Michael Barbella, Managing Editor03.08.16
David D. Teuscher, M.D., knew he would have to make the most of his tenure as American Academy of Orthopaedic Surgeons (AAOS) president. He had, after all, been given ample warning.
"Several past presidents told me before I began the year as president that it’s going to come at you very fast and they were absolutely correct,” Teuscher recalled. “It’s been just an incredible year. I [traveled] over 150,000 airline miles this [past] year, flying all over the North American continent, meeting with state societies, regional societies, specialty societies—all AAOS members and colleagues. They were all incredibly gracious, very supportive and very grateful that there’s somebody out there leading the charge. They have a lot of concerns because there’s a lot going on right now in orthopedics.”
Quite a lot, indeed: Between pricing pressures, industry consolidation, dwindling reimbursement, research funding, continuing education and patient safety, there was no shortage of challenges awaiting Teuscher during his presidency. Though he did not set a specific agenda to define his reign, Teuscher nevertheless identified several goals during his tenure—namely, improving surgical safety, ensuring the value of musculoskeletal care, and advancing educational technology as well as expanding online offerings in continuing education.
Before passing the presidential gavel to his successor, Gerald R. Williams Jr., M.D., Teuscher spoke with Orthopedic Design & Technology about his presidency, the industry, and the challenges he encountered leading the world’s largest medical association of musculoskeletal specialists.
Michael Barbella: Upon taking office as president last year, you said you wanted to improve surgical safety. How did you attempt to fulfill that goal?
David D. Teuscher: I’m going to give a lot of credit to Dr. Bill Robb, who heads up our patient safety committee. He, Dr. Dwight Burney (III), Dr. John Tongue, and others have through the years really advanced the cause of patient education, patient communication and surgical safety. I realized that over the last almost two decades, the Academy has been a leader in promoting mechanisms for surgical safety including “sign your site.” People like past President Jim Herndon were champions of this. “Patient Safety is No Accident” was the lapel pin he had. Then we realized we were doing more wrong-side surgery than we were 17-18 years ago when we started this program, so what are we not doing? In talking to those gentlemen and other colleagues, I realized we really needed to double down. We needed to have a new commitment to patient surgical safety. Military and civilian aviation was changed by some of the contributions that my father made in the U.S. Air Force and then subsequently with United Airlines, so I grew up in that culture. Now people feel confident that “I’m going to get a safe experience on this airplane, I’m not going to crash.” We need to really commit to providing the same thing to all of our patients.
So what we did was start a series of discussions with the American College of Surgeons. I reached out and specifically contacted their executive director, Dr. David Hoyt, and began a dialogue that has gone on now for almost two years. We are now at the jumping off point where in Rosemont, [Ill.] during the first week of August this year, the entire perioperative community will have the first National Surgical Patient Safety Summit. We will invite folks from industry, the payer community, and those that are involved in other non-profit organizations dedicated to safety. We will bring everyone that’s involved with the perioperative community together—the entire continuum—from the time when you say “yes I’m going to have surgery and I’m ready to start getting scheduled,” all the way to the point where you are discharged from the hospital. That means nurses, anesthesiologists, surgeons, and the physicians that also take care of the patients – everyone will be involved. We will come together and have statements on the right way to do things and the wrong way to do things. It’s really designed to actually change the paradigm so we really understand there is no high quality if there’s not a safe surgical experience. There’s no quality without safety. An error rate of 10 percent in medicine is unacceptable, certainly unacceptable in surgery, although I don’t think it’s that high in surgery. What is acceptable? Zero is acceptable. We have to do this for our patients, we have to do this for our profession, and if we’re not going to lead, who will?
The most important thing is we want to have consensus, best practices and statements so we can actually come out with a compendium that becomes a document that has enduring life. It’s become somewhat frustrating that we haven’t been able to move the needle. We need to move the needle to the right for our patients and change our culture. The first thing you learn in medical school is do no harm. If we’re dedicated to that, let’s be really dedicated. Let’s make it happen.
Barbella: One of your other goals as president was to ensure the value of musculoskeletal care. How did you accomplish this?
Teuscher: There’s a two-pronged approach. One is we had a project team on value that under John Tongue’s leadership, researched the value of a particular procedure. You can get this on our website www.anationinmotion.org. There were two methodology and five procedure studies done and there are more being done in other areas. One was on total knee, another on hip fracture, and anterior crucial ligament. That’s tremendous. What was happening was we would go to Capitol Hill and they would say, “Well doctor, you’re doing a lot of total knee replacements and they’re very expensive.” We would respond, “Well, these patients are disabled. They’re not able to work, they can’t take care of themselves, they can’t get back in the game and this is a game-changer, a life-changer for them.” But we didn’t have statistics and no one researched it for us, so we paid for our own researchers. We hired an economic modeling team and they built an economic model. They looked at things like what does it cost to do a total knee on average? How much does society and/or the patient benefit from that—i.e., they go back to work, they pay taxes, they’re no longer needing a caretaker. It’s a life-changer, if you will. For instance, in the total knee article, you’ll read it’s about $21,000 in costs but about $40,000 in benefits. It’s a two-for-one return on investment. Where I sit, that’s pretty good. That doesn’t even factor in the change it makes in that person’s life. We actually change lives. That’s what orthopaedic surgeons do. We put people back in the game, put them back to work and give them an independent life. We restore function. That’s what I mean by value.
Communication with patients—a big part of that is our www.orthoinfo.org. We have an amazing amount of information that’s all scientifically based, it’s based upon the evidence that we give to our patients and we give it to them for free. The public can look at this. We are an education organization. We understand the primary people that need to be educated are those who are about to consume orthopaedic or musculoskeletal services. Another area in which we’ve done a lot of good work on is www.orthoguidelines.org, where all of our clinical practice guidelines, appropriate use criteria guidelines and soon to be our performance measure guidelines will be there for not just our doctors but for payers, purchasers, the government and the patients. This can help them understand what’s appropriate. I’m 40 years old, I don’t have X-ray changes, and my knee is unstable, I’ve had X-rays and an MRI and I can’t play my sport, is it appropriate for me to have an anterior cruciate ligament reconstruction? Yes, and it ranks it according to the levels of evidence that we have. We’ve invested in this. It’s an investment we’ve paid for on our own. It’s going to benefit everyone. That’s out there for the public. Those three websites are tremendous websites that we want to tell our patients and colleagues about. You know, our colleagues in primary care can benefit from looking at that data. It helps them understand how to treat a patient if they have osteoarthritis in the knee. They don’t need an MRI, they probably need some treatment, maybe a weight-bearing X-ray but they definitely don’t need an MRI and they don’t need to be referred for a knee arthroscopy for osteoarthrosis.
Every group I talk to, I talk to about this. If you’re not using these websites, if you’re not giving these websites to your patients then you’re not helping them the best you can. Another great website is a collaboration we had with the American Orthopaedic Society for Sports Medicine called www.stopsportsinjuries.org. Six to eight years ago we saw a tremendous amount of overuse injuries in adolescent and youth athletes. Throwing the baseball too many times and too hard lead to preventable overuse injuries in their arm or their shoulders. The reason they had pain in their shoulder wasn’t because they had torn a rotator cuff, they were actually tearing their bone apart, quite literally. That’s another resource we’ve put out there. I’m just one of many presidents that has had the bully pulpit – I call it the milk crate and the bullhorn…I get up on the milk crate and I use the bullhorn and am privileged to tell about all the great things that so many of our colleagues are doing. We have 3,709 volunteer orthopaedic surgeons that are contributing to Academy activities this year. That’s a big number. I’m just one of those.
Barbella: Please characterize the past year (2015) for the orthopaedic industry (elaborate on your answer).
Teuscher: I continue to see amazing developments. There was concern over whether innovation and technical development of new products and services was going to be stifled with the healthcare reform act that was passed in 2010. I don’t think so. I’m amazed at the new things coming out in that way. The big industry news [last year] was the merger of Zimmer-Biomet and we’ll have to see how that is fully realized. I think if you look several years back there was a lot of focus put on the implant industry and yet at the same time they continued to innovate. When we look at this, and the folks coming to Orlando to exhibit their orthopaedic industry offerings to our members, we have a tremendous response. If anything, I think we’re more invigorated than we have been in the past and I’m seeing some really amazing innovating things from our orthopaedic industry partners. I think the one area where we’re going to see some real innovation is in skills training and testing. I think that is very ripe and there’s a tremendous opportunity. Let’s use aviation again as a model. The Commandant of the Air Force Academy came and talked to us several years ago at our fall meeting and said the first time the pilot flies the aircraft is the first time they’re in the aircraft. They’re literally flying it for the first time because their simulators are that good. While I was in medical school I had the opportunity to fly that simulator, and you realize wow, it feels like you’re actually flying the airplane. Is there an opportunity for us to simulate surgery so that it’s so real that you’d be competent, safe and able to independently do that surgery after using the simulator? I don’t know, but maybe you get to the point where you’re almost competent and then you do some live surgery with proctoring with a faculty member. I think that’s very exciting. And it may allow you to do an awful lot on your own—again with that flipped classroom where you’re not there connected with the educator, you’re working on your own, and you’re getting a feedback loop of what you did and didn’t do, almost like a video game. You missed this, you didn’t do this, you cut this corner, you shouldn’t do it that way. I think the future of musculoskeletal education and continuing education is absolutely essential, as is the ability to continue to certify that you are competent and improving your competencies. All of us want to be the very best. The patients don’t care if we’re certified, they want to know if you’re competent. Are you really good? If we can demonstrate that and we can prove those competencies, and those competencies don’t involve just using a scissors or knife or sewing machine. They involve taking history, communication, patient safety. Those are all core competencies that we all can become better at and need to become better at for the good of our patients and the betterment of our profession.
Barbella: What was the most difficult challenge of your presidency?
Teuscher: I would tell you this is the same answer as every one of the presidents I have served with in the past. It’s keeping the house united. We have a very broad and diverse subspecialty interest within orthopaedics and keeping us unified, realizing that together we’re stronger and unified is sort of like what Ben Franklin said—if we don’t hang together we’ll surely hang separately. We need to stick together. We’re 2.7 percent of the physicians in the United States, we have the largest medical pact in the United States. We have a great past PAC chairman and new PAC chairman who are going to take us to unprecedented heights. We’re under constant assault from all sides, including the government, the payers, and the purchasers. There’s a lot of challenges out there but keeping us unified, keeping us together – the House of Orthopaedics was the topic of my discussions as the incoming president. That means we need to respect that each of us has unique needs and expectations, and we have to respect and support each other through constant communications.
Barbella: What advice would you give to your successor, Gerald R. Williams Jr., M.D.?
Teuscher: I’ve known Jerry Williams for 30 years. The presidential line has three individuals, and I’ve been blessed with Dr. Williams and Dr. Bill Maloney as my one VP and two VP. They have been my wingmen. So, I would say number one, always, always trust your wingmen. Get a consensus, move forward and always do what’s right for the House of Orthopaedics. You’re leading a family, and I’m not going to call you, you can call me for advice when you need it, but you won’t need to. I’ve watched Jerry Williams, he doesn’t need much advice. He is a superb educator, advocate and leader. He grew up on the education side, that’s his strong suit. He’s incredibly well-respected for his technical abilities as a shoulder surgeon. I’ve known him as a confidant and a very good friend especially the past two years. The Academy is in good hands. Jerry is very well-prepared and he gets it.
"Several past presidents told me before I began the year as president that it’s going to come at you very fast and they were absolutely correct,” Teuscher recalled. “It’s been just an incredible year. I [traveled] over 150,000 airline miles this [past] year, flying all over the North American continent, meeting with state societies, regional societies, specialty societies—all AAOS members and colleagues. They were all incredibly gracious, very supportive and very grateful that there’s somebody out there leading the charge. They have a lot of concerns because there’s a lot going on right now in orthopedics.”
Quite a lot, indeed: Between pricing pressures, industry consolidation, dwindling reimbursement, research funding, continuing education and patient safety, there was no shortage of challenges awaiting Teuscher during his presidency. Though he did not set a specific agenda to define his reign, Teuscher nevertheless identified several goals during his tenure—namely, improving surgical safety, ensuring the value of musculoskeletal care, and advancing educational technology as well as expanding online offerings in continuing education.
Before passing the presidential gavel to his successor, Gerald R. Williams Jr., M.D., Teuscher spoke with Orthopedic Design & Technology about his presidency, the industry, and the challenges he encountered leading the world’s largest medical association of musculoskeletal specialists.
Michael Barbella: Upon taking office as president last year, you said you wanted to improve surgical safety. How did you attempt to fulfill that goal?
David D. Teuscher: I’m going to give a lot of credit to Dr. Bill Robb, who heads up our patient safety committee. He, Dr. Dwight Burney (III), Dr. John Tongue, and others have through the years really advanced the cause of patient education, patient communication and surgical safety. I realized that over the last almost two decades, the Academy has been a leader in promoting mechanisms for surgical safety including “sign your site.” People like past President Jim Herndon were champions of this. “Patient Safety is No Accident” was the lapel pin he had. Then we realized we were doing more wrong-side surgery than we were 17-18 years ago when we started this program, so what are we not doing? In talking to those gentlemen and other colleagues, I realized we really needed to double down. We needed to have a new commitment to patient surgical safety. Military and civilian aviation was changed by some of the contributions that my father made in the U.S. Air Force and then subsequently with United Airlines, so I grew up in that culture. Now people feel confident that “I’m going to get a safe experience on this airplane, I’m not going to crash.” We need to really commit to providing the same thing to all of our patients.
So what we did was start a series of discussions with the American College of Surgeons. I reached out and specifically contacted their executive director, Dr. David Hoyt, and began a dialogue that has gone on now for almost two years. We are now at the jumping off point where in Rosemont, [Ill.] during the first week of August this year, the entire perioperative community will have the first National Surgical Patient Safety Summit. We will invite folks from industry, the payer community, and those that are involved in other non-profit organizations dedicated to safety. We will bring everyone that’s involved with the perioperative community together—the entire continuum—from the time when you say “yes I’m going to have surgery and I’m ready to start getting scheduled,” all the way to the point where you are discharged from the hospital. That means nurses, anesthesiologists, surgeons, and the physicians that also take care of the patients – everyone will be involved. We will come together and have statements on the right way to do things and the wrong way to do things. It’s really designed to actually change the paradigm so we really understand there is no high quality if there’s not a safe surgical experience. There’s no quality without safety. An error rate of 10 percent in medicine is unacceptable, certainly unacceptable in surgery, although I don’t think it’s that high in surgery. What is acceptable? Zero is acceptable. We have to do this for our patients, we have to do this for our profession, and if we’re not going to lead, who will?
The most important thing is we want to have consensus, best practices and statements so we can actually come out with a compendium that becomes a document that has enduring life. It’s become somewhat frustrating that we haven’t been able to move the needle. We need to move the needle to the right for our patients and change our culture. The first thing you learn in medical school is do no harm. If we’re dedicated to that, let’s be really dedicated. Let’s make it happen.
Barbella: One of your other goals as president was to ensure the value of musculoskeletal care. How did you accomplish this?
Teuscher: There’s a two-pronged approach. One is we had a project team on value that under John Tongue’s leadership, researched the value of a particular procedure. You can get this on our website www.anationinmotion.org. There were two methodology and five procedure studies done and there are more being done in other areas. One was on total knee, another on hip fracture, and anterior crucial ligament. That’s tremendous. What was happening was we would go to Capitol Hill and they would say, “Well doctor, you’re doing a lot of total knee replacements and they’re very expensive.” We would respond, “Well, these patients are disabled. They’re not able to work, they can’t take care of themselves, they can’t get back in the game and this is a game-changer, a life-changer for them.” But we didn’t have statistics and no one researched it for us, so we paid for our own researchers. We hired an economic modeling team and they built an economic model. They looked at things like what does it cost to do a total knee on average? How much does society and/or the patient benefit from that—i.e., they go back to work, they pay taxes, they’re no longer needing a caretaker. It’s a life-changer, if you will. For instance, in the total knee article, you’ll read it’s about $21,000 in costs but about $40,000 in benefits. It’s a two-for-one return on investment. Where I sit, that’s pretty good. That doesn’t even factor in the change it makes in that person’s life. We actually change lives. That’s what orthopaedic surgeons do. We put people back in the game, put them back to work and give them an independent life. We restore function. That’s what I mean by value.
Communication with patients—a big part of that is our www.orthoinfo.org. We have an amazing amount of information that’s all scientifically based, it’s based upon the evidence that we give to our patients and we give it to them for free. The public can look at this. We are an education organization. We understand the primary people that need to be educated are those who are about to consume orthopaedic or musculoskeletal services. Another area in which we’ve done a lot of good work on is www.orthoguidelines.org, where all of our clinical practice guidelines, appropriate use criteria guidelines and soon to be our performance measure guidelines will be there for not just our doctors but for payers, purchasers, the government and the patients. This can help them understand what’s appropriate. I’m 40 years old, I don’t have X-ray changes, and my knee is unstable, I’ve had X-rays and an MRI and I can’t play my sport, is it appropriate for me to have an anterior cruciate ligament reconstruction? Yes, and it ranks it according to the levels of evidence that we have. We’ve invested in this. It’s an investment we’ve paid for on our own. It’s going to benefit everyone. That’s out there for the public. Those three websites are tremendous websites that we want to tell our patients and colleagues about. You know, our colleagues in primary care can benefit from looking at that data. It helps them understand how to treat a patient if they have osteoarthritis in the knee. They don’t need an MRI, they probably need some treatment, maybe a weight-bearing X-ray but they definitely don’t need an MRI and they don’t need to be referred for a knee arthroscopy for osteoarthrosis.
Every group I talk to, I talk to about this. If you’re not using these websites, if you’re not giving these websites to your patients then you’re not helping them the best you can. Another great website is a collaboration we had with the American Orthopaedic Society for Sports Medicine called www.stopsportsinjuries.org. Six to eight years ago we saw a tremendous amount of overuse injuries in adolescent and youth athletes. Throwing the baseball too many times and too hard lead to preventable overuse injuries in their arm or their shoulders. The reason they had pain in their shoulder wasn’t because they had torn a rotator cuff, they were actually tearing their bone apart, quite literally. That’s another resource we’ve put out there. I’m just one of many presidents that has had the bully pulpit – I call it the milk crate and the bullhorn…I get up on the milk crate and I use the bullhorn and am privileged to tell about all the great things that so many of our colleagues are doing. We have 3,709 volunteer orthopaedic surgeons that are contributing to Academy activities this year. That’s a big number. I’m just one of those.
Barbella: Please characterize the past year (2015) for the orthopaedic industry (elaborate on your answer).
Teuscher: I continue to see amazing developments. There was concern over whether innovation and technical development of new products and services was going to be stifled with the healthcare reform act that was passed in 2010. I don’t think so. I’m amazed at the new things coming out in that way. The big industry news [last year] was the merger of Zimmer-Biomet and we’ll have to see how that is fully realized. I think if you look several years back there was a lot of focus put on the implant industry and yet at the same time they continued to innovate. When we look at this, and the folks coming to Orlando to exhibit their orthopaedic industry offerings to our members, we have a tremendous response. If anything, I think we’re more invigorated than we have been in the past and I’m seeing some really amazing innovating things from our orthopaedic industry partners. I think the one area where we’re going to see some real innovation is in skills training and testing. I think that is very ripe and there’s a tremendous opportunity. Let’s use aviation again as a model. The Commandant of the Air Force Academy came and talked to us several years ago at our fall meeting and said the first time the pilot flies the aircraft is the first time they’re in the aircraft. They’re literally flying it for the first time because their simulators are that good. While I was in medical school I had the opportunity to fly that simulator, and you realize wow, it feels like you’re actually flying the airplane. Is there an opportunity for us to simulate surgery so that it’s so real that you’d be competent, safe and able to independently do that surgery after using the simulator? I don’t know, but maybe you get to the point where you’re almost competent and then you do some live surgery with proctoring with a faculty member. I think that’s very exciting. And it may allow you to do an awful lot on your own—again with that flipped classroom where you’re not there connected with the educator, you’re working on your own, and you’re getting a feedback loop of what you did and didn’t do, almost like a video game. You missed this, you didn’t do this, you cut this corner, you shouldn’t do it that way. I think the future of musculoskeletal education and continuing education is absolutely essential, as is the ability to continue to certify that you are competent and improving your competencies. All of us want to be the very best. The patients don’t care if we’re certified, they want to know if you’re competent. Are you really good? If we can demonstrate that and we can prove those competencies, and those competencies don’t involve just using a scissors or knife or sewing machine. They involve taking history, communication, patient safety. Those are all core competencies that we all can become better at and need to become better at for the good of our patients and the betterment of our profession.
Barbella: What was the most difficult challenge of your presidency?
Teuscher: I would tell you this is the same answer as every one of the presidents I have served with in the past. It’s keeping the house united. We have a very broad and diverse subspecialty interest within orthopaedics and keeping us unified, realizing that together we’re stronger and unified is sort of like what Ben Franklin said—if we don’t hang together we’ll surely hang separately. We need to stick together. We’re 2.7 percent of the physicians in the United States, we have the largest medical pact in the United States. We have a great past PAC chairman and new PAC chairman who are going to take us to unprecedented heights. We’re under constant assault from all sides, including the government, the payers, and the purchasers. There’s a lot of challenges out there but keeping us unified, keeping us together – the House of Orthopaedics was the topic of my discussions as the incoming president. That means we need to respect that each of us has unique needs and expectations, and we have to respect and support each other through constant communications.
Barbella: What advice would you give to your successor, Gerald R. Williams Jr., M.D.?
Teuscher: I’ve known Jerry Williams for 30 years. The presidential line has three individuals, and I’ve been blessed with Dr. Williams and Dr. Bill Maloney as my one VP and two VP. They have been my wingmen. So, I would say number one, always, always trust your wingmen. Get a consensus, move forward and always do what’s right for the House of Orthopaedics. You’re leading a family, and I’m not going to call you, you can call me for advice when you need it, but you won’t need to. I’ve watched Jerry Williams, he doesn’t need much advice. He is a superb educator, advocate and leader. He grew up on the education side, that’s his strong suit. He’s incredibly well-respected for his technical abilities as a shoulder surgeon. I’ve known him as a confidant and a very good friend especially the past two years. The Academy is in good hands. Jerry is very well-prepared and he gets it.