key: cord-0771100-vkqfne2v
authors: Azoury, Saïd C.; John, Tamara; Cheema, Adnan N.; Behar, Brittany J.; Zapolsky, Ivan; Levin, L. Scott
title: American Society for Surgery of the Hand (ASSH) Presidential Address Themes, 1964-2018: Revisiting Our History as We Move Forward
date: 2020-04-22
journal: Journal of hand surgery global online
DOI: 10.1016/j.jhsg.2020.04.006
sha: 991e2bff4ddc9e38176622b64fc1f3cc33054ea9
doc_id: 771100
cord_uid: vkqfne2v

Abstract The American Society for Surgery of the Hand (ASSH) was established in 1946. Since then, significant advances have been made in diagnosis and treatment of conditions affecting the upper extremity. However, there has been little documentation regarding how the largest and oldest society dedicated to hand surgery has evolved over time. Further, an understanding of the history of the ASSH and the specialty of hand surgery should be emphasized in resident and fellow education. The authors aim to provide a historical overview of the ASSH through the speeches of ASSH past presidents which sheds light on future directions and long-term goals. Presidential addresses from 1961 to 2018 (courtesy of ASSH Chase Library historical archives) were reviewed. The overall percentage of ASSH presidents by specialty was 67% orthopaedic, 25% plastic surgery, and 8% general surgery. The most common speech theme overall was “how to be a good hand surgeon” (31%). The most common speech themes were as follows by decade: 1960’s, “history and the current state of ASSH”; 1970’s and 80’s “assessments of how to be a good surgeon” and “goals for ASSH”; 1990’s, “healthcare and governmental regulation”; 2000’s, “how to be a better hand surgeon”; 2010’s “goals for ASSH”. In earlier years, there was more of a focus on education and technical skill development in the ASSH. Work-life balance, introduced in the 1990s, has become more of a focus in the past 20 years. Revisiting the history of the ASSH and its goals allows us to reflect on the progress made while recognizing what is important as we look into the future. Further, as we strive to make progress in the field of hand surgery during the current pandemic, valuable tools surface that will allow the specialty to strengthen its education, research, and patient care delivery in the future.

Established in 1946, the American Society for Surgery of the Hand (ASSH) is the oldest 24 and largest society devoted exclusively to hand surgery. 1 Prior to World War II, care for hand 25 injuries and pathology was highly disjointed and delivered by various specialists including 26 neurosurgeons, general, orthopedic and plastic surgeons. 2,3 A unified, coordinated treatment 27 approach to surgery of the hand was lacking at that time, and there was a need for change. 28

General surgeon Dr. Sterling Bunnell was a pioneer and is recognized for leading the initiative to 29 standardize hand surgery. 2 He is considered the true founder of the specialty, referring to surgery 30 of the hand as a "composite problem requiring the correlation of the various specialties-31 orthopaedics, plastic and neurologic surgery-the knowledge of any one of which alone is 32 inadequate for repairing the hand." 1 In the 1940s, Bunnell was designated as a special civilian 33 However, there are no prior reports on the trends in the ASSH presidential address topics, which 59 indirectly reflect the priorities of the ASSH as a whole. Further, an understanding of the history 60 of hand surgery and its largest society should be emphasized in resident and fellow education. 61

With the evolution of hand surgery and societal changes in the United States, the authors were 62 interested in the progression of the hand society's focus over the years. Traditionally, the ASSH 63 president will give a "Presidential Address" at the conclusion of their term to iterate the overall 64 focus for the year. The presidential address is meant to identify the main objectives that were 65 achieved in the previous year, and to suggest new areas of focus for the coming years. 66 67

Fifty-two presidential addresses (1964-2017) were available for review, courtesy of 69 ASSH Chase Library. These were reviewed to find trends to observe trends in goals, objectives, 70 and priorities of the ASSH over time. The percentage of ASSH presidents by specialty were: 71 67% (35/52) orthopaedic, 25% (13/52) plastic, and (4/52) 8% general surgery. The number of 72 ASSH presidents with plastic and general surgery backgrounds decreased over time, while there 73 has been an increase in the number of orthopedic surgery-trained ASSH presidents. One of fifty-74 two presidents, Dennis Phelps (2003), was from a private/community practice while the 75 remaining presidents were from academic institutions. 94% (49/52) of presidents were from the 76 USA and 6% (3/52) from Canada. 77

Seven main themes emerged from the speeches: work-life balance, education of trainees, 78 how to be a good surgeon, government healthcare regulation, patient care, the history and current 79 state of the ASSH, and future goals of the ASSH (Figure 1) . The most common speech theme 80 overall was "how to be a good hand surgeon" (16/52 speeches or 31%). The most common 81 theme of ASSH presidential addresses from the 1960s to today was how to train physicians and 82 hand surgeons. In the 1960's, the most common speech theme was "history and the current state 83 of ASSH" (Figure 2) . In the 1970's and 80's, both "assessments of how to be a good surgeon" 84 and "goals for ASSH" were the most popular topics of discussion (Figure 2) . In the 1990's, 85 "healthcare and governmental regulation" was the most common theme, often in conjunction 86 with discussion of healthcare bills proposed by the Clinton administration (Figure 2) . In the 87 2000's, the most common theme was "how to be a better hand surgeon". Finally, in the 2010's 88 "Goals for ASSH" was the most common discussed topic. Additionally, themes discussing the 89 concept of work-life balance were introduced only in the 1990s and became more prevalent 90 throughout the 2010's (Figure 2) . 91

The future of hand surgery lies in optimizing education and exposure for residents, 92 fellows, and young attendings to continue the legacy of the hand society. In addition, refining 93 surgical skills and understanding surrounding the upper extremity is paramount to ensuring 94 optimal patient care in years to come. In reviewing the past themes, it is obvious that a focus on 95 training and developing better hand surgeons will continue to be an important goal of the ASSH. 96

This will involve not only the training of surgeons in the US, but around the globe as 97 collaboration and spread of ideas becomes easier through the internet. ASSH will also need to 98 continue to emphasize the improvent of new technology, development of novel techniques and 99 utilization of increasing data points through electronic medical records to create more focused 100 and useful analysis of patient outcomes. The recent shift in focus to more optimal work-life 101 balance by ASSH presidents is an important indication that this will be paramount to the well-102 being of ASSH members for years to come. 103

In the face of the Covid-19 pandemic, clinical care, education, and ongoing research have 104 been challenged. Innovation in care delivery includes an expanded use of telemedicine and this 105 technology has rapidly expanded to meet the healthcare needs of all patients. Hand surgery is no 106 exception. New patient evaluations and follow-up visits can now be done online, and this will 107 have a long-lasting impact on how hand surgery will be practiced in the future. Education will 108 most likely rely more on digital platforms such as BlueJeans, Zoom, and GotoMeeting, which 109 present advantages for the resident, fellow and practicing surgeon. Perhaps face-to-face meeting 110 time could be reduced, with less time out of practice for the busy hand surgeon. In person 111 meetings may involve cadaver labs or master classes, rather than several thousand people sitting 112 in a lecture hall. The digital connectivity that has been encouraged may facilitate multi-113 institutional research projects with video recording of patient reported outcomes. Each advancement in surgical procedures and technology results in expanded reporting in journals, 115 meetings, books, and other forms of communication. The future is bright in these domains. 116

Future presidential lectures will look back on events today, both in society and the world of 117 surgery, and reflect on the continuum of progress and current challenges that remain to be 118 Others suggest that the plastic surgery residency exposure to hand surgery is inconsistent and 132 limited at many programs. One way to reverse this trend is to assess the current plastic surgery 133 curriculum nationally and ensure consistent and adequate hand surgery training prior to the 134 fellowship application process. 135

Early on, the emphasis for the ASSH was on education and becoming a good surgeon. 136 Speeches in later years had an increased focus on healthcare and governmental regulation. In national hand trauma system that protects the public trust. Based on our legacy and the hand 161 surgeons whom have served as ASSH presidents, we know that our work is never done. 162 However, our trajectory and momentum are strong and hopefully will remain so for the next 74 163 years. 164

Recommendation 166

An understanding of the history of hand surgery and its largest society should be 167 emphasized in resident and fellow education. Presidents of the ASSH have been respected as 168 leaders, collaborators, and inspirational individuals who prioritize and reflect the goals of the 169 hand society. The speeches of past presidents provide an invaluable window into the ASSH's 170 evolving priorities. Further, as we strive to make progress in the field of hand surgery during the 171 current pandemic, valuable tools surface that will allow the specialty to strengthen its education, 172 research, and patient care delivery in the future. The legacy of the ASSH is dependent on a 173 consistent reminder of where we were, where we are, and where we hope to be. 

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addition, work-life balance has become more of a focus over the last twenty years. Studies on 138 physician burnout and suicide began to raise awareness around work-life balance and the 139 importance of surgeons caring for themselves, and this should continue to remain a focus long 140 term. Surgeons with burnout are at increased risk for cynicism, depression, and physical illness 141 such as heart disease. 6 Several orthopedic surgery studies published in the 2000s have reported 142 burnout rates of 40%-60%. 6-8 In 2016, it was reported that the age-adjusted rate of suicide 143 among Americans was 13 in 100,000 compared to the suicide rate among physicians in the 144 United States at nearly double that: 28-40 physicians in 100,000. 9 Speeches in the past two 145 decades have focused more on holistically developing the hand surgeon, as will likely be shared 146 goals amongst members and leadership moving forward. This included technical skill, research, 147 investment in teaching, giving back, and mental health maintenance. 148Hand surgery is a unique and evolving specialty which embodies collaboration, 149 excellence in patient care, research, education, and a profound history that is imperative for all 150 hand surgeons to appreciate. We are currently standing on the shoulders of several pioneers in 151 the specialty such as ASSH founder Dr. Sterling Bunnell and others. This review aimed to 152 reflect on the distance travelled in hand surgery and to understand trends in the goals and 153 composition of the ASSH. Revisiting the history of the ASSH and the goals of its leadership 154 allows us to reflect on the progress we've made, while recognizing likely future trends and 155 common goals that are important to our society moving forward. Over the last 74 years, the 156 ASSH has provided exemplary leadership in the field of hand and upper extremity surgery. 157Major strides have been made in the last decade, with advances in outreach (Touching Hands  158 project), a ten-fold return on investment of the AFSH's funding of research, launching of a 159 knowledge platform (HAND-e) that is providing hand surgery education around the world, and a