously support the development of a musculoskeletal outcomes database. To this end, your Board of Directors, at its December meeting, recommended the creation of a separate not-for-profit corporation called the Musculoskeletal Education and Research Institute and committed one million dollars of our reserves to fund its operation over the next two years. This organization will promulgate outcomes instruments, collate the information derived from those instruments, and provide useful feedback to the individual practitioner. It will be a broad-based organization comprising individuals from within and without orthopaedic surgery. The Board of Directors has made a strong commitment to this initiative, hoping that within the next two years the outcomes database will be sufficiently large to provide useful information about many musculoskeletal conditions. To enhance its chances of success, I am calling on the Council of Musculoskeletal Specialty Societies to become more actively involved in this process. Already a couple of our subspecialty societies have made a commitment to use the outcomes instruments that have been developed through the MODEMS program, and I am going to ask the leadership of the Council of Musculoskeletal Specialty Societies this year to encourage all of the specialty societies to become active participants in that program. The second focus of our educational endeavors this year will be on surgical skills. Your Academy is committed to the enhancement of the surgical skills of all orthopaedic surgeons. Despite the fact that, as I said earlier, there is much more to orthopaedics than surgical intervention, what distinguishes us from all others is our surgical skills. One practical program that we have initiated at this Annual Meeting is an effort to eliminate the rare but unfortunate occurrence of wrong-site surgery. Characterized by the theme "mark your site," this program, when implemented and enforced in the surgical suite, has been shown to virtually eliminate the chances of operating on the wrong limb or body part. I hope that you will take the information about this program home and start to use it right away. With the Arthroscopy Association of North America, we presently have the most sophisticated state-of-the-art surgical skills education facility in the world in the Orthopaedic Learning Center at the Academy's headquarters in Chicago. This year, there will be a major advance in the Academy's long-term support of that facility to enhance it with new and contemporary surgical instruments, improved classroom facilities, the creation of a hotel facility on the adjacent parking lot that will provide first-class hotel rooms and superb meeting-room space for both the Orthopaedic Learning Center's educational activities and the Academy's administrative needs, new methods of evaluating on the spot the effectiveness of teaching surgical skills so that a participant in one of our courses can go home with the assurance that he or she has learned the appropriate method of performing a new procedure, and an enhanced library of educational resources with individual study carrels and computer terminals that access the entire world of orthopaedic information. An environment will be created in the Orthopaedic Learning Center where one can learn about any aspect of orthopaedics and even practice for the Board recertification examination without leaving the facility. In addition, the Academy's support will provide a mechanism whereby the continuing escalating costs of surgical skills education for the fellowship will be held in check, at least for the next five years, so that the cost of learning does not exceed its value. This financial commitment to surgical-skills education is a landmark decision on the part of the Board of Directors. It endows what we as an organization are all about: enhancing the education of the orthopaedic surgeon. This Annual Meeting remains the preeminent educational event in American medicine. Thanks to years and years of effort from the staff and volunteers, what you are experiencing today is a showpiece for continuing medical education. While some may call it a wild and crazy circus that tries to do too much for too many folks in too long a time, over a three-year period 80 per cent of the fellowship attends this meeting. The Annual Meeting is admired by many medical specialty societies who try to emulate our success. In these changing times, however, it is necessary that we remain contemporary. After a very critical self-appraisal that was conducted this past year, we are going to be adapting and modifying the Annual Meeting over the next two years to even better meet the educational needs of the fellowship. Finally, in the educational arena, we look aggressively toward the future. There may be a time not too far off when surgical skills education and all that you can acquire at the Annual Meeting, except perhaps the opportunity to share a meal with a colleague, can be accomplished through virtual reality as you sit at your home computer. While I am not sure how Bill Gates could ever transport Bourbon Street to my office, we must be prepared to embrace effective new educational modalities as they come along. Thus, this next year we are going to continue to explore and experiment with new methods of continuing medical education such as teleconferencing, live surgical demonstration projects, and the more esoteric medium of virtual reality. Whatever seems to be a possibly effective means of delivering orthopaedic knowledge will be explored and tailored to the needs of the practicing orthopaedic surgeon. This is a bold agenda for the coming year. It will be accomplished as we go through some structural changes that have become absolutely essential to protect the major educational and research missions of our Academy. Your Board of Directors will operate under the guidance of an overarching strategic plan that ensures that the patient remains the primary focus of all of our activity. I am deeply honored to serve as President of this superb organization, and I simply ask as we go forward this year: "Let's keep our eye on the sparrow." Doing so, we cannot go wrong. Thank you very much.
Department of Orthopaedics, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284.
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