It Is What It Is*

Crawford, Alvin H. MD

Journal of Bone & Joint Surgery - American Volume:
The Orthopaedic Forum
Author Information

1 Department of Pediatric Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Building C, MLC 2017, Cincinnati, OH 45229. E-mail address:

Article Outline

Fellows, honored guests, board members, speakers, and, most importantly, the Fellowship Class of 2004:

I have had the unique opportunity to fill the president's shoes. While a resident at the Massachusetts General Hospital in 1969, an unexpected tennis challenge arose, something not infrequent in my career, and I hadn't brought my tennis gear. Dr. Herndon lived in an apartment across the street and was kind enough to let me use his sneakers... I wish I could say the match was 6-0, 6-0!

First, please join me in expressing appreciation to the many spouses, parents, teachers, friends, and significant others for their support of the new fellows during their long formative years.

It is a rare privilege and a great personal honor for me to address you on this most important occasion. I am filled with awe, humility, and inspiration to join the list of people preceding me in this capacity.

Today you are being inducted into the American Academy of Orthopaedic Surgeons (AAOS). You have probably wondered what it is to be a member of the Academy. Well, today I will share my concept of the Academy's vicissitudes, foibles, successes, and failures and synthesize it as: “It is what it is”—truly the secret of most of life's imponderables.

Today you become a member of one of the largest and most respected medical organizations on the planet. You represent the future replacements for all of the Academy's leadership; some of you will fill their shoes. By virtue of your induction, you will raise the level of computer literacy among our fellows by 300%!

Well... It is what it is.

Many challenges face orthopaedic surgeons over the next decade: the malpractice crisis, increased federal regulations and scrutiny, decreased reimbursement, and the ability of our specialty to remain whole without fractionalization.

I have formulated my counsel into a set of Crawfordian directives about ethics, mentoring, partnering, malpractice, error prevention, specialization, technology, remaining current, cultural diversity, taking control, giving back, and family.

Ethics. Ethics sometimes become whatever your mother taught you. Ethics define what is right or wrong in human behavior. Ethical guidelines are inspirational, defining what a physician ought to do, and thus they are not legally binding and not enforceable. It is amazing in academic forums how often, even when one has been apprised of entrenched blocks to decision-making based on flawed data (commonly called biases), one is unable to choose appropriate behavior. Some of you have a tremendous debt burden, and the call to unethical behaviors can be seductive.

It is what it is.

Mentoring. Hopefully, you love this specialty and will pass on your passion and wisdom to those aspiring to fill your shoes. The ideal or quintessential role of a mentor is to be a resource and to help in making decisions about partners, contracts, and salaries when entering the business of medicine. My mentors always told me how hard they worked and how many hours they put in to get where they were. To some older doctors, long hours, late nights, and always being on call were a testimony to their devotion to medicine. You will always have a more credible tale because you can always profess that you were training before the eighty-hour rule, and you only left the hospital every other Sunday except for the day off after your child was born or to mourn a family member.

Being a member of the AAOS will give you instant credibility. Be a mentor. Talk and listen to students, all learners, patients, anyone interested in musculoskeletal issues. Mentoring enhances your image and supports the goals of perpetuating and propagating our fellowship.

It is what it is.

Partnering. Establish a partnership with your colleagues, referring physicians, and patients. Discuss lab reports, x-rays, and physical therapy progress with them and hear them out. “I don't know” is a good answer when asked a question you don't know the answer to. You too are human. They will understand and appreciate your honesty. Pediatric orthopaedists have special challenges. My fourteen-year-old patients with scoliosis usually get the answers to all of their questions from the Internet. They have answers, but they are interested in my opinion on the basis of their trust. You can't blow them off. You have to be honest. Let your patients participate, give them choices, options.

It is what it is.

Malpractice. The premiums for professional liability insurance have reached a level that threatens the very financial viability of medical practice in many areas of the United States. “Junk lawsuits” against health-care providers may be driving up health-care costs and are driving some physicians out of business—especially those performing high-risk procedures. We live in a litigious society. Americans sue each other at the slightest provocation. They sue doctors over misfortunes that no doctor could prevent, sue when their injuries are severe but self-inflicted, when their hurts are trivial, and when they have not suffered at all. Many sue because they have come to believe that they have the right to impose the costs and burdens of a lawsuit on anyone who angers them regardless of fault or blame. Doctors spend, or perhaps waste, fifty to 100 billion dollars each year on defensive medicine. Malpractice allegations may be unfounded in as many as 80% of the cases. It is indeed a source of frustration. Semmelweis may have missed the mark on the germ theory, but what he did discover was a phenomenon just as remarkable: the idea that physicians may themselves be responsible for the morbidity and mortality of patients. The father of antisepsis was, in fact, the father of iatrogenesis—physician-induced disease.

Error prevention. Error prevention is our best defense, a challenge championed by our president in his sentinel article “One More Turn of the Wrench.”1 The Institute of Medicine in its report To Err Is Human: Building a Safer Health System2, suggests that as many as 98,000 patients each year are fatally harmed by medical errors. Medication errors, inappropriate and poorly conducted surgical procedures, wrongsite surgery, and failure to diagnose limb and life-threatening conditions may be preventable. The overwhelming majority of untoward events involve a communication failure.

What about instituting a “time out” requiring surgeons, nurses, and anesthesiologists to “huddle” to verify the correct surgical site and procedure prior to beginning the incision? What a remarkably unique concept—surgeons, nurses, and anesthesiologists being required to communicate prior to making an incision!

Fear not, however. In spite of the negatives regarding physicians, a recent Wall Street Journal poll showed that 63% of the public trusted their doctors to do the right thing; however, 65% trusted nurses to do the right thing for the health care of the general public.

It is what it is.

Specialization. When I was a resident, orthopaedic surgery was one of the three “O” specialties—ophthalmology, otolaryngology, and orthopaedics—leading to a Rolls-Royce, and it was high on the list of medical students' choices. No more. The top three specialties now are dermatology, anesthesia, and radiology. Not only is income not an issue but family and lifestyle have risen as priorities.

If you went into this specialty to help others, there are tremendous opportunities waiting for you. Our society's current emphasis on fitness and exercise virtually guarantees you an unending supply of arthritic patients and chronic pain sufferers for your practice lifetime. They, or perhaps I, should say we deserve your best.

It is what it is.

Technology. Over the past thirty years, significant advances have occurred in the care of patients with musculoskeletal conditions because of the ingenuity and perseverance of orthopaedic surgeons. Stem-cell and gene-therapy research will come to fruition during your careers. Cutting-edge technology and often contradictory studies now seem to appear every day, making it hard for readers concerned about their own and their family's health to sort out what is accurate and important. The implant and pharmaceutical industry is now marketing directly to consumers, or should I say to patients. Medications are touted directly during television commercial breaks without physician involvement. Remember the Super Bowl? “When the moment is right, will you be ready?” The treatment of erectile dysfunction was the compelling, competitive pharmaceutical touted during the Super Bowl, but is that more disturbing than a golfing icon pitching a specific total hip replacement product, inferring equal if not greater performance? We won't consider the possibility of “equipment malfunction” with either product!

It is what it is.

Remaining current. It is extremely important to remain current and keep up. Those who are not interested in academics should attend hospital specialty conferences and “town-gown” grand rounds. As a service director, I am now being challenged to initiate performance-based credentialing, a JCAHO (Joint Commission on Accreditation of Healthcare Organizations) requirement to rate all certified hospitals in the future. Get ready.

It is what it is.

Cultural diversity. The diversity of the races is extremely important. Look around you and the faces will reflect the changing colors of America. You are a rainbow of cultural, ethnic, educational, and geographic diversity, making you uniquely equipped to assume our Academy's leadership in the twenty-first century. Remember where you came from and, in most cases, from whom and on whom you honed your craft and what they looked like. A lot of them may have looked like me. Having cross-cultural sensitivity and practicing culturally competent, compassionate care will be a way of getting along in your practices. No longer will we be able to take care of only patients who look just like us, whoever “us” is. We are approaching a true American melting pot that will not be Eurocentric in complexion. All of us should explore our biases and achieve cultural competence.

The 2003 Institute of Medicine report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care3 highlighted the disparities between physicians and minorities, prompting the American Medical Association to focus on becoming more inclusive. African Americans, Native Americans, and Hispanics are at least twice as likely to suffer diseases and encounter serious complications. We African Americans also die younger than any other racial group. Awareness of health-care disparities will allow you to develop patient-education programs for your staff. We must be prepared and willing to respect and serve all humans, including those in same-sex relationships and those with multiple piercings, too many tattoos, and multicolored hair. This is an awesome responsibility but one that you in this room are probably better prepared for as a group than are many other humans.

Significant errors are made because of a lack of communication or a misunderstanding, and some are directly related to cultural misinterpretations. In some cases, our society produces biases so conditioned that you cannot relieve them by education. The AAOS is preparing a culturally competent musculoskeletal curriculum. It is important; we are messing with people's lives! However, one speech doesn't change behavior. Culturally competent compassionate care of our patients should be paramount. This becomes a nonissue if you exercise the F-squared (F2) principle: to treat all humans as though they were either family or friends.

It is what it is.

Taking control. Remember, you are the masters for change. I implore you to think now of the opportunities as well as the challenges that you will have over the next twenty years. You will be tasked by a number of organizations for participation and for financial contributions, including local, national, political action, and research organizations. Be a visionary—remain ahead of the game and don't be afraid of thinking out of the box. You're in the driver's seat. There are opportunities for collaborations and selective mergers to avoid fellowship fractionalization and to obtain more efficient time commitments and lower costs for greater educational value. Your Academy is interested in your thoughts. The current response rate to surveys, polls, and questionnaires is less than 20% and cannot be validated. Please consider volunteering. You have more time at this point in your career... now... than ever to become active and give your input.

Giving back. Will Rogers commented, “A man makes a living by what he gets. He makes a life by what he gives.” Consider the Orthopaedic Research and Education Foundation in your giving. Remain active with residents, physician extenders, assistants, and nurse practitioners. Join committees. Remember, the person who best represents you is you.

It is what it is.

Family. Finally, and most importantly, is family. Many of you men stayed home and changed diapers, took the kids to music lessons and soccer practice while she was on call... and vice versa. This day is another jewel in the family crown. Always remember family. We're all a part of our family's dreams. Don't be afraid to dream. Dream and hold fast to your dreams. For if dreams die, life is a broken-winged bird that cannot fly.

Now, when asked “What is the American Academy of Orthopaedic Surgeons?” you know what it is: the preeminent society for the study and management of musculoskeletal conditions in all human beings on the planet. Please join me in welcoming our new fellows into the honorable and noble fellowship of the American Academy of Orthopaedic Surgeons. It is what it is.

The author did not receive grants or outside funding in support of his research or prepara-tion of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

* Welcoming Address to the Class of 2004. Read at the Opening Ceremony of the Annual Meeting of the American Academy of Orthopaedic Surgeons, San Francisco, California, March 11, 2004.

1. Herndon JH. One more turn of the wrench. J Bone Joint Surg Am. 2003;85: 2036-48.
2. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.
3. Smedley BD, Stith AY, Nelson AR, editors; Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Board on Health Sciences Policy, Institute of Medicine. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academy Press; 2003.
Copyright 2004 by The Journal of Bone and Joint Surgery, Incorporated