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“Those who cannot remember the past are condemned to repeat it” (1). The famous quote from Hispanic American philosopher George Santayana reminds us of the critical importance of constantly reflecting on the most important lessons garnered from both our own personal experiences and those of our peers. In 49 years of academic orthopedic practice, I have frequently reflected on the most important lessons I have learned, and to which, in addition to hard work and perhaps simple luck, I attribute much of my success:
With near constant growth and increasing complexity in orthopedics, an organized team of strong physician leaders with diverse skills is a necessity. In searching for potential associates, it has been a guiding principle to acquire only the most talented individuals whose intellectual wit and work ethic are unmatched among current team members, as to avoid a gradual decline in quality and energy. It is not enough just to recruit “the best”, but a successful organization must also retain its talent. In an effort to establish a sense of fairness and avoid the crippling influence of jealousy, financial transparency is paramount. In addition to offering all partners a contract virtually identical to the founder’s, which if nothing else guarantees equality of earning opportunity, detailed financial data are made fully available to all partners on a monthly basis. Once provided clear equitability, what else leads to an interminable sense of contentment among team members? According to a well-known tenet in business management, a sense of controlling of one’s own destiny, which can be achieved through an open and democratic system of leadership, is key (2). Second, thoughtful and constructive feedback, both good and bad, on a weekly basis will foster self-advancement and satisfaction. Finally, the opportunity to develop a high level of skill in one’s work without ostensible limitation will encourage both personal development and fulfillment. For a surgeon, this means providing a rich culture of sub-specialization that allows for a deep focus on technical and intellectual abilities that can maximize one’s potential. Although important, monetary return is not the leading factor contributing to satisfaction at work (3, 4).
As originally propounded by Sir John Charnley in 1960, the proposed advantages of a focused center for excellence in total joint arthroplasty, including but not limited to a reduced rate of surgical complications and lower costs, have been proven true over the ensuing decades (5). The benefits of a large and highly focused center are pervasive, providing the leverage and fiscal strength to recruit effective corporate leaders, acquire necessary infrastructure and personnel, and negotiate with payers, health systems, and other large organized entities. While the merits of an employee versus entrepreneurial physician model will continue to be debated, it is my longstanding view that private enterprise, though not without its flaws, remains the most productive and motivating strategy. Sister Irene Kraus, a recognized health care administrator, directly addressed this: “no margin, no mission” (6).
As Warren Buffett once noted: “There seems to be some perverse human characteristic that likes to make easy things difficult.” Seemingly complex and often overwhelming technical processes, such as with a surgical procedure, can often be broken down into a finite collection of much simpler and easily reproduced steps (7). The expedience of simplicity is not limited to processes achieved by the surgeon, but can translate into proficiency throughout the operative experience. Multiple members of the surgical team can perform tasks in parallel to achieve optimal efficiency. Just as it no longer makes sense to allow complete setup of the operative suite prior to bringing in the patient, anesthesia may be administered in a separate blocking area during completion of the preceding case. Time is a commodity that should not be wasted; perhaps time may even remain to be spent with family!
There’s nothing more important than proper patient selection for obtaining good clinical outcomes in elective joint arthroplasty. Patients should, in fact, be thought of as life long partners. If in doubt, consider encouraging patients to wait until symptoms worsen and the necessity for surgery becomes completely clear. Further, consider what you would do if you were in your patient’s situation. In addition to proper patient selection, it is important to ask yourself who is best for the job. In an era of increasing specialization, would the best outcome not most reliably be achieved by referring patients to a surgeon with a degree of focus and specialized skills for the required intervention? Finally, surgeons should urge patients to exhaust their efforts to minimize surgical risk. This means working with morbidly obese patients on weight loss goals and diabetic patients on glucose control. Patients will have a greater peace of mind about their decision to undergo surgery and will, ultimately, be better able to accept the result of the operation if they are completely invested in the decision and feel they have made every effort to achieve the best possible outcome.
The responsible adoption of new innovations is another area in which good judgment will serve you well. Ill-fated revolutions, such as metal-on-metal bearings, modular necks, and minimally invasive approaches, demonstrate the potential dangers of hastily jumping from fad to fad. New technology not only needs to provide a clear solution to an existing problem, but also should be implemented cautiously and not before 5-year level I data exist to support a change in practice. Don’t be afraid to stick with what works for you.
A healthful life balance is critically important to preserve long-term emotional and physical health with the rigorous demands of surgical practice. This means a thoughtful balance between job, family, and friends. Maintaining physical health with a weekly exercise program and proper nutrition has always to me been vital to my overall health. This includes following the nutritional guidance of a distinguished internist- more to the point, “don’t eat crap”. Happinessis an often sought after but elusive goal. Achieving happiness through service to friends, patients, and the community has a greater positive impact on our health and long-term satisfaction, and should be held above personal pursuits. Economic success can be achieved simply as a function of living beneath one’s means. By his rule of thirds, former CEO of Sears Julius Rosenwald reserved $1 for living expenses, $1 for savings, and $1 for philanthropy from every $3 earned (8). One simple and effective investment program embraces dollar cost averaging and the use of index funds.
Hard work, life balance, and at the right moment, a stroke of luck are all keys to success. Thomas Jefferson once stated: “The harder I work, the luckier Iget.” As we are living in the best time in history and work in the best of all professions, we must indeed not forget to count ourselves as lucky.