Well, thank you, Jim, for that introduction, and thank you for the friendship over the years. I greatly appreciate it. So I'm going to talk about the various aspects of the burden of craft, and my disclosures in the program. The burden of craft is a term that I came across several years ago in this book by Edward Tinner, where he actually specifically talked about the surgeon's burden of craft, which is his obligation to use his craft for the patient's greatest benefit. There are a lot of other burdens of our craft that I want to get into as well, but this is the most important, so I'm going to come back and talk about it again at the end. So this book, The Burden of Craft, struck a chord with me as I read a second book, Shop Class as Soul Craft. This is written by Matt Crawford, who is a motorcycle mechanic who's the most articulate mechanic you've ever known or ever read. But you put the message of these two books together, and you would come out thinking that one of the surgeon's burdens is to uphold the value of manual competence. Now there's a lot of doublespeak these days in this age of technology, and I think two of the things that affect us in our trade, which is surgery, is the knowledge-based economy and value-based healthcare. What does that have to do with craft, and what does that have to do with us? It has a lot to do with us. If you look at the origin of this knowledge-based economy phrase, I think that as best I can tell, this is where it came from, this article by Powell and Snellman, where they said the key component of a knowledge economy is a greater reliance on intellectual capabilities than on physical inputs or natural resources. And that would lead you to believe that this type of job is on its way out forever, and that this is going to be supplanted by this type of job, which should be a real blessing to the human race in terms of getting rid of the back-breaking jobs. But this is also a manual job. So is that going to be replaced with a desk job, or is there something different about our manual competence as surgeons? Are our livelihoods in danger? Well, if you talk to people like this, you might think so. Michael Porter is a professor at Harvard School of Business who has developed this theory of value-based healthcare delivery. And he first expounded on this in the New England Journal of Medicine in 2010 with this article where he came up with this value equation where value equals outcomes over cost. His message basically is that medicine and medical care is a commodity. Surgeons are a commodity. They're interchangeable. Operate medicine like you operate an assembly line, and everything's going to be fine. But there's a certain mythology, a lot of mythology, to this medical technology doublespeak that I want to get into. As I said, the burden of our craft is that surgeons are obligated to use their craft to the best of their abilities to help their patients. No question, surgery is a craft, I think maybe the ultimate craft. If you go back to Matt Crawford, he talked about this concept of virtualism, which is a vision of the future that some people have where we just take leave of material reality, go out about in a pure informational economy, but the fact of the matter is that knowledge-based manual competence, that is not virtual skills, are going to retain the greatest value. So despite this, the insurance companies would have you believe that value is all about the denominator, it's all about cost, but the fact of the matter is there's a numerator here too, and the better your outcomes are, the higher the value. So if you're better at your craft, you can create higher value. Niall Ferguson is a well-known British historian who said that, in this book, that computers will be able to simulate the human brain by 2030. But I don't think they're going to be able to do surgery. The ability to perform surgery requires a combination of intelligence, knowledge, manual skills, and judgment that computers, I don't think, in my lifetime for sure, but I don't think they're ever going to be able to attain. He also goes on to talk about disruption as opportunity, but opportunity for whom? Is it opportunity for the surgeons or opportunity for the bean counters? And it depends on how you look at the value equation. So the bean counters look at it as being totally about cost, but I think surgeons need to look at outcomes and how we can influence the value equation and redefine the value equation by quantifying and distinguishing differences in outcome and differences in skill, differences in craft. How do you do that? Well, there is an analogy from the world of sports. There's another book I think you'd really enjoy reading by Matthew Futterman, Players, and it talks about how professional sports evolved. He says that in 1958, Arnold Palmer was the best golfer in the world. He had just won the Masters, and that put $1,500 in his pocket. Prior to that, the same year, he'd won some other tournaments. Each one, he won $500 for first place. So he made a few thousand dollars, he needed additional employment to make ends meet and defeat his family that year as the best golfer in the world. Then he met a guy named Mark McCormick, who was the first professional sports agent, and Palmer became his first client. McCormick knew that a lot of people were making a lot of money off professional sports, but it wasn't the athletes. But yet, professional sports wouldn't exist without professional athletes, and they needed to be compensated fairly, and if they were recognized for the excellence and the skill of their craft, that ought to happen. So how does that apply to surgeons? Well, you really just have to substitute the word surgeon for athlete in all of these bullet points here, but the value of athletes or surgeons was minimized and discounted in the past, despite their special talents. But sporting events or surgery can't take place without athletes or surgeons, and people are going to demand to see athletes or surgeons with proven abilities. So let's get a little closer to home and talk about something we know other than professional sports, but something I know for sure is the treatment of rotator cuff tears. I was surprised in 2016 to see this front page headline on Orthopedics Today, Open Surgery Still Plays a Substantial Role in Modern Rotator Cuff Repair. My first thought was, really? So I got my wife to memorialize that, to take my picture with that front page, because I couldn't believe that was happening in 2016. Because I knew that in 2016, just as in 2019, the state of the art is arthroscopic rotator cuff repair. But things evolve. They don't happen, they don't appear suddenly as arthroscopic cuff repair. It had to evolve. And how did that happen? We've got a lot of people that have taken on this burden of craft over the years. One of the earliest ones, or maybe the earliest significant one, was Dr. E.A. Codman, you see here as a long-haired toddler, and then a serious young man, and a dashing or serious young boy, and then a dashing young man, and then a serious older surgeon. But Dr. Codman kept careful records of everything. And this is his own graph of his rotator cuff surgeries. You see, in 1912, he did eight rotator cuff repairs. That's the most he ever did in a single year in his life. And between 1914 and 1926, he only did two of them. But despite this small number, it was enough to encourage his followers and for them to become so enthused and to improve the craft. Here was an early book from the 1940s by Moseley, one of his disciples. Moseley, you know, he really had a lot of physical tests that he—physical exam tests that he came up with. They seemed to work better on men with pencil-thin mustaches back in the day. He also did diagnostic injections for rotator cuff pathology. The difference, you see how he had to have an assistant that would give the patient a black eye and then hold his arms down when he got a shot, but it seemed to be pretty effective in diagnosis. Also, about this time, Dr. Bateman, James Bateman, had his book out where he did what looks like a maxi-open repair, a shoulder strap incision with a chromial osteotomy and a fascial graft. If the patient were lucky enough to survive that, he got put into post-abtraction in the hospital for three weeks. And then if he survived that, he got three more weeks in an airplane splint. But things were going forward by the 60s and 70s. You started having rock and roll and disco. You wanted things to be more cosmetic, match your hairdo, as you can see. But this still had pretty generous incisions, but still subcuticular closure, which made it look better. Melvin Post in the 60s and 70s, he was from Chicago, had kind of the Chicago treatment. This guy in the upper left looked like he's in the holding area, but looks like he's about to get gunned down by the mob. And no wonder, because look at the incision he's about to have put on his shoulder. Then if he survived that, he got to look forward to two different shoulder spica casts. One of them with him in about 60 degrees, and then after four weeks, they lowered it down to about 20 degrees. Guy hasn't slept in about six weeks, it looks like to me. And Dr. Near in the 1980s came out with his book, and you see he had this wonderful artist who put these beautiful small incisions in Langer's lines. Somehow, though, when they took the photographs of the same operation, the incisions seemed to have multiplied in size. This is from an academy publication from about two years ago, where this is a recommended treatment by the AAOS for repairing rotator cuff. I was a bit astounded to find this one. So my personal journey through arthroscopic cuff repair began in the 80s. I started doing cuff repairs in the mid-80s in the same city where this prominent shoulder surgeon was saying the arthroscope is the instrument of the devil. Right there in San Antonio, probably the single most hostile point in the universe at that time for shoulder arthroscopy, and I began doing some side-to-side repairs with some homemade suture passers and outpushers that I got a local aircraft machinist to make. Made some great friendships. We were all kind of outcasts at the time. Very creative guys, like you see here in this photo, Dr. Ash, Dr. Wolf, Dr. Snyder. These were guys with great three-dimensional skills who kept the craft alive because they could repair the shoulder pathology with just the most rudimentary instruments. Little did we know it, but the paradigm shift was underway. If you haven't read this book by Thomas Kuhn, you should, The Structure of Scientific Revolutions. He's the one who coined the term paradigm shift. There were these early radical books. Dietrich Second Johnson had the arthroscopic shoulder anatomy, Dr. Ash's shoulder arthroscopy book, Dr. Snyder's shoulder arthroscopy book. So we were beginning now to go through all of those phases of conflict that Mahatma Gandhi had talked about where he said, first they ignore you, then they laugh at you, then they fight you, then you win. By the 90s, there was a quest for more sophisticated instruments and implants. There was partnering with industry to try to come up with those. But first, there's this other burden of craft. You're going to participate in a paradigm shift in surgery. You've got to prove that your new technology and your new surgical constructs are biomechanically as sound and as strong as the older ones. So one of the early burdens that I took on myself was doing biomechanical experiments in the lab to look at cyclic loading and failure of cuff repairs through bone tunnels versus anchors just to prove that anchors were as good as bone tunnels. As it turns out, they were much stronger than the bone tunnels. What about the burden of craft arthroscopic identification? We'd never looked inside the shoulder before for the scopes of what's normal, what's important. What the hell is this? And this led to cause us to think about the biomechanical reasons why things developed the way they did. And these points that are fixation points for the rotator cuff that are so important that we need to pay special attention to reinforcing these cable attachments. Developing instruments and implants where there were these spring-loaded hook retrievers initially because everything had to be very simple. That's all we had. And then this advances. We had CAD programs for design. You could get more complex types of shapes for anti-grade instrumentation. This is one of the early prototypes for the nitinol needle that pushes the suture through. And then that developed. And what about nautilus repair? This is my first nautilus cuff repair in February of 2000 where I used an ACL screw and just used the friction fit of that against the suture. And then we tried other ways of just using lashing-like fixations where we would twist the suture. And the problem with that, you see, that's ethamine suture. That suture would often break as it hit the corner. It wasn't very strong. As it hit the corner of the bone, it would break. So I had the idea that we needed to use an extended-tip inserter that was much narrower that you could atraumatically pass it to the bottom of your bone socket and then bring an anchor in on top of that. First these were push-in anchors and then later twist-in anchors, screw-type anchors. So today's gold standard, I think, is double row with these cinch loops to reinforce cable attachments. If you have an irreparable cuff, the SCR with dermal allograft, I think, is an example of maybe perhaps the most advanced example of the burden of craft because it has a high technical degree of difficulty. So you really have to up your game for that. The thing about technological advancement is that the more technically advanced a surgery becomes, the more it requires craftsmanship. The public doesn't really recognize that. They think it becomes easier for the surgeon, but we all know that it actually becomes more difficult that we have to be more aware and look and feel to a greater degree than with a simpler technique. So there is that burden of craft to up our game. Not everyone has these skills, but if you're going to treat these people, you need to learn these skills and if you accept this opportunity to treat these patients. There's still some cuff repair deniers who say massive cuff tears can't heal and it must be the patient's fault. They have a biologic deficit, but in some cases, I think it's a surgeon's fault and maybe a skill deficit. And I think that's part of what's responsible for what we'll call reverse mania where there's a trend now, not just in the U.S., but other countries, too, toward reverse total shoulder for massive cuff tears even in the absence of arthritis, and I think one of the biggest reasons is that for the average surgeon, the reverse total shoulder is easier and faster to perform than an arthroscopic cuff repair, an SCR. But it's not what's best for the surgeon or easiest for the surgeon, it's what you'd want if it were your shoulder and what's best for the patient. After all, that's our contract with the patient is what is best for that patient. If you're going to do these arthroscopically, you need to know these advanced techniques that you've heard about at this meeting. The British had a saying for this, it's a poor carpenter who blames his tools. The tools for arthroscopic cuff repair and reconstruction exist, they're available, and they're excellent. You still hear from the podium, do what's best in your hands, I could not disagree more because I think you do what's best for your patient, and if you can't do what's best for your patient, if that's not what's best in your hands, you need to let the patient know where it can be available for him. So the burden of craft is the surgeon's burden, surgeon's obligation, we must accept the challenge and the responsibility of that burden. I would highly recommend this book as well, this is written by one of our own members, Chris Ahmad, it's called Skill, but it's 40 Principles that Surgeons, Athletes, and Other Elite Performers Use to Achieve Mastery, it has just some fantastic comments about how you can develop your skill. So in 2019, is open surgery still something you should be using for cuff repair? And I would say no, I said, and the reason I say that is I've spent pretty much my whole career trying to refine techniques and try to make it easier for arthroscopic techniques in the shoulder, and thereby upholding the burden of craft. I've got to say it's been a great journey, and I could not have imagined a more fulfilling ride. Thank you.

burden of craft

surgeons

manual competence

value-based healthcare delivery

rotator cuff repair techniques