The inaugural reverse fellowship that brought Boutros Farhat to three centers of excellence was a resounding success for both the fellow and the hosts. Our hats off to the hosts who made this a great experience for the fellow. We are well underway in planning next year's fellowship. The expansion of our Board to include advanced care providers began in July, with the plan to progressively expand this exciting partnership. Please look for the launch of our amazing new promotional video that highlights our organization's members, achievements, and goals.

The instructional courses cover the full gamut of upper extremity topics and the panel symposia will highlight debates amongst the experts on controversial topics as well as attempts to convince the audience to try new approaches to old problems. We welcome the French Society for Surgery of the Hand as our guest nation and learn from their extensive experience in multiple areas, especially novel techniques in arthroscopy and small joint arthroplasty. We are excited to announce our featured guest speaker, former USPS team cyclist and New York Times Bestselling Author Tyler Hamilton. The meeting will end with a bang as Ann Compton, the former White House correspondent for ABC news, delivers the keynote address. We look forward to seeing you there!

R. Glenn Gaston, MD & Christina M. Ward, MD

Evidence for conservative care shows positive effects of exercise, orthoses and joint protection education (JPE) for CMC OA to reduce pain, improve function. However which orthosis or which exercises are best? Also, little is known about dosage of exercise for the small muscles of the hand¹.

Dynamic stability rehabilitation strategies are used for injuries and OA at other joints in the body, such as the knee and the shoulder^2-3. What is Dynamic Stability, and why is it used? To restore functional motion, re-education of specific muscles to improve the strength, reduce pain and disability, and to promote self-management of pain during function. So why not use this same approach for the thumb?

The 1^st Dorsal Interosseous (FDI) and the Opponens (OP) are emerging as key muscles for thumb stability. Multiple studies show radiographically the FDI and OP can act to help center the metacarpal on the trapezium. Interestingly one study showed concomitant activation of the FDI and OP reduced subluxation significantly, and when more force was applied, a greater radiographic reduction was noted^4-7. This may help answer dosage.

There are 3 important points for a stable thumb: release the adductor to widen the thumb webspace and keep it supple; use appropriate thumb motors to stabilize and centralize the 1^st metacarpal on the trapezium, with an emphasis on the combined motions of the FDI and Opponens; and educate the person to stabilize their own thumbs for a lifetime.

It is the author’s opinion is that every conservative plan include a program of dynamic stability, and orthosis as needed, with a plan to wean out of orthosis or to continue to wear as needed, as pain and stability dictate.

Since there is no consensus for one specific orthosis to provide thumb stability, this predisposes the need for the custom fitting of the “best orthosis” for each person individually; be it custom or off the shelf, hand or forearm based.

Another area of emerging evidence surrounds the proprioceptive end organs in the stout CMC dorsoradial ligament structure and its influence on thumb motors. A most interesting finding is proprioception of OA CMC ligaments respond differently than those of non-OA ligaments. Joint instability ALONE may not be the primary etiological factor in development of OA of CMC. Dynamic proprioceptive function of the joint is subject of exciting continuing studies and more to come^8-10.

1. American College of Sports Medicine. (2011). Position Stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Medical Science of Sports Exercise, 43:1334-59
   
   
2. Wilk KE, Macrina LC, Reinold MM. Invited clinical commentary: Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. N Am J Sports Phys Ther. 2006;1:1-10.
   
   
3. Chmieleweski TL, Hurd WJ, Rudolph KS, Axe MJ, Snyder-Mackler L. Perturbation training improves knee kinematics and reduces muscle co-contraction after complete unilateral anterior cruciate ligament rupture. Phys Ther. 2005;85:740-749.
   
   
4. Adams, J.E., O’Brien, V. H., Magnusson, E., Rosenstein, B. Nuckley, D. J. (2018). Radiographic analysis of simulated first dorsal interosseous and opponens pollicis loading upon thumb CMC joint subluxation: A cadaver study. Hand, 13(1);40-44. DOI: https://doi.org/10.1177/1558944717691132
   
   
5. O’Brien, V.H., & Giveans, M.R. (2013). Effects of a dynamic stability approach in conservative intervention of the carpometacarpal joint of the thumb: A retrospective study. Journal of Hand Therapy, 26, 44-52.
   
   
6. McGee, C., O’Brien, V.H., Van Nortwick, S. Adams, J., & Van Heest, A. (2015). First dorsal interosseous muscle contraction results in radiographic reduction of healthy thumb carpometacarpal joint. Journal of Hand Therapy, 28, 375-381
   
   
7. Mobargha, N., Esplugas, M., Garcia-Elias, M., Lluch, A., Megerle, K., & Hagert, E. (2015) The effect of individual isometric muscle loading on the alignment of the base of the thumb metacarpal: A cadaveric study. Journal of Hand Surgery (European Volume); XXE[X]:1-6
   
   
8. Hagert, E., Lee, J., & Ladd, A.L. (2012). Innervation patterns of thumb trapeziometacarpal joint ligaments. Journal of Hand Surgery; 37A:706-714.
   
   
9. Halilaj, E., Rainbow, M.J., Moore, D.C., Laidlaw, D.H., Weiss, A-P. C., Ladd, A.L., & Crisco, J.J. (2015). In vivo recruitment patterns in the anterior oblique and dorsoradial ligaments of the first carpometacarpal joint. Journal of Biomechanics, http://dx.doi.org/10.1016/j.jbiomec.2015.04.028
   
   
10. Mobargha, N. (2015) The proprioception and neuromuscular stability of the basal thumb joint. (Unpublished doctoral dissertation) Karolinska Institutet. Stockholm, Sweden.

	Figure 1: The usual point of pain: the thumb CMC Joint		Figure 2: Even normal thumbs can have a typical deformity: a Boutonniere thumb.
	Figure 3: The 1st Dorsal Interosseous, a key muscle for thumb stability. Start with active motion, progress to isotonic strengthening.		Figure 4: The Opponens Pollicis, another key muscle for thumb stability. Progress to firing the OP with FDI.

Virginia H. O’Brien, OTD, OTR/L, CHT

Deana Mercer, MD, MSCR, FAOA
At the University of New Mexico (UNM), I have the opportunity to direct research and the hand fellowship within the Department of Orthopaedics & Rehabilitation. After completing medical school and residency at UNM, I completed my first fellowship in Shoulder and Elbow Surgery at the University of Washington. A year later, I returned to UNM to complete a second fellowship in Elbow, Hand & Microvascular Surgery. I soon obtained a Masters of Science in Clinic Research with Distinction at UNM to enhance my research capabilities. As the Director of Research, I focus on building a didactic research team. Balancing clinical duties with research efforts has been challenging and rewarding. But most importantly, it is doable.

It is crucial to approach any discipline with an open mindset—after all, the research process entails far more just one school of study. There are papers, IRB submissions, website development, and networking. An interdisciplinary team allows us to combat these various processes. For example, our current team comprises an English major to assist with publications, a public health major to help coordinate studies, and a computer science major to develop online outreach.

To be successful leaders, we must listen and communicate with our team. Take the time to meet with them at least once a week. This can be difficult owing to busy clinic schedules, but it is necessary to ensure all members stay up to date and well informed.

Finally, we must remember that we cannot do it alone. Learning how to delegate and prioritize tasks is an often-overlooked aspect of leadership and research. This is where the success of an interdisciplinary team truly shines—for example, you may not understand a new IRB rule, but your team member does.

My research interests include pathology of the shoulder, elbow, and hand. I am also fascinated with biomechanical studies on orthopaedic musculoskeletal problems, including arthritis and osteoporosis. To further my research and encourage interdisciplinary collaboration, I work closely with engineers from our in-house laboratory directed by a fantastic PhD faculty member. We conduct numerous studies together to solve and publish salient questions in modern orthopaedics.

I believe success comes from support, diligence, and guidance. Joining the AAHS research committee has been a wonderful way to give back to the community—which continues to be encouraging and supportive in all aspects of my career.

Simon G. Talbot, MD
I am an attending plastic and reconstructive surgeon at Brigham and Women’s Hospital (BWH) in Boston, MA. I am an Associate Professor of Surgery at Harvard Medical School. I completed medical school at the University of Auckland in New Zealand and shortly after finishing moved to Memorial Sloan-Kettering Cancer Center in New York, NY to undertake basic science research in the area of molecular genetics.

I then joined the Harvard Combined Plastic Surgery Residency Program and completed a fellowship in hand and microsurgery under Dr Joseph Upton. After completing training, I became very involved in hand transplantation and am the Director of Upper Extremity Transplantation at BWH. My research focus is around nerve regeneration including the use of growth factors to promote nerve growth and prevent motor endplate senescence. This is collaboration with Dr David Mooney at the Wyss Institute and Dr Leon Nesti at Water Reed Military Medical Center, where we are using a large animal model, initially funded by the NIH and now with .4 million in Department of Defense (DoD) funding. I also have a research interest in the area of psychosocial predictors of outcomes in major upper extremity trauma and transplantation. This is also funded with million from the DoD. I joined the AAHS Research Committee to help further research into hand surgery and help promote this as part of academic careers.

The ABOS WLA to renew Surgery of the Hand Subspecialty Certification will be available.

Contact:
Peter M. Murray, MD
President, American Board of Orthopaedic Surgery
Email: president@ABOS.org

For additional questions:
David F. Martin
Executive Medical Director
Email: dmartin@ABOS.org

Learn more: www.abos.org

For most, we proceeded to residency While some would continue beyond residency to complete a fellowship program. In all those years of learning, shadowing, training, and then practicing medicine a common theme existed: study hard, sacrifice yourself for the betterment of the patients, and do no harm. What most of us lacked was direction on how to look for a job, how to evaluate potential positions, and how those positions could be used to help negotiate the employment opportunity that would be right for you. For those still in training, I would recommend interviewing for jobs in your chief year of residency. There will be more flexibility in your schedule during your final year, than during your fellowship year. If you do not plan on participating in a fellowship, then start interviewing in the latter half of your junior-chief year of residency. I took advantage of the job fair at the yearly national meeting for the American Academy of Orthopaedic Surgeons (AAOS). The AAOS has a process where one can submit a curriculum vitae in November for publication in a database that is readily available for recruiters and those looking to interview during the national meeting that occurs in March (www.aaos.org/careercenter). Similar opportunities exist in other specialties as well. The stress of solidifying your future position at the same time training comes to an end is a large distraction that will prevent you from enjoying the last few months of training. We have all been culprits, at one time, of relaxing our clinic responsibilities because of concerns pertaining to our job search. Instead of repeating that potential mistake, start your career search early and use the last year of training to focus on refining your talents and synthesizing your future goals for success.

Now comes the decision of choosing what kind of practice suits you most, private practice or the employed model. My Orthopaedic Chairman, suggested, “if you are uncertain of the business model that will suit you, start in private practice. If it doesn’t work, it is easy to be rescued by an employed position. The reverse scenario of starting in an employed position and leaving to start a private practice is much harder on your personal finances.” This is great advice.

For me personally, I considered myself hardworking, a team player, and one who could add value to a hospital system, so I selected the employed model. While both models have pros and cons, the employed model offered less financial risk during the years when my medical school debt would have a significant impact on my monthly budget.

What happens next is based upon how much effort you spend learning about contracts. As interviews begin, practices will ask you for professional references, review your online persona, and request a direct meeting. Use this time to educate yourself on contracts and begin interviewing healthcare employment attorneys. Two books I studied were The Final Hurdle: A Physician’s Guide to Negotiating a Fair Employment Agreement by Dennis Hursh and Physician’s Guide: Evaluating Employment Opportunities and Avoiding Contractual Pitfalls by Thomas C. Crawford. Another great resource is the American Medical Association’s Annotated Model Physician-Hospital Employment Agreement and the companion version for Physician-Group Practice Employment. Also, hire an attorney. As Abraham Lincoln once said: “He who represents himself has a fool for a client”. The interview process of attorneys should continue until you find one who has experience in health law and employment law, a personality that matches your own, is willing to listen carefully to your goals, and provide a concrete strategy with multiple counter strategies. Once you find an attorney, consider asking them to provide you with a couple of sample contracts for review. Let them know that you are not looking for a template, but rather educating yourself about the different concepts so you can communicate better what is important to you and be a better client. Also, you will find yourself to be more efficient during interviews if you understand what you should be looking for. This knowledge will give you substantial leverage in negotiations now that you understand the basics of physician contracts when presented with an offer of employment. One learning point worth mentioning focuses on the statement, “the contracts are the same for all physicians at our institution.” I heard this when I entered negotiations. Lawyers hear this all the time too. While contracts are similar they are not all the same. Removing certain clauses in a contract may be more difficult but adding clauses that protect you or provides balance to clauses that may not work entirely in your favor is much easier to accomplish. These subtle negotiation tools are paramount to future negotiations or exit strategies. Use an attorney to help you maximize these strategic opportunities. Remember always, if there is not a good exit strategy, you better love the terms of the agreement and the people you will be working with because you may be with them for several years; absent moving out of the area or negotiating/litigating your way out. None of these options are favorable and all of them can get quite expensive. For example, you could elect a multi-year contract with an automatic renewal to provide an opportunity for financial security in the long term but include a clause that would allow you to refund any signing bonus by a certain date to void a restrictive covenant. This provides a narrow window to invest time and evaluate the practice after the honeymoon phase to determine if it could be a good long-term fit with little downside risk. Aside from the restrictive covenant, the other deterrence for physicians to leave a practice if renewal negotiations are not going well is the cost of tail coverage. This is the premium that must be paid to the medical malpractice policy to cover any liabilities that might occur after you leave a practice. Tail coverage for physicians is a multiple of 1.5-2 times (sometimes higher) the annual premium charged for that specialty after factoring in the numbers of years worked for a practice or a hospital. Depending on your time in a practice, this can be a significant amount that may cost in excess of ,000, especially if you have been practicing for many years or are in a high-risk specialty. Negotiate your contract so that your tail coverage premium is covered by the practice if the malpractice policy is a claims-made policy. A better option is to seek to include an “occurrence” coverage medical liability policy, as this policy usually protects you for malpractice suits even after leaving a practice at no extra cost, meaning tail coverage is built into the policy. For more information regarding this topic I would recommend a good article written by Thomas Fleeter, M.D. called The Hidden Cost of “Tail” Insurance). The American College of Physicians website also provides succinct information regarding this topic. As always, talk with an attorney about the right type of coverage for you. Lastly as part of any exit strategy, it is important to keep open lines of communication with the previous practices that you interviewed with. Maintaining the relationship, even after accepting a position, will help you in the future if the position you selected does not turn out to be exactly what you wanted. Although some of your focus should be on exit strategies, it is also equally, if not more important, to place provisions in the contract that will help build your practice. For example, consider including a clause that details a specific monthly and yearly budget for marketing expenses. How much the community is aware of you and your talents will determine how successful your ramp up phase will be which will have a direct impact on the longevity of your practice in the community.

Dedicate 100% of your effort to making your first practice successful (You only want to do this once). As young physicians entering the work force we dedicated countless hours to learning medicine, however little time was spent learning the business of medicine, the politics of hospital systems, and how to navigate the balance between your professional and personal happiness. Add to all this, the task of building your practice, and all these tasks can seem daunting for your first year in practice. Be engaged with the practice. Attend administrative meetings so you learn the inner workings of the practice. Participate in hospital committees, as this will serve to create relationships with other physicians that you will interact with. It will also give you insight to future business decisions the hospital may be considering and help you understand how that will impact your practice. Most practices have transitioned to an electronic medical record system. Use the system to review your personal financial dashboard monthly to identify trends. Keep track of your referrals to other physicians, referrals for laboratory studies, and referrals for imaging studies as these are all sources of income you have created for the hospital system. Having this detailed information will help you in future income negotiations to be compensated in a manner that is lawful and consistent with fair market value standards. Most importantly, invest in the care of your patients. If you build a strong interpersonal relationship with every single patient, your patients will serve as your best marketing strategy. People know if you truly care about them and will happily make that known in the community. The opposite is also true. If you show indifference and lack of respect as patients trust you with their health, you will find yourself with empty waiting rooms and a short-lived practice.

Once you have landed your dream job and have been working there for some time, know when to recognize that sometimes your first choice can no longer be your first choice and figure out how to redirect. Not everyone will have the opportunity to practice in one location for the same practice/institution for a lifetime. The American Academy of Orthopaedic Surgeons has published data demonstrating that 50% of orthopaedic surgeons will change practices within the first two years. Over the lifetime of an orthopaedic career an individual may make at least two career changes.

Finding your true home.

Looking back on my first experience, I am thankful I recognized my early personal dissatisfaction and made a change. When speaking to colleagues, I often heard how their first years in practice were also difficult and the inequality was sometimes unbearable, but that it would get better over time. Making sure it gets better over time is tricky to evaluate and different for everyone. From my own experience, it made me reflect more on my goals as an orthopaedic surgeon, as a husband and a father, rather than placing importance on the location of my practice. With that in mind, I began my search for a new practice and identified a group of physicians that held professional and personal beliefs that were more in tune with who I wanted to be. I took the steps to critically evaluate the future opportunity with this group from what I had learned in the past and the information gained from an article I reviewed written by Ryan Dopirak, M.D. The rest, as they say, is history and I now find myself in my second practice, equally productive, but much happier that I am now on a path that compliments me more as a physician and as a person.

Starting your practice is hard. Building your practice is hard. Maintaining your practice is hard. I do not advocate quitting and starting over simply because the practice may not be perfect. I do however recommend that you are objective about why you might be unhappy and search for ways to rectify your unhappiness prior to making the decision to terminate your current employment. Once that decision is made, move forward and don’t look back. Remember, there was something you could not rectify which is why you even contemplated the decision to leave. Now you know what you did not know. Use it to create or find your true home: the practice that will last throughout your career.

Dr. Florez is an Orthopedic Hand and Upper Extremity Surgeon at St. Clair Orthopedic Associates for St. Clair Hospital in Pittsburgh, PA. He is an active member of the American Board of Orthopedic Surgery and holds a Subspecialty Certificate in Surgery of the Hand. He is a byproduct of his training at Georgetown University School of Medicine, Philadelphia’s Einstein Medical Center Orthopaedic Surgery, and the University of Pittsburgh Hand and Upper Extremity Fellowship. His elective practice focuses on shoulder, elbow, wrist and hand surgery.

Added Resource Links:

• Evaluating Orthopaedic Practice Opportunities by Ryan Dopirak, M.D.
• 25 Key Concepts for Young Orthopedic & Spine Surgeons to Build a Successful Practice by Laura Dyrda
• Dissatisfied Hand Surgeons: What Causes Them to Change Jobs? By Anthony A Smith, M.D.
• Navigating the Transition from Residency to Physician Practice by John Fromsom, M.D.
• Practice Transition Planning: When Is the Right Time? By Karen Zupko, BSJ
• Annotated Model Physician-Hospital Employment Agreement, 2011 edition: E-Book by Sidney S. Welch
• Annotated Model Physician-Group Practice Employment Agreement, 2014 edition: E-Book by Norman Jeddeloh, Esq.

2019 Volunteer Scholarships Available
The HSE will provide 3 volunteer scholarships to hand surgeons and hand therapists in 2019. Recipients will be funded $3,500 each to be used towards volunteerism trips in 2019. Both plastic and orthopedic surgeons (fellows and individuals 5 years in practice or less) as well as hand therapists are encouraged to apply. Individuals must be AAHS members to receive funding. The application deadline is November 1, 2019. Apply now!

AAHS/PSF Combined Pilot Research Grant
The Plastic Surgery Foundation (PSF) and the American Association for Hand Surgery (AAHS) recognize the importance of fostering the development of surgeon scientists and innovative research in hand surgery and hand care. The AAHS and PSF are committed to increasing the amount of research funding dedicated to funding pilot research studies that set the stage for applications to larger funding agencies. The grants are funded by The Plastic Surgery Foundation and Hand Surgery Endowment and administered by the AAHS and PSF. The application deadline is December 3, 2018. Apply now!