Being president of our academy is a tremendous honor. I'm really glad to serve my colleagues and look forward to the year ahead. But like those in the past who have sat in this chair, it's not about what I want to accomplish, but what our 16-member board that supports the 39,000 members of our organization will accomplish. We constantly try to build on the successes of our predecessors. As the saying goes, “Rome wasn't built in a day, but they're laying bricks every hour,” so we're going to continue to lay bricks.

Some things we will build on this year have been in process, and some are rolling out as new initiatives. We started our Resident Assembly to engage young colleagues in training a number of years ago, and it continues to grow. We don't quite reach every residency training program in the country, but we do have the majority of them. We’ve found it very valuable to introduce them to life after their training, and where they can be involved in our academy.

Another thing that’s growing is our family of registries. Our hip and knee registries started several years ago, and now we've added shoulder and elbow registries, and we’ve engaged ambulatory surgery in participation. We also have registries for tumors that involve the musculoskeletal system — most of those will be done in an inpatient setting, of course. We initiated a collaboration with our neurosurgery colleagues with a spine registry that rolled out last year, and we're adding one for fracture and trauma. Both of those are opportunities for both inpatient and outpatient data collection.

Also picking up steam is the biologics initiative the academy started about two years ago. We want to help define what biologic therapies and treatments offer benefits and which really don't. And we want to continue to advocate for patients and the profession, as there's no question that the healthcare arena continues to move steadily toward more outpatient opportunities. As president, my job is to help steer the course on a voyage that has a lot of destinations, but never stops. My goal is just to keep the academy on course and moving forward.

I think it is the natural progression of surgery. When I trained, if you had your hip done, we’d keep you in the hospital two or three weeks. Over time, it's gradually gotten shorter and shorter. A few years ago, I thought a three-day stay was exactly right.

I don't think the pace is wrong; I think it's something that's been coming, and it may accelerate because it is a great opportunity for patients — just not all of them. Some of our older patients have significant health issues. They'll sometimes be better served where we have immediate access to our colleagues in other areas of medicine, such as pulmonology, cardiology or internal medicine, to name a few.

It's picking the right setting. Orthopedic surgeons are well-trained. They can make the best decisions regarding the site of service because they know their patients and their needs, and they know the capabilities of the facilities where surgery is generally performed. Successful surgery depends on good decision-making. Just like in every other corner of life, one size doesn't fit all.

The CMS decision was carefully made over a number of years. But their guidelines perhaps could have been a bit clearer. We might have avoided some coverage decisions being made by third parties that, at times, have put patients in the wrong setting, and they’ve risked adverse outcomes.

You mentioned pumping the brakes; I think we need to at least follow the speed limit. Surgeons wish their patients the best. They know facilities’ strengths, and also their limitations. The surgeon should be unencumbered when they're making decisions to provide the best in care for patients, and then everybody's happy.

The biggest challenge still is related to COVID-19. We're not back to normal, but we have adapted. One of the other big challenges that seems to have become greater is the regulatory burden and prior authorization that interferes frequently with timely patient care. It is more and more of a problem for us. The academy continues to engage members of both Congress and state legislatures, regulators like CMS and commercial insurance carriers [about it].

From an advocacy point of view, we are quite interested in seeing some remedy. There is a House bill in Congress (HR 3107) that attempts to address this, but insurance is at all levels. That bill would address federal insurance like Medicare; it would not address your Blue Cross provider, for example. It's a 50-state problem, and it's a federal problem. I think it's one of the biggest problems facing not just orthopedic care, but health care in general.

We have a lot of implants in orthopedic surgery, and they have become excellent. We see incremental changes, but not as great a change as we've seen in the past. Our surgical techniques, on the other hand, have continued to evolve. There are new minimally invasive advances available, seemingly on a daily basis.

Virtual reality, augmented reality and mixed reality devices offer more precision in surgery. These are enhanced devices the surgeon wears. They provide a great ability to perform surgery more precisely and are substantially more affordable than some of the robotic devices being used by our general surgery and GYN colleagues, which are beyond a million dollars to purchase. Reality devices are being used for some spine cases, and some shoulder arthroplasty cases; I've seen a video demonstration for each. I'm taking a field trip, if you would, up to Rush in Chicago — an ASC, actually — to see the technology used for spine cases.

We're very interested in the practical application of reality devices because we feel they offer the opportunity to have an extra layer of expertise when we’re operating. It’s like a heads-up display that our military pilots use while flying. It's something that is out in front of you, that you can see when you're looking down at a patient you're working on. Because [the view is based on] MRI or CAT scans, it's overlaying the exact anatomy you're looking at [while] operating. It’s an exciting enhancement that could have great utility in both the inpatient and outpatient settings.

Something that is being used across the country has been the simple addition of liposomal anesthetic agents. They allow local anesthetics to last sometimes as long as 24 hours or more. That has increased our ability to make surgery more comfortable, and more comfortable surgery allows you to do more cases in an outpatient setting.

Robots offer real precision, but not too many smaller ambulatory surgery centers can afford to purchase them. For instance, the platform used for total hips costs $1.3 million. A colleague told me the software updates each year are between $150,000 and $200,000, and the per-case charge for the disposables is $500 to $600. The margins on surgery are shrinking all the time. When you layer in those costs, it just may not be cost effective to use robotics. They're fantastic devices, but the price point needs to drop a good bit for us to use them in the ambulatory setting.

Robotic technology is great for precision, particularly in orthopedics. The positioning of implants in a total knee or total hip is clearly more precise, but they've not been able to demonstrate that they last longer. Do you actually need that couple millimeters more precision to give somebody a good outcome? The majority of joints are lasting 20 to 30 years. That's pretty good, particularly when you’re putting them in people who are not going to live 20 or 30 years. The implant is outliving the patient in most cases.

I think we’re going to see more definitive fracture care. Over time, the care of broken bones has become more minimally invasive. More surgeons are allowing the soft tissue injury to settle down before the definitive fracture care — applying a splint or a device for external fixation. I think there's an opportunity for more fracture care in the outpatient setting. Most wrist fracture repairs are done in the outpatient setting now. In our new fracture trauma registry, we'll be studying wrist fractures, but we're also going to be studying ankle fractures and shoulder fractures. More total shoulder replacements are being done in outpatient facilities, primarily because regional anesthesia is being used to send patients home in comfort.

Orthopedic surgeons have embraced multimodal pain control. That's allowed us to reduce the number of pain pills that are prescribed. Plus, longer-acting anesthetics have cut down on the need for post-op opioid use. Patients are most uncomfortable during the initial 24 hours of recovery. I give 20% of the amount of opioids I used to give patients after outpatient procedures. Patients want opioids to treat breakthrough pain or are nervous to go without them. I often recommend that patients take Tylenol or ibuprofen to treat their discomfort, and very few say they need something stronger.

I think orthopedic surgery as a specialty has drastically reduced the use of opioids. If you asked 100 orthopedic surgeons, you're probably going to get the same answer — we think providing definitive care is how you get rid of patients’ pain. Pain medicine is helpful, but it won’t make them better.

That's a great question. It's one that’s top-of-mind across the country, regardless of what business or area of life you’re in. AAOS wants diversity in our members because we want to look like the patients we care for. But that change can’t be affected overnight.

Secondly, we want to be role models to young people so they're interested in orthopedics long before they ever start thinking about their career in medicine. When my kids were seven or eight years old, I'd go to their class and take a skeleton and talk about broken bones, and they loved it. That role modeling needs to continue to make people aware of orthopedics as a profession.

Our pipeline of trainees continues to improve, but we're lagging behind almost every other specialty. Over 50% of medical students now are female. We don't even get close to that in orthopedics, but that number is growing. At one point, 6% of surgeons in residency training programs were women. Now, 15% are women. Progress is being made, but there’s more work to be done.

We're very intentional about encouraging people of all backgrounds to go into orthopedic surgery. We have implicit bias training as part of our new Leadership Institute that rolled out last year. Everybody has biases, and we need to recognize those and work to resolve them.

Your biggest impact is on the things you can control. Our academy can't control who’s interested in orthopedics, or who gets into the training programs. But we can control — to a degree and in a fair way, of course — being intentional, finding our role models, engaging people. I think we’ve been really successful at it. We want to provide the role models that encourage people to say, “I see this person doing it. I ought to be able to do it.”

This interview has been edited for clarity.