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© 1999 The Journal of Bone and Joint Surgery, Inc. Five Rings of Musashi* , BOSTON, MASSACHUSETTS
Mr. President, fellow members of the American Orthopaedic Association, distinguished guests, ladies, and gentlemen: I want to thank you for the honor you have bestowed upon me. This is a proud moment, and, like my predecessors, I am both humbled and excited by the task you have set for me. The humbling part, by the way, came quickly, as soon as I started preparing for this speech. There is nothing quite so intimidating as going back through the history of our Association and reviewing the thoughtful commentaries of its past leaders. But as I did so, and as I took stock of our current situation, my excitement began to build. I found, in my reading, that our history as an association is as rich and diverse as the worlds of science and medicine, paralleling the changes in our society and nation. It is replete with the timely words and exceptional deeds of renowned medical and scientific thinkers and scholars who led this Association from its beginnings, back in 1887, with the election of its first President, Dr. Virgil Gibney—although in those days we were considered nothing more than "fitters of apparatus," according to our fourth President, Dr. DeForest Willard19. Then the American Orthopaedic Association entered the twentieth century—a century of extraordinary discovery and remarkable advances in orthopaedic surgery6. Stu Weinstein, in his 1997 Presidential Address, observed: "At its inception, The American Orthopaedic Association had only one purpose, which was unmistakable and unambiguous: the advancement of orthopaedic science and art, a goal aimed at the establishment of our specialty as a recognized branch of medicine."18 This original purpose has changed and expanded over our 112 years of existence. Our current mission statement, adopted last year, reads as follows: To build our second century of leadership and excellence in musculoskeletal care worldwide, the American Orthopaedic Association will (1) develop, recognize, and engage leaders, (2) initiate and sustain collaboration among all interested organizations to serve our communities, shape orthopaedic policy, and achieve our shared missions, (3) foster graduate and undergraduate medical education of orthopaedists, (4) foster education pertinent to all caregivers and to patients, (5) encourage and support scientific investigation, and (6) monitor, assess, and support highest-quality care2. Now, standing at the portal of a new millennium, we are the ones to whom the charge has fallen. We must accept it with humility and pledge to continue the legacy of our founders. The challenges may be great and the obstacles may be many, but the opportunities for success are as boundless as our creativity, as positive as our resolve, and as thoroughly enriching as our imaginations will allow. We are leaders in the amphitheater of medicine's future and are poised at the threshold of unimaginable technological advancements: incredible diagnostic care, molecular technology, genetic research and gene therapy, tissue engineering, new arthroscopic equipment, and minimally invasive operative techniques. There is an ancient Chinese curse: May you live in interesting times. As we all know, these are interesting times for our profession—at once difficult and demanding and yet, to me, also invigorating. What lies before us is a rare opportunity to shape the fate of our discipline as we make the transition into a new millennium. And that, I believe, is an opportunity not to be missed. As I looked back in time and read the commentaries and speeches of my predecessors, I realized that for so many of those years, in the early history of this Association, change came very slowly, and we were equally slow to react to it. Now, change comes at the speed of light, with the click of a mouse, and in an electronic flash that circles the world in an instant. We must not only react to it; we must capture it and make it work for us. Indeed, we must initiate it. We seem, these days, to find ourselves constantly bombarded with choices and decisions and forced to adjust to new ideas, new plans, explosive global technocracy, economic pressures, an information glut, and a shrinking world made even smaller by bigger and faster computers. All of these changes are fundamentally altering our way of life and our way of medicine—in some ways for the better and, sadly, in some ways not. The architect William McDonough, Dean of the School of Architecture at the University of Virginia, likes to ask his new students who they think is the most powerful person on a ship. Most answer the captain, some suggest the cook, but almost no one guesses the correct answer. The most powerful person on a ship, McDonough tells them, is its designer, because that, after all, is who decides how fast, how efficient, and even how seaworthy the ship will be. McDonough poses this riddle to make a point about his profession, of course. But his deeper message is that if we want something to work a certain way, our first task is to design it that way. Positive results are the product of good design. Some of you may know the Longfellow poem called "The Building of a Ship."14 In it he wrote:
Build me straight, O worthy master! Staunch and strong, a goodly vessel, That shall laugh at all disaster, And with wave and whirlwind wrestle.
What I would like to suggest today is that what is true of ships and buildings is true as well of the profession of orthopaedics. As the current practitioners of this art, we are the architects of its future, and we will one day be measured by the integrity of our design. Now, that may be a challenging notion. Professions by their nature are complex organisms, exponentially more intricate than either ships or buildings4. It could be argued that professions evolve organically, in response to stimuli too numerous to count and too independent to control. A profession is a dynamic system operating within a host of other dynamic systems. How could it be possible to design for such complexity? If you think about it, however, a ship is a system, and so is the sea. We cannot control the sea, yet we can design a vessel capable of weathering its storms. We can design a vessel that takes us not just to where the sea decides but to the places where we actually want to go. That, as I see it, is our challenge and the challenge for this Association: to continue charting a course for our profession and ensuring that this ship of ours will be capable of surviving the journey. The sea is rough. We are being driven by the crosscurrents of managed care and big business and buffeted by the high winds of technological, social, and political change. In this environment, the price of drift—both for us and for our patients—is unacceptably high. Just as well designed ships sail forth on the unpredictable sea, so do ill designed ships founder. Similarly, just as well designed systems produce positive results, so do ill conceived systems produce perverse results. Nowhere is this more evident than in managed care. As medicine becomes more about profit than about health, and as physicians are given even more powerful incentives to withhold care, the interests of the doctor and the patient are being pushed out of alignment. We find ourselves operating within a health-care system that is almost perfectly designed, however inadvertently, to undermine the essential bond between patient and doctor. That bond is the foundation of all good medicine, yet that is precisely the direction in which the medical profession now finds itself drifting. Drift might be too gentle a word to describe how managed care is tugging at us. It is more of a riptide than a gentle current. Mergers are rampant, at the expense of commonsense medical care. Spending on medical research is inadequate. Funding for medical education has been cut and its survival threatened. Our major academic institutions are operating in the red. In a recent New York Times editorial entitled "Hospitals in Crisis,"11 Bob Herbert stated: "A deep financial crisis is spreading like a virus through the nation's teaching hospitals. It is undermining their honorable and historic mission, which has been to train new generations of physicians, to conduct critically important medical research and to provide treatment, for, among others, the poor." Many academic medical centers are losing money, beginning with the Allegheny Health System, which filed for Chapter 11 protection last year with a 1.5-billion-dollar debt. The University of Pennsylvania Health System lost ninety million dollars; Temple University Health System, twenty-four million; and Jefferson Health System, thirty million. In Boston, Care Group lost ninety million dollars and is rumored to have an even larger loss this year, and Partners HealthCare System is expecting a loss from operations of between fifteen million and sixty-one million dollars. University of California at San Francisco/Stanford Health System is experiencing increasing losses, projected at 135 million dollars next year, forcing Stanford to announce plans to eliminate 2000 positions, or 15 percent of its workforce. Hospital bond ratings are falling, making it difficult or impossible to borrow. Philadelphia is a classic example of today's marketplace: Moody's Investor Services has downgraded all four academic medical centers in that city. There, the formation of rapidly built networks without major restructuring has led to duplications and excessive overhead. As a result, extreme price competition is hammering the academic medical centers. The Balanced Budget Act of 1997 was designed to eliminate the federal budget deficit by the year 2002. Almost 75 percent of the savings are derived from reductions in Medicare spending for hospitals, managed-care organizations, physicians, and other agencies. Less than 20 percent of the reductions have occurred, and the rest will occur over the next two years. The impact of the act on Partners HealthCare System over four years will be a loss of 340 million dollars. Hospitals' total margins will drop by 50 percent during the life of the act. In Partners's case, the total Medicare margins will be -10 percent by 2002. If the federal government provides no relief, Partners's only responses will be to continue cutting expenses (which will threaten patient care), to cut programs, or to change its mission. Dr. Stuart Altman, Professor of National Health Policy at Brandeis University, said: "The concern is very real. What has happened to teaching hospitals is that all of the cards have fallen the wrong way at the same time."8 These "cards" include decreased payments from managed-care companies, increased expenses to prepare for the Y2K computer problem, the billing fraud issue, the expenses of forming integrated delivery systems (which, in most cases, have not led to cost reductions), and, lastly, the major blow—the Balanced Budget Act. Currently, there is a lot of discussion centered on these issues, especially the cuts in support for graduate medical education, including direct medical education payments, indirect medical education payments, and disproportionate share payments. To date, there is no policy and no strategy. Senators Moynihan and Kennedy have introduced a bill to provide additional funding for graduate medical education by freezing the Budget Act's reduction in indirect medical education payments at 6.5 percent and carving graduate medical education and disproportionate share payments from the Medicare Plus Choice payments and paying them directly to eligible hospitals. However, it is doubtful that such legislation will pass, and our teaching hospitals will continue to see a steadily rising tide of red ink. With this alarming information as background, I now want to give you a brief snapshot of our academic orthopaedic departments in order to demonstrate how ill prepared we are for these changes—so ill prepared that I think our departments and training programs need to change course. According to a recent publication from the Association of American Medical Colleges, we are smaller, in terms of the number of full-time faculty, than medicine and surgery; slightly smaller than biochemistry and cell biology; and similar in size to two other surgical subspecialties, ophthalmology and otolaryngology20. We don't have adequate endowments. We don't have appreciable state support. We don't receive much support from our medical schools. We do, however, generate more clinical revenue per physician than our colleagues, but we generate only small amounts of research support. Most of our faculty's research efforts have been supported by the department's clinical earnings. Obviously, with the rapid cutbacks occurring and planned for the next several years, this level of support can't continue. What are we doing about this looming disaster? How are we positioning ourselves to protect our essential mission adopted by our founders—to advance orthopaedic science and art? Additional data from the National Resident Matching Program reveals that from 1991 to 1999 we increased the number of first postgraduate year (PGY1) orthopaedic positions16. Compared with our colleagues, we have more residents per faculty member than surgery, ophthalmology, and otolaryngology, and twice as many as medicine. Are our residents mainly providing service for us as we attempt to increase our surgical volume and maintain revenue in these difficult times? Let me share one final look at our faculties. At Harvard Medical School and its teaching hospitals—which have an outstanding record of research, funding from the National Institutes of Health, and publications—there are more Ph.D. scientists in other major departments than there are in orthopaedics. And Harvard orthopaedics has a large number compared with other orthopaedic departments. Have we not kept pace, with regard to research faculty, with our successful colleagues? Can we do better in research leadership by following the Department of Medicine's model of increasing its Ph.D. census? These are challenges for all doctors, not just orthopaedists. In an odd way, though, our discipline has made it simpler for this riptide to pull us along in its wake. If you ever visited the beach as a child, you probably remember your parents warning you about riptides and advising you that if you were ever caught in one, you should not panic but, instead, just go along for the ride. The problem with that advice is that if you are pulled too far out to sea, you drown. These days, swimmers are still advised not to fight the current, but they also are told to swim laterally out of it. That is a lesson we should learn to heed in orthopaedics. In the mid-nineteenth century, as noted in E. H. Bradford's 1889 Presidential Address3, orthopaedic surgery "became an almost despised and rejected branch" of general surgery. Bradford continued, "The orthopedic surgeon was regarded as a man of mere straps and buckles, or the custodian of that surgical chamber of horrors, the orthopaedic institute." At the time of our founding, American surgeons were disposed to look upon orthopaedics as belonging to mechanics rather than to surgeons. Dr. DeForest Willard, in his 1890 Presidential Address19, stated: "Many orthopedic specialists are doing surgery which we would consider very crude and not at all in accord with the great surgical advances of the past few years. ... In some other cases the special work requiring massage, electricity, gymnastics, etc., showed the same tendency toward degeneration into a business aspect that is the danger in our own country." True more than 100 years ago, it is still true today. Willard went on to say: "The chief reasons for the lack of proper advancement seemed to me to lie in the fact that the pure specialist had failed to realize that the science of true orthopedic surgery demanded the exercise of the highest skill in both surgical and mechanical measures. Until this broad ground is taken, orthopedic surgery will not attain the rank that it deserves." This last statement also remains true today, with the additional proposition that it is essential for us not only to understand the science of the genetics and biology of orthopaedic tissues and their diseases, injuries, and repair, but also to lead the way in their investigation. Following World War I, there was an obvious increased need for orthopaedic surgeons. This need continued and expanded to include medical as well as operative care of the orthopaedic patient. Dr. Alfred R. Shands, Jr., in his 1954 Presidential Address17, stated: "As specialists in orthopaedic surgery, we must clearly demonstrate knowledge and ability superior to those of other physicians in the management of the medical and surgical problems of bones, joints, and allied structures. ... No specialty has closer affiliations with both medicine and surgery than orthopaedics; it has been stated that we must always be prepared to serve the two masters, medicine and surgery." However, with the increase in orthopaedic subspecialties as well as the development of new innovative procedures, minimally invasive techniques, and new tools and implants, not to mention the enormous price differential between operative and nonoperative treatment, operative management has now assumed first priority and is, in many cases, our sole interest. We need to take heed of Dr. Shands's sound advice about who we are and "must clearly demonstrate knowledge and ability superior to those of other physicians in the management of the medical and surgical problems of bones, joints, and allied structures."17 We must remain leaders in diagnosis, medical management (including the use of new microbiological techniques), and operative management. In short, we have come a long way. Nonetheless, I sometimes wonder if we are not also coming full circle. The buckle and strap have been replaced with more distinguished tools such as computed tomography, magnetic resonance imaging, and the scalpel. The rough props of amateurs have been replaced with the sophisticated instruments of skilled professionals1. But once again, as our progenitors were when this profession began, we are becoming known for our tools. This is a logical result both of human nature and of the system in which we work. That system emphasizes technology and our ability to push back the frontiers of treatment. In that sense, we have been highly successful. And make no mistake—surgery is fun, lucrative, and prestigious—we all know that. We as professionals hold in highest esteem those who can operate with precision and, in some cases, those who earn the most money. Medicine, in that sense, is a reflection of society. But there is another word for professionals who are known mostly for their tools: they are called technicians. While we have been honing our skills with the tools of our trade, the system in which we operate has been placing more and more power in the hands of general practitioners and other doctors known less for their tools than for their care. Our role risks being reduced to that of the assembly-line worker, a technician performing preassigned tasks on patients as they roll down the line. Inevitably, if that happens, there will be less fun, money, and esteem. More importantly, however, there will be less quality care for our patients. It is both undesirable and outright inappropriate for orthopaedists to cede the diagnostic high ground as we have been doing. We know better than any other branch of medicine how to think about the musculoskeletal system as a whole. At least, we should. In medical school, we teach future doctors about differential diagnosis. This is the process that encourages us to act as detectives, to interpret clues, and to construct theories based on them. A runny nose may just be a runny nose, but sometimes it may be due to syphilis. It is our job to find that out, and the ability to do so is really all that differentiates us from other health-care providers who are perfectly capable of treating symptoms. Under managed care, though, that's what we risk becoming. As we all know, treating symptoms can be effective. Most of the time, it leads to the right treatment. But not always. If we are wrong 10, 15, or 20 percent of the time, is that acceptable? Is that why we went into medicine, to be wrong one time in five or one time in ten? I don't believe so. It isn't acceptable for us, and it certainly isn't acceptable for our patients. If this is the riptide in which we are caught, we absolutely cannot just go along for the ride. We have to learn how to swim laterally out of it. But how can we do that? How do we fight back? How do we consolidate our strengths and direct our efforts? In short, how do we prepare for the future? How do we adequately prepare, for example, to seize the Internet explosion and use it to our advantage? How do we continue to attract, train, and keep the best and the brightest young students who prefer medicine but are increasingly entering the business world because of opportunity costs? How do we engage current notions on a host of topical issues—whether they be ethical, political, economic, social, or cultural—to make us wise and more informed about the people who come to us and about the forces driving their lives? Do we reach out more to seek their opinions about how we can do better? How do we change our medical curriculum and our residency programs to address the future? How do we encourage young scientists who will be the next wave of world leaders in research and discovery to keep caring when we seem to have stopped? How do we strengthen partnerships between medical colleges, hospitals, patients, and caregivers to unite on common ground in the face of a society of increasingly individualized interests? In short, are we as prepared as we think we are—as physicians, as human beings, as a community—for the new century and the new millennium?9 Those of you who know me well know how intrigued I am by business models for change. In preparing for this speech, I did a great deal of reading, and I came across a book by Donald Krause called The Book of Five Rings for Executives13. The title of that book was derived from the ideas of Miyamoto Musashi, a samurai who lived in Japan 350 years ago. Considered the greatest swordsman of his day, Musashi developed a system of five interlocking rings (the Five Rings of Musashi) that would prepare an individual for battle (Fig. 1).
Krause reinterpreted Musashi's system for those competing in the modern business world, and I think this system has relevance for our world as well. We, too, are engaged in a competition—the competition to maintain the integrity and value of our profession. In describing competition, Krause notes that there is "nothing glamorous about the challenges we face. ... They have a tendency to get very personal and very deadly (to our bottom line or to our careers)."13 That is very much the case for us. We are engaged in a battle for survival. How do we make sure we win it? Looking back at the early days of this Association, we can nostalgically lament the changes in our profession and our society, or we can find a creative way to make them work for us and for this organization. According to Krause, at the center of Musashi's rings lies the notion of ordered flexibility. Since I have been working with a water motif here, you won't be surprised to learn that Musashi's model for this notion is water flowing to the sea. A stream is a perfect mix of order and creative chaos. It follows a path, but in a decidedly disorderly fashion. If either this ability to flow freely or the constraint of the riverbed were absent, the stream might not reach the sea. In other words, the most effective way of reaching a goal is to combine both order and flexibility. This means being extraordinarily flexible and ordering that flexibility to accept every change as it comes, without question. A philosophy of ordered flexibility will enable us to build a dynamic organization that is prepared and positioned to apply the right tactics to any situation—an organization that is ready to move forward, to adapt, and to make a difference to its members. We should follow the lead of former Senate minority leader Everett Dirksen, who said: "I am a man of fixed and unbending principles—the first of which is to be flexible at all times." I want the American Orthopaedic Association to have the Resources, the Environment, the Attitude, the Concentration, and the Timing to execute its tasks creatively and effectively and to be dynamic and competitive. We face incredible competition each day as doctors, as an association, and as human beings. We experience loss. We know failure. We seek a model for a better way. In the Five Rings Model, we do not leave our success to the winds of fate or the whims of others. Resources, Environment, Attitude, Concentration, and Timing—R-E-A-C-T. REACT—that is our model. It is our guidance, and it can be our strength. We must have the will, the resolve, the knowledge, the compassion, and the presence to REACT to the challenges we face individually and together as doctors, as leaders, as teachers, as researchers, and as an association. I think about the problems of managed care and about the tremendous problems facing our academic medical centers, our departments, and our teaching programs. I hope that we will embrace the Five Rings Model, so that we can enhance the American Orthopaedic Association's ability to react at the right time, to the right issues, and for the right reasons; that we will know everything about ourselves, including our advantages and disadvantages; that we can keep open minds and not remain as we often are—rigid, too conservative, self-serving, and unforgiving; that we can remain flexible through preparation, observation, positioning, and readiness; that we can more easily respond to changing medical, political, economic, and social circumstances; that we can better evaluate our available assets, redirect them, and reorder them; that we can manipulate the dynamics of being in the right place at the right time, and use them to the full and best advantage of our members; that we can analyze the facts and let the facts govern our decision-making process with use of a decision-tree format; that we can focus on our strengths and direct our resources to take every opportunity as a chance for improvement; and that we can use our flexibility to maximize those strengths and to take the most appropriate action, in the right situation, at the right time, to achieve maximum competitive success. The Five Rings Model—Resources, Environment, Attitude, Concentration, and Timing (REACT)—is, I believe, the best way to move this Association competitively and successfully into the next century and, in so doing, to find a way for us, as orthopaedic surgeons, to respond to the needs of our profession, our training programs, and our research initiatives. Using Musashi as our guide, we have, I believe, a tremendous opportunity to achieve the goals of an aggressive "A.O.A. action-items menu" as our new strategic plan, led so effectively by our Executive Committee, dictates. We must continue to spend the time and continue to do the intellectual work that enable us to direct the flow of our stream as we move toward the sea with steadiness under pressure. The Five Rings Model tells us first that we must maximize our Resources by putting the right people in the right places, by knowing our assets, and by maximizing our skills. Our greatest resource is the talent of our young people. We must attract and keep the best and brightest young minds by giving them the best education and training and by adjusting the curricula of our medical schools and, especially, of our postgraduate educational programs. These changes must reflect the changing needs of society and must adjust to the trends in our educational environment. To maximize this resource, we should teach humanism as well as technical skill. The time has come to take a critical look at the product of our teaching, to realize that success is attributable not only to competence but also to compassion for our patients and an understanding of their needs and concerns, and to examine the obstacles that we face in providing the best care that we can, given our skills and talents. How many times have we read and heard that young physicians today have no bedside manner, that they are cold, heartless technicians driven by logic and skill if not by fear of litigation or the whimsical medicine directed by an insurance executive or a managed-care administrator? That perception may be fundamentally wrong, but we know in our hearts, if we are honest with ourselves, that there is some sad truth in it15. It is incumbent on each of us and all of us to let others know that we are not only analytical and critically thinking physicians but also caring physicians who feel pain and suffering as deeply as they do. Our primary challenge is to demand of every physician the best medical skills and techniques possible. But we must also demand a keen, intense social awareness and an open heart, and we must continually strive to protect the physician-patient relationship. To do so, we need to care for the patient and not just treat his or her hip or elbow. And we surely cannot withhold treatment for a year-end financial bonus! If we lose our bond with our patients, we will become part of this managed-care problem. What we teach and how we teach are critical, but there is another problem. Today's medical students are financially overburdened. They are graduating with an average debt of $86,500, according to the American Medical Association. As a result, too many of our best young people are making career decisions on the basis of financial need. If we want to keep the best and the brightest among us, the time is now for the American Orthopaedic Association to collaborate actively with other organizations, such as the Academic Orthopaedic Society, the American Academy of Orthopaedic Surgeons, and the Orthopaedic Research and Education Foundation, to find new sources of funding, to increase our commitment to orthopaedic education, and to make a commitment to begin to educate orthopaedic surgeons in less time. Another challenge that we face in our effort to maximize our assets is how to train and teach new residents to be the best physicians, the best scientists, the best surgeons, and the best researchers that they can be. If that means dramatic curriculum changes, then so be it. We have the skill and the resources to make those changes. We must find the resolve and the collective will to do so. Our greatest resource in this endeavor is each of you—the physicians, the surgeons, the experienced experts, the caregivers, the administrators, and the front-line residents who know what we need in our schools and hospitals. We need you to bring your considerable expertise to bear on the training of new orthopaedists. We must continue to broaden our participation by initiating new collaborative efforts with all interested groups and organizations and by involving our members in a think-tank atmosphere dedicated to problem-solving. Stu Weinstein, our past President, and Jody Buckwalter, our Second Vice-President, while serving as program chairman, renewed this effort at our annual meeting last year. It was very successful, and I know you will agree with me that Andy Weiland and Andy Koman have repeated this successful format this year. Our meetings in the past have been attempts at retreats or think tanks, but Thornton Brown, in his 1979 Presidential Address5, pointed out that we were not taking "full advantage of these features." In 1973, Charles Gregory urged the Association "to give serious consideration to calling an annual, invitational conference of the principal officers of those allied orthopaedic organizations which carry the burden of the day to day business of our specialty."10 We need to continue this renewed effort to make our annual meeting relevant. I would like it to become a "Renaissance Weekend" where leaders of all walks gather yearly to participate in open forums, panel discussions, and debates concerning major economic, societal, and political issues. We also should discuss and debate critical issues in orthopaedics, including those related to science, technology, ethics, education, economics, and society, to name a few. Consensus opinions and action plans resulting from this meeting should be disseminated to all orthopaedists through journals and the Internet. It will take time. It will take effort. It will require more and timely information. It will take commitment. It will take money. We should, right now, set a goal of doubling our commitment to fund not only research but also education. I believe we can do it. It will also take effort to develop improved mentoring programs in which a limited but definite number of research scientists and clinical scientists in every department collaborate with each other, work together to form partnerships, and reach out together to increase the overall commitment to developing new programs for young clinical scientists. The Five Rings Model tells us that we must understand the Environment in which events are occurring and then adopt an offensive, a defensive, or a neutral approach. As a surgeon, I prefer being on the offensive. This means that, in order for us to be as competitive as we can, we must look beyond ourselves and our profession. Accordingly, we need to hold seminars and workshops to fully understand economic trends, political realities, social issues, and cultural phenomena; we need to know the factors that affect interns and residents, physicians, hospitals, managed care, insurance, and health benefits; and we need to understand patient trends, consumer interests, and the public's opinion of who we are, what we do, and how well we do it. But to be on the offensive we must first be informed. We should continue the new annual meeting format and share updated information not only to keep current but also to remain unified in our determination to succeed. We need, for example, to find the best, most effective, and most technologically advanced way to share information on the World Wide Web with each other, among universities and hospitals, and with the public. We need to develop, finally, a marketing strategy that works—one that mitigates the poor image of physicians in general and surgeons in particular and that promotes our Association and the overall interests of everyone in this room. We should take a proactive role in educating the public about the value of basic research and in ensuring that important results of clinical trials are incorporated into our practices. To do that, we need to understand fully the fast-paced, media-driven, instant-information-based environment that will dominate the new century. In that environment—with all of its technological potential and demands, practical advances in operative treatment as well as complementary and alternative medicine, and new discoveries in research, molecular technology, and genetics—we must be advanced, accessible, adaptable, and prepared to bring the warm touch online and into a world of virtual medicine. The Five Rings Model also tells us that we must have an Attitude of ordered flexibility that allows facts to govern our actions. Musashi said: "Your mind will be as you have conditioned it."13 He also said that we must be "competent, confident, aware, and ready—not afraid or careless."13 According to Musashi, "failure is not an option" but with "increased control comes increased risk."13 We cannot be complacent. We must change our attitude about who we are and what is best for our Association and, especially, for our future—the residents and students entering orthopaedics. We must continue to work closely with the Academic Orthopaedic Society and others who are interested in modernizing our undergraduate and graduate programs for the twenty-first century. Times are moving quickly, and the old ways cannot stand. The proud traditions of our past are our legacy. They are our history. They are our models. Nevertheless, they belong to a bygone era, however honorable, venerable, and steadfast they may be. Now, at the end of this century, we must be more dynamic in our approach and flexible enough to accept new, young voices. We must encourage youthful, progressive leaders—born in a new era, a new century, a new millennium—who will be more prepared than most of us to understand and accept the coming new age of orthopaedic medicine. All of us who are the "oldies but goodies" (and I say that with a deep affection and more than a little regard when I look in the mirror) should be willing to step aside gracefully when the time comes. But if, as an organization, we have the proper attitude—enough flexibility, humility, and resolve—the next generation of leaders will follow our example, and they too will seize the opportunity to redefine, reorganize, reengage, and reinvigorate the American Orthopaedic Association. If that happens, our efforts today will not have been in vain. We will have led the way. In short, we will have forever changed the attitude of this profession and made a difference to the people we serve. The Five Rings Model also tells us that Concentration is our greatest asset. The ability to focus our strength and our limited resources will allow us to take full advantage of our best opportunities. In practical terms, this means directing the extraordinary talent and experience in this room toward the implementation of our strategic plan. I strongly believe that the Executive Committee should continue to take the opportunity at its midyear meeting to fine-tune this plan by reassessing and restructuring our goals, priorities, and objectives. Furthermore, I believe that each of us should participate in the implementation of this plan however, whenever, and wherever we can. This plan is our bible. It is our hope. It is the best we can offer to those who will follow us. It should strengthen our foundation, invigorate our spirit, and help us to build a strong, vibrant, flexible, energetic association by first increasing membership. We must reach out to those whose interests complement ours and encourage them to take an active part in our efforts. We must explore new ways to recognize the leaders among us and develop fellowships for promising future leaders. Our annual meeting should be exciting. It should be a meeting where new, bold, creative initiatives and ideas are intelligently and openly debated and discussed—a meeting at which leaders come together to explore every possibility, every problem, and every potential solution. But we should not talk only among ourselves. We should invite experts from divergent fields to join us. It should be a meeting that brings together opposing notions not only of medicine but also of those controversial and sometimes divisive political, economic, cultural, and social issues that affect our lives as well as our profession. I believe it should be our Association's "Renaissance Weekend," during which we invite prominent, knowledgeable guests to lead intensive discussions and workshops on a broad range of topics. I want it to be a place where we learn, where we share ideas, where we identify problems and find solutions, and where we pose questions and seek answers. We should be willing and anxious to learn all we can, and to discuss as much as we can, in order to build a stronger Association. It will take time to engage everyone. It will take money to achieve our goals. It will take leadership to create a think-tank atmosphere that moves us from the traditional to the innovative, from the sublime to the creative, from the comfortable to the adventurous. But to do nothing in the face of extraordinary opportunities would be shameful. We can become not merely an association of professionals, but a community of physicians united in a common purpose, sharing a common bond, and working toward a common goal. But it will take all of us working together to accept our leadership role. If we focus our strength and concentrate our effort, we will take ownership of medical education. We will welcome a new generation of energetic, highly trained, compassionate, competent young surgeons into the fold. It will include more women and, hopefully, doctors with less debt and a greater potential for success. Lastly, the Five Rings Model tells us that the Timing of our actions is essential to that success. Quite simply, there is no better time for action than now. Let's not fool ourselves. We have already taken too long to reach this point; to adapt to change; to make decisions; to assess our skills, our resources, and our environment; and to focus our strengths to achieve our goals. Now we have an opportunity to reinvent ourselves, and we cannot let that opportunity pass. It is time to organize ourselves—time to encourage younger leadership, to engage them in decision-making and dialogue, and to set the stage for a new millennium in which we open our minds to the extraordinary opportunities and the endless possibilities awaiting us. What does all of this mean in terms of this Association? I began this speech by talking about design, and I would like to return to that concept. The American Orthopaedic Association was formed and has survived to this day because of a belief in leadership. Leaders are people who dare to shape the future. They recognize that the path ahead will be designed either as an act of will or, in the breach, as an act of negligence. Leaders decide which of those it will be. Either way, a design will emerge and those who follow will be bound by it. Designing a profession is not, in the end, the same as designing a ship. The ship, once fashioned, is built and released to the seas. A profession, if it wants to stay relevant, must be constantly reinventing itself—adapting, focusing, and reassessing. The design process is endless. The world around us is changing rapidly, at a pace never before seen in human history. Our place in that world is anything but assured. The key to our survival will be a design based on ordered flexibility. We must remain faithful to our core values, but at the same time we must be willing to adapt to new ways of advancing them. Yogi Berra once commented: "Wherever you go, there you are." That's a fine philosophy for those with no particular destination in mind and who won't be disappointed when they get there. It's not a fine philosophy for us. That is why this organization has adopted a strategic plan to guide us in the years ahead. That plan provides our order. But flexibility also matters. We must make this plan of ours a living document by constantly testing it, reassessing it, and opening it up to discussion and scrutiny. At a time when technology changes overnight and policies swing on the vagaries of unpredictable whim, the day of static plans is past. Our plan must be vital and alive. We have taken some steps in this regard and are planning to make greater use of the Internet. Now we should go further: the Executive Committee at its midyear meeting will reassess and prioritize our strategic plan. I hope we will continue our efforts to increase our membership and to include future leaders by encouraging all of our members to recognize the best and the brightest and to bring their names forward. We need their active participation in our organization, especially during our think-tank activities. Our undergraduate and graduate educational programs are in need of attention. Currently, medical schools are adjusting their curricula to the times, but orthopaedics lags behind. The Association of American Medical Colleges is emphasizing educational change as reflected in President Jordan Cohen's annual address, entitled "Honoring the `E' in GME."7 We need to change our strategic course in two ways. At the national level, we must have engaged leaders from the American Orthopaedic Association, the Academic Orthopaedic Society, and the American Academy of Orthopaedic Surgeons at the Council of Academic Societies pushing for the musculoskeletal system to be included in the curriculum. Otherwise, orthopaedics will not be recognized by future doctors as the leader in musculoskeletal problems. At the local level, each chairperson should empower a champion to lead the way for the involvement of orthopaedists in the new curriculum they develop. The education must be based in science and humanism together, with the emphasis on data-based decision-making. I believe that, at the graduate level, we are on a very slippery slope. In my travels, I have seen service becoming the primary component of residency education—reducing programs from an educational environment to a training, technical-skills-only environment. Residents are being forced into the operating room by the economic pressures of managed care. That must change. They must learn how to examine, diagnose, and manage patients. They need to see patients before the patients are on the operating table, to learn how to examine them properly, and to continue to develop their caring skills under our guidance and mentorship. No one wants to pay for education anymore. The hard facts of the Balanced Budget Act, the drive for profit, and the changing economic climate have us worried. We must do something about the tremendous debt of our students and residents before the quality of our applicant pool declines. We need to develop plans to deal with this impending crisis. I don't know the answers, but this organization and our other leadership organizations, all of us together, must address the problems. Doug Jackson has started such an initiative in education as well as one to strengthen research in our academic departments. Our leadership should not hesitate to participate. We cannot let ourselves be caught in the riptide of change. We must heed the words of Musashi and use them to our advantage. For example, we have the opportunity to reassess the fourth-year medical-school curriculum and the duration of our residency and fellowship programs and the chance to increase our personal and organizational giving for education through the Orthopaedic Research and Education Foundation and at each of our institutions. We must take it. We are also not keeping pace with our colleagues in preparing for the future in research. We continue to lose bright young people from academic careers. We are producing practitioners but not clinician-scientists12. We have not developed our strength in research by recruiting enough Ph.D. scientists and changing our postgraduate programs to educate and support clinician-scientists. We need to understand our environment, to learn from our colleagues, to learn from ourselves, and to react. We need to improve our mentoring programs, and each department should develop plans to increase its number of scientists. We need to collaborate with each other as well as with other clinicians and scientists both locally and at other institutions. Department walls need to come down. Obviously, institutional commitments may not be immediately forthcoming, but if we want that support we must react and, if necessary, provide the initial support ourselves until enough outside funding and resources are available. We need to increase the endowments of our departments and our organization. We can't wait any longer. The time is now. We all need to give, for this is our future. None of us has all the answers to the questions I have raised, but looking at this audience I know the answers are out there. They are also in the minds of our young residents and students of the last graduating classes of the twentieth century and the first classes of the twenty-first century. We all need to step forward to help lead the American Orthopaedic Association, its Executive Committee, department chairpersons, program directors, and scientists into the future. Let us use our annual meeting, our "A.O.A. Renaissance Weekend," as our beginning, dedicated to making us more aware, informed, and interactive. What we learn should be available through the World Wide Web, and it should be updated, discussed, and disseminated to all musculoskeletal-care providers, educators, students, and researchers as the clock ticks down to the new millennium. We already recognize our outstanding scientists with the annual Bristol-Myers Squibb/Zimmer Award. Today I am also recommending that we recognize our outstanding clinician-educators. I am asking the Executive Committee to initiate plans to develop funding for such an award. When we look into the mirror, we need to know that we as a group have done our best to find the resources, to understand the environment, and to keep the attitude and the concentration to do the right thing at the right time for the right reasons. I know this list of initiatives is ambitious. It forthrightly tackles the difficult and dirty issues that face us and every medical professional—the strategic, scientific, and social issues that demand the vigilant attention of our profession and our specialty. I also know that change does not—and will not—come easily. But we must change, even if we go kicking and screaming into the new century while doing so. Change is hard fought. It often makes enemies and sometimes alienates friends. But, if the cause is just and the actions are sound, then the change is right, and, in the end, what is right will prevail. The American Orthopaedic Association was formed and has survived to this day because of a deep and abiding belief in strong, effective, persuasive leadership. As I have said, leaders are people who dare to shape the future. They recognize that the path ahead will be designed either as an act of will or, in the breach, as an act of negligence. Leaders decide which of those it will be. But either way, a design will emerge, and those who follow will be bound by it. Designing a profession is not, in the end, the same as designing a ship, which is released to the sea after it is built. Longfellow commanded the completed ship when launched: "Sail forth into the sea, O ship. Through wind and wave, right onward steer."14 A simple command, but our profession—unlike a well designed ship moving right onward through wind and wave—must constantly reinvent itself if it wants to stay relevant, to stay afloat. It must be adaptive, focusing, and reassessing. The design process for us is endless. Our place in this changing world is anything but assured. The key to our survival will be designed on the basis of ordered flexibility. We must in the end remain faithful to our core values but at the same time we must be willing to adapt to new ways of advancing them. If I have made only one point today, let it be this: We must make our strategic plan a living, breathing document by constantly testing it, reassessing it, and opening it up to discussion and scrutiny. Our design must be vital and alive, for we are heirs to a proud line who have built this craft of ours into a noble profession. Now it is our turn to design it anew, to weather the seas ahead. But we cannot be complacent. We cannot rely on theory. Ours is not a fanciful endeavor with no real or lasting consequences. For us as physicians, the stakes are high. It demands our full-time attention, our skill, our intellect, the strength of our resolve, and our will to succeed. I look forward to the journey.
*First President-Elect's Address. Read at the Annual Meeting of the American Orthopaedic Association, Sun Valley, Idaho, June 8, 1999.
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