|Hand Association News
|Message from the President
Brian D. Adams, MD
This year is off to a great start after a very successful Annual Meeting in Phoenix despite a quick change in venue due to the hurricanes. The agenda for 2018 is full of exciting initiatives to bring even more value to our members.
Our international missions are growing, with new venues and expanding resources to reach even more underserved regions of the world. A "reverse" fellowship was created to bring international young superstars in hand surgery to the US for special training with our members at centers of excellence. We continue to make bilateral partnerships with international hand surgery organizations to expand relations and education around the globe, with France being our wonderful partner at next year’s Annual Meeting in sunny southern California.
We are well underway in expanding our partnerships with other affiliate providers, which will broaden our important role in hand care and education throughout the country and to help tackle many of the shared bureaucratic changes and challenges facing our specialty.
Our Hand Journal volumes and readership have steadily increased, including excellent contributions from both domestic and international authors. I wish there was more space to present all of our recent and upcoming activities, but I promise to highlight these in the next newsletter. Enjoy your spring but don't forget to mark your calendars now to be in Palm Desert on January 30th 2019!
Saving for College... Gunner or Slacker?
Richard J. Tosti, MD
It has been said that, "an optimist is a college student who opens up his/her wallet and expects to find money!" - Or perhaps that optimist had a parent who was a Gunner for education. Either way, as educational costs rise at an average of 6% per year, we can expect a significant chunk of our earnings to support the educational ambitions of our progeny. Here are a few tips up for discussion.
Pitfall 1: Be aware that, as a physician, you probably will not qualify for Federal Student Aid. The FAFSA calculation for need-based aid computes that your "Expected Financial Contribution" is 30% of your annual income and 6% of non-retirement assets. Most likely, 30% of your annual income will be greater than the cost of attendance, which will disqualify you for need-based grants, scholarships, and possibly loans.
Pitfall 2: You will notice debt is NOT one of the pillars. You can rely variably of each of the following, but hopefully you will not need to borrow for school. Truly, in knowing the frustrations of starting a family and "a real life" with student debts, I can think of no greater gift than to free my children of this burden (ok perhaps there are greater gifts, but this freedom surely ranks in the top 5!).
The "4 Pillars of Paying for College" was coined by Jim Dahle, MD at the White Coat Investor Blog. Each are important and will be discussed separately.
- School Selection
- College Savings
- Your Child's Contribution
- Your Cash Flow
Pillar 1: School Selection is probably the most important. The cost of attendance to each school does not necessarily correlate with the value of the education, expected future earnings, or size of the alumni network. Sometimes the difference between in state and out of state schools may be as much as 4-8 times the cost. The same is arguable for private versus public schools. However, I appreciate that school selection is a very personal decision. I am not saying a more expensive school is not worth the value... perhaps it is worth the value to you or your child. I am only highlighting the fact that cost of education with respect to the experience and/or future earnings should be taken to consideration when deciding to pay for college.
Pillar 2: College Savings are usually done in tax advantaged education accounts. The following two accounts function much like a Roth IRA in that the contributions are made with your post tax money but the earnings can be invested and will grow tax free. One option is Coverdell Education Savings Account. Advantages of this account are that it can be used for private grade school/high school expenses, but the disadvantage is that the annual contribution is limited to $2000 per year. The other (and more common) option is using a 529 account. A parent can contribute $14000 per year ($28000 if married). The money can also be front-loaded in a five-year contribution ($70,000 for single, $140,000 for married). Recently, the president changed the laws on 529 accounts, which now allows them to be used for K-12 education expenses up to $10,000. Each state has a 529 account, which can be found with a simple Internet search. Most states offer a tax credit or deduction for contributions into your own state's 529 programs, so usually the first step is to look into the advantages of your own state's plan. However, some states do not offer a credit/deduction and some states will give you a deduction for contributions in other states 529 programs. Why might you look into another state’s plan? They are not all invested the same, and some out perform others. So if your state doesn't have a significant tax advantage you might be better off investing in another plan. Which are the best ones? Morning star has given a "gold" rating to the top programs, which can be found here:
Pillar 3: Although parenting philosophies may differ, I believe the child should contribute something to the cost of education so that they appreciate the value and take it seriously. Your child contribution comes in the form of the scholarships they might earn, their savings, educational trusts, summer jobs, or part time work while in school. If you decide you still have to borrow, their school loans are in this category too.
Pillar 4: Part of your monthly income could be budgeted to the educational balance as well.
It is far more advantageous to reduce the cost up front. For example, if you choose to pay for 4 years of college with loans, choose a school at $25,000 annual tuition, and choose a 10 year repayment plan (most common) at 6.8% interest (current subsidized federal Stafford loan rate), then the total cost will be about $140,000 (which is 40% more than the original tuition – NOT 6.8%!).
Combining Dr. Dahle's pillars could make a different picture for that $25K/year school: if you contribute $5K per year, your child contributes $5K per year with an in-school job, earns $5K each summer, and has a $5K/year scholarship, then you would need to save $20K in Pillar 2 to complete college debt free.
Dr. Tosti is a practicing hand and microvascular surgeon and a paid consultant of the White Coat Investor, LLC.
He is not a licensed financial advisor and has not completed any formal financial training.
Please be aware the advice written herein should be considered personal advice for the purposes of informal discussion and diffusion of ideas.
All information given should be verified with a professional advisor.
AAHS Research Committee Members and How They Launched Their Research Careers
Every member of the Research Committee has devoted time and energy to encourage others to conduct research in the field of hand care. Read about the paths taken by members of the AAHS Research Committee.
Jonathan Isaacs, MD, Research Committee Chair
I'm the Herman M. & Vera H. Nachman Distinguished Research Professor, Chief of Hand Surgery, and Vice Chair of Research and Education, in the Department of Orthopaedics within the Virginia Commonwealth University Health System. I completed medical school and residency at VCU and did my Hand and Microsurgery Fellowship at Duke University Medical Center. While at Duke, my attending and I envisioned the reverse end-to-side nerve transfer (now known as "supercharging") when trying to augment an incompletely recovered upper trunk brachial plexus injury. This became my fellowship research project supported with a grant from the Piedmont Society. I had not finished the project by the end of my year and, every Monday, for the first six weeks of my new job at VCU, I would drive to Duke at 5am, spend the day in the lab, and drive back to Richmond in the evening. This launched my research career and, I believe, demonstrated my commitment to my chairman who provided me with unwavering support through the remainder of his tenure. Though I continued to dedicate an uncompensated day a week to research for a couple of years, the department eventually hired me a full time research assistant and I began working a full clinical schedule (but continued to do research and academic related activities on nights and weekends). With the exception of an ASSH basic science grant, we squeaked by with departmental funds. Though we has submitted many applications, it was not until my 7th year that I received our first federal funding in the form of a Department of Defense Idea Development grant. We struggled for a few more years but finally our perseverance paid off and the rejection letters turned into "congratulations" letters. Over the last several years, we have received funding from the Department of Defense, the NIH, the American Foundation for Surgery of the Hand, the Musculoskeletal Transplant Foundation, as well as industry support totaling more than $1.5 million dollars in funding. I now have two full time assistants in the lab and spend 1 1/2 days a week on research, academic, and administrative activities. Though over the years, I have participated in several biomechanics studies, my real passion is nerve research. I am currently involved in basic science, small animal, and clinical nerve and muscle regeneration research. I attribute my success to persistence, support, and the generous mentorship and guidance from members of the ASSH and AAHS. I joined the AAHS research committee to offer fellow association members the same mentorship and support that I have received in the past.
John Fowler, MD
I am an Assistant Dean for Medical Student Research at the University of Pittsburgh School of Medicine and an Assistant Professor in the Department of Orthopedics at the University of Pittsburgh. I completed medical school and residency at Temple University Hospital and then a hand and upper extremity fellowship at the University of Pittsburgh. Based my experience with current undergraduates and medical students, I had a late introduction to scientific research. My undergraduate degree was in chemistry and I did not get involved in any research studies beyond my regular classwork. In medical school I participated in some bench research in a cardiovascular lab between my first and second years, but mostly performed simple tasks and honestly didn't learn very much from the process. My first research experience in Orthopedics came as a 4th year medical student. I met with Saqib Rehman, one of the Orthopedic trauma surgeons at Temple, and he tasked me with performing a meta-analysis to determine the optimal sequence for repair in patients with femur fractures and a concomitant vascular injury. I really enjoyed the meta-analysis process as I learned a great deal from the literature review. I appreciated how the "success" of the project was almost solely based on my own effort in reviewing the literature and collecting the data. Based on this experience, when medical students come to me looking to get started with orthopedic research, I often offer them a systematic review-type project. It allows me to gauge their work-ethic and ability to complete tasks.
The meta-analysis research sparked a true passion for answering the unknown or controversial questions in orthopedics. Much of my early work tried to answer questions such as, "Should we give antibiotics for clean, soft-tissue hand surgery" and "Is it better to use a VAC or dermatotraction for fasciotomy wounds" and "Do different types of suture attract more bacteria?" My current research focus is on the use of musculoskeletal ultrasound for diagnosis and prognosis of carpal tunnel syndrome. I am absolutely convinced that we will abandon the use of routine nerve conduction studies for carpal tunnel syndrome during my career.
I believe that my experience with the grant writing process mirrors that of most young researchers. Early on, I was able to secure small foundation grants from local foundations. I was lucky to be aware the ASSH Clinical Grant for my ultrasound research and recently obtained a larger foundation grant from my institution. I have participated as a co-investigator in a multi-center R01 trial with Kevin Chung and I have learned a great deal from that process. Thus far, I have been unsuccessful in securing my own R01 funding. This is likely a combination of failing to express my vision clearly to the reviewers and their impression that my study ideas are not necessarily novel. I hope to change that in the near future.
Kevin J. Little, MD, FAOA
I'm Director of the Pediatric Hand and Upper Extremity Center at Cincinnati Children's Hospital Medical Center, Associate Professor of Orthopaedic Surgery at the University of Cincinnati College of Medicine, and Fellowship director of the Mary S. Stern Hand Surgery Fellowship. I completed medical school at the Johns Hopkins University School of Medicine and residency at the University of Cincinnati followed by a Hand and Microsurgery Fellowship at the Philadelphia Hand Center at Thomas Jefferson University. I completed a second fellowship in Pediatric Hand and Upper Extremity Surgery at Cincinnati Children's Hospital before joining the faculty. During residency I was awarded an OREF grant which we used to study how repetitive stress can induce cartilage damage in skeletally immature rabbit knees. From this I was able to attend the AAOS Clinician Scientist Development Program, which was instrumental in helping me to decide to pursue a career as a clinician scientist. Upon starting on the acadmic faculty at Cincinnati Children's and the University of Cincinnati, I began to research how bioresorbable metals could be used to augment nerve and bone recovery following injury. Using an AAHS research grant, we were able to demonstrate that bioresorbable magnesium metal microfilaments appeared to augment early recovery of sciatic nerve defects treated with a nerve conduit. From this success we have been able to diversify our research interests to include healing of other tissues. We have also begun researching how magnesium metal flexible implants may be able to promote bone healing while keeping a fracture stabilized. I joined the AAHS research committee to give back to the association and help association members to pursue a fulfilling career in academic hand surgery.
Therapist Corner: The Confidence Code
The ingredient therapists lack when discussing patient care with the surgeons.
Saba Kamal, OTR, CHT
What traits define a successful therapist in outpatient care? The essential elements that allows the therapist to be successful at their job includes knowledge of the anatomy, the injury, the pathology, the procedure performed and its precautions, and the ability to foresee the prognosis or its pitfalls based on the personality being treated.
Complicated cases require therapists to extra vigilant and have the ability to collaborate with surgeons for a successful outcome.
Unfortunately, therapists often find it difficult to articulate their message in person or on the phone. Given the surgeon's track record with written notes, critical information may never make its way to the surgeon at the detriment of patient care.
Based off my experiences, therapists hesitate to speak their minds to surgeons. And I wonder Why?
Is it because we are seemingly functioning at two different levels? Surgeons may disregard therapists' knowledge or therapists may not find surgeons approachable. Competent therapists who lack confidence may unintentionally cause surgeons to interpret their reluctance as insecurity, and influence the surgeon to devalue the therapist's opinions.
Could this be the reason surgeons fail to seek the therapist's input when designing new surgeries and protocols? To earn the view from the top, therapists must put in the work —it is the therapist's responsibility to sharpen their skillset to open the lines of communication with surgeons to provide the best care to patients. Therapists' inability to communicate to surgeons is not only a matter of substandard care but it may even be unethical for preventing patients from receiving the best care attainable.
So how can therapists get to a place of successful collaboration with surgeons? What would it take to climb that ladder, albeit daunting at first, and approach surgeons?
There are two necessary ingredients: One-part Competence and One-part Confidence.
Competence is defined as the ability to do something proficiently and with the expertise it demands. Without the core knowledge of basic skills, therapists cannot develop the skill and latter ingredient, Confidence. However, when therapists possess competence, they will also gain confidence to take the first step and voice their opinion. This starts a positive cycle that will continue to build upon competence while boosting confidence.
Some therapists have competence but have not learned the skills to effectively express their opinions. When a message is received incorrectly, it may ultimately be detrimental to the population being treated as it may disrupt power dynamics between therapists and surgeons. Conversely, therapists who are overly confident and challenge surgeons without the requisite experience may harm the reputation of other therapists in the field.
Competence is required to build confidence, and both need the right fire - communication to express their opinion to enhance the outcome of the patient being treated.
One useful tool for therapists is to acknowledge that the surgeon is still in a superior decision-making role, and to remember it's the surgeons' job as a leader to listen and promote open dialogue. At the same time, it is the therapists' job to educate themselves, see the big picture, and discuss the surgeons' concerns at their level. The buck ultimately stops with the surgeon; thus, he has the final say. The therapists can climb that ladder one step at a time communicating their competence with confidence and building on it to reach to the apex.
Unequivocally, surgeons respect therapists who prove competency through repeated successful results. Once this dynamic is established, surgeons can and do rely on therapists' skills for treating difficult cases.
While generally the relationship between therapists and surgeons are improving, we need more therapists to have a seat at the table, design the rehab for their latest techniques and surgeries.
This could be fostered while therapists are still in school, such as implementing a required rotation with physicians and surgeons in a clinic. Therapy students need to develop the skills necessary to discuss cases with surgeons and articulate in an intelligent and meaningful way. In addition, surgeons would start to acknowledge the therapists as part of the team.
This will promote the free flow of information and prepare the next generation of therapist to build the bridges that will ensure the therapist a seat at the table.
I welcome any thoughts and comments that will help us improve our patient care from both sides. Looking forward to hearing from you all.
|Message from the Editor
John Fowler, MD
The 2018 AAHS Annual Meeting in Phoenix, Arizona was a great success. Attendees were treated to outstanding instructional course lectures and panel discussions on a wide range of topics in hand and upper extremity surgery. I am already looking forward to the 2019 meeting in Palm Desert, California.
This issue of the AAHS Newsletter contains a number of new features designed to bring additional information about the AAHS to our members and to highlight the different committees and groups within the AAHS. The AAHS research committee will have a regular feature introducing the committee members and their personal journeys getting started in research. Rick Tosti, MD has provided an excellent article on saving for college. Saba Kamal, CHT defines the traits necessary to be a successful therapist in the outpatient setting. Our president, Brian Adams, nicely summarizes the current agenda for the AAHS.
There continues to be numerous opportunities within the AAHS to serve on committees and participate in educational opportunities. I hope that you find this issues of the Newsletter informative and enjoyable to read.
|AAHS/AAOS/ASHT Webinar: Management of Peripheral Nerve Gaps
Tuesday, May 29, 2018
8:15 PM ET / 7:15 PM CT / 5:15 PM Pacific
|The latest issue of HAND is now available online
View the Table of Contents for HAND Volume 13, Issue 3
Rajani Sharma's 2017 Ghana Mission Report
I had volunteered in KATH-Hospital in Kumasi, Ghana in 2016 as an Occupational/hand therapist. That trip gave me an appreciation of the enthusiasm and interest that local health care providers showed to learn and collaborate with volunteers to treat patients with hand injuries. It also made me realize the lack of resources in the hand therapy department in terms of treatment equipment and furniture. The potential to improve care to its patients with hand and UE injuries seemed enormous. I was delighted to receive a AAHS scholarship that enabled me to return to Ghana in October of 2017.
I had two objectives for the trip in 2017: help to set up the physical space of the hand therapy room in the PT department and to educate local therapists on clinical assessment skills of the wrist and hand. I communicated with Robert Sowa (primary hand therapist in KATH Hospital) for a few months leading up to the trip to best help him set up the therapy space. During my time there, I helped Robert purchase treatment table and chairs, shelves, two cabinets and few other supplies needed to set up a hand clinic. A fellow volunteer from the US (Jenna Millman) helped to purchase orthosis pan and various therapy equipment. On the second last day of our visit, we had the greatest pleasure of setting up the department and treating patients in the newly designed space! Rest of my time was spent teaching labs, surface anatomy lessons, patient consultations, presentations on various hand therapy topics (therapists and MDs)
The most rewarding experience however on this trip (as it was on the last trip) was to teach occupational therapy students, who were doing their internship with a physical therapist due to lack of OT clinics in Ghana. The concept of OT is very noble and new in Ghana and it was such a pleasure to role model for the students. In the world of PTs, these students must find how to function as an OT. One of the students, Gifty, recently emailed me "I have really missed you. The lessons I picked from you at your last visit have been very helpful. And find a lot of encouragement everyday as I read your parting note and teachings". I continue to be in touch with Robert and Sowa and help them as I can.
Kath hand therapy clinic before and after pictures
Orthosis Pan with new base
OT student Gifty with new supply cabinet
Local therapists looking at the new space, supplies.
Robert and Gifty showcasing their new treatment space.
Teaching on wrist and hand clinical assessment skills in various places, off course at a dinner table when you don't have.
|Award and Funding Opportunities!
Lean & Green Award
2019 International Reverse Fellowship
2020 Miguel Vargas International Hand Therapy Teaching Award
Application and nomination deadlines for all awards and grants is June 1, 2018. Visit www.handsurgery.org for more information.
CALL FOR ABSTRACTS
We welcome the submission of your abstract for the 2019 AAHS Annual Meeting. Please visit the abstract submission site for instructions and details. The 2019 AAHS Annual Meetings will be held in Palm Desert, California, at the JW Marriott Desert Springs, January 30 - February 2, 2019.
Abstract Submission Deadline: Sunday, July 8, 2018 at 11:59 p.m. CDT
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