American Society for Surgery of the Hand (ASSH) Presidential Address Themes, 1964–2018: Revisiting Our History as We Move Forward

Abstract

The American Society for Surgery of the Hand (ASSH) was established in 1946. Since then, important advances have been made in the diagnosis and treatment of conditions affecting the upper extremity. However, there has been little documentation regarding how the largest and oldest society dedicated to hand surgery has evolved over time. Furthermore, an understanding of the history of the ASSH and the specialty of hand surgery should be emphasized in resident and fellow education. The authors aim to provide a historical overview of the ASSH through the speeches of ASSH past presidents that sheds light on future directions and long-term goals. Presidential addresses from 1961 to 2018 (courtesy of ASSH Chase Library historical archives) were reviewed. The overall percentage of ASSH presidents by specialty was 67% orthopedic, 25% plastic surgery, and 8% general surgery. The most common speech theme overall was how to be a good hand surgeon (31%). The most common speech themes were, by decade: the 1960s, history and the current state of ASSH; the 1970s and 1980s, assessments of how to be a good surgeon and goals for ASSH; the 1990s, health care and governmental regulation; the 2000s, how to be a better hand surgeon; and the 2010s goals for ASSH. In earlier years, there was more of a focus on education and technical skill development in the ASSH. Work–life balance, introduced in the 1990s, has become more of a focus in the past 20 years. Revisiting the history of the ASSH and its goals allows us to reflect on progress made while recognizing what is important as we look into the future. Furthermore, as we strive to make progress in the field of hand surgery during the current pandemic, valuable tools surface that will allow the specialty to strengthen its education, research, and patient care delivery in the future.

Established in 1946, the American Society for Surgery of the Hand (ASSH) is the oldest and largest society devoted exclusively to hand surgery.¹ Before World War II, care for hand injuries and pathology was highly disjointed and delivered by various specialists including neurosurgeons, general, orthopedic, and plastic surgeons.^2,3 A unified, coordinated treatment approach to surgery of the hand was lacking at that time, and there was a need for change. General surgeon Dr Sterling Bunnell was a pioneer and is recognized for leading the initiative to standardize hand surgery.² He is considered the true founder of the specialty, referring to surgery of the hand as a “composite problem requiring the correlation of the various specialties—orthopaedics, plastic and neurologic surgery—the knowledge of any one of which alone is inadequate for repairing the hand.”¹ In the 1940s, Bunnell was designated as a special civilian consultant to the secretary of war at the request of General Norman Kirk. In this role, he founded 9 hand surgery centers at US Army general hospitals focused on education, training, and the treatment of hand ailments.³ To facilitate the exchange of ideas among the different centers, Bunnell and 34 hand surgery colleagues met in Chicago on January 20, 1946 immediately before the annual meeting of the American Academy of Orthopaedic Surgeons. Dr Bunnell’s passion for the collaboration and unification of hand surgery became the impetus for the creation of the ASSH in 1946. This set the stage for the first ASSH meeting, in which Bunnell served as the first president (1946–1947). Thus, he set a precedent for future leaders in hand surgery to emphasize the mission of the ASSH: to advance the science and practice of hand and upper-extremity surgery through education, research, and advocacy on behalf of patients and practitioners.⁴ Initially, only 11 new members were admitted to ASSH in any year.⁴ However, a more inclusive membership philosophy was adopted in the early 1970s, ensuring more widespread access to quality hand care throughout North America. Since its inception in 1946, ASSH has had 74 presidents.

Over time, the evolution of hand surgery has paralleled the general specialization of other medical fields. Our knowledge of hand surgery has grown tremendously over the years; ASSH has a total of 4,673 active members today. Previous presidents of the ASSH have been respected as leaders, collaborators, and inspirational individuals who prioritize and reflect the goals of the Hand Society. The president of the Hand Society motivates the ASSH council to further the objectives established by the society’s strategic plan.¹

Problem Statement

Advances made in hand surgery understanding and technique are well-documented. However, there are no prior reports on the trends in the ASSH presidential address topics, which indirectly reflect the priorities of the ASSH as a whole. Furthermore, an understanding of the history of hand surgery and its largest society should be emphasized in resident and fellow education. With the evolution of hand surgery and societal changes in the United States, the authors were interested in the progression of the Hand Society’s focus over the years. Traditionally, the ASSH president will give a presidential address at the conclusion of the term to iterate the overall focus for the year. The presidential address is meant to identify the main objectives that were achieved in the previous year and suggest new areas of focus for the coming years.

Proposed Solution

A total of 52 presidential addresses (1964–2017) were available for review, courtesy of ASSH Chase Library. These were reviewed to find trends to observe in goals, objectives, and priorities of the ASSH over time. The percentage of ASSH presidents by specialty were: 67% orthopedic (35 of 52), 25% plastic (13 of 52), and 8% general surgery (4 of 52). The number of ASSH presidents with plastic and general surgery backgrounds decreased over time, while there has been an increase in the number of orthopedic surgery–trained ASSH presidents. One of 52 presidents, Dennis Phelps (2003), was from a private/community practice, whereas the remaining presidents were from academic institutions. Of 52 presidents, 49 (94%) were from the United States and 3 (6%) were from Canada.

Seven main themes emerged from the speeches: work–life balance, education of trainees, how to be a good surgeon, government health care regulation, patient care, the history and current state of the ASSH, and future goals of the ASSH (Fig. 1). The most common speech theme overall was how to be a good hand surgeon (16/52 speeches or 31%). The most common theme of ASSH presidential addresses from the 1960s to today was how to train physicians and hand surgeons. In the 1960s, the most common speech theme was history and the current state of ASSH (Fig. 2). In the 1970s and 1980s, both assessments of how to be a good surgeon and goals for ASSH were the most popular topics of discussion (Fig. 2). In the 1990s, health care and governmental regulation was the most common theme, often in conjunction with discussion of health care bills proposed by the Clinton administration (Fig. 2). In the 2000s, the most common theme was how to be a better hand surgeon. Finally, in the 2010s, goals for ASSH was the most common discussed topic. In addition, themes discussing the concept of work–life balance were introduced only in the 1990s and became more prevalent throughout the 2010s (Fig. 2).

Figure 1.

Hierarchical chart representing organizational structure for thematic classification of speeches.

Figure 2.

Stacked 100% bar graph displaying number of ASSH presidential speeches, organized by theme and graphed over time.

The future of hand surgery lies in optimizing education and exposure for residents, fellows, and young attendings to continue the legacy of the Hand Society. In addition, refining surgical skills and understanding involving the upper extremity is paramount to ensuring optimal patient care in years to come. In reviewing the past themes, it is obvious that a focus on training and developing better hand surgeons will continue to be an important goal of the ASSH. This will involve training not only surgeons in the United States but around the globe as well as the collaboration and spread of ideas become easier through the Internet. The ASSH will also need to continue to emphasize the improvement of new technology, development of novel techniques, and use of increasing data points through electronic medical records to create more focused and useful analysis of patient outcomes. The recent shift in focus to more optimal work–life balance by ASSH presidents is an important indication that this will be paramount to the well-being of ASSH members for years to come.

In the face of the Covid-19 pandemic, clinical care, education, and ongoing research have been challenged. Innovation in care delivery includes an expanded use of telemedicine, and this technology has rapidly expanded to meet the health care needs of all patients. Hand surgery is no exception. New patient evaluations and follow-up visits can now be done on-line, and this will have a long-lasting impact on how hand surgery will be practiced in the future. Education will most likely rely more on digital platforms such as BlueJeans, Zoom, and GotoMeeting, which present advantages for the resident, fellow, and practicing surgeon. Perhaps face-to-face meeting time could be reduced, with less time out of practice for the busy hand surgeon. In-person meetings may involve cadaver labs or master classes rather than several thousand people sitting in a lecture hall. The digital connectivity that has been encouraged may facilitate multi-institutional research projects with video recording of patient-reported outcomes. Each advancement in surgical procedures and technology results in expanded reporting in journals, meetings, books, and other forms of communication. The future is bright in these domains. Future presidential lectures will look back on events today in both society and the world of surgery and reflect on the continuum of progress and current challenges that remain to be solved.

Future Direction and Long-Term Focus

The ASSH continues to foster collaboration among orthopedic, plastic, and general surgeons to create a unified subspecialty. The 35 founders of the ASSH consisted of 13 plastic surgeons, 14 general surgeons, and 8 orthopedic surgeons.³ In 2016, the percentage of orthopedic surgeons, plastic surgeons, and general surgeons in the ASSH was 78%, 16%, and 5%, respectively, which is similar to ratio of ASSH past presidents of 67% orthopedic surgeons, 25% plastic surgeons, and 8% general surgeons.⁵ There has been an overall decrease in the percentage of plastic surgeons in hand surgery over time. This may likely be the trend in the future and largely reflects the relative makeup of the hand society in general. Some suggest that the percentage of plastic surgeons in hand surgery has decreased because plastic surgery residents are deterred by the lower reimbursements compared with other plastic surgery subspecialties.⁵ Others suggest that the plastic surgery residency exposure to hand surgery is inconsistent and limited at many programs. One way to reverse this trend is to assess the current plastic surgery curriculum nationally and ensure consistent and adequate hand surgery training before the fellowship application process.

Early on, the emphasis for the ASSH was on education and becoming a good surgeon. Speeches in later years had an increased focus on health care and governmental regulation. In addition, work–life balance has become more of a focus over the past 20 years. Studies on physician burnout and suicide began to raise awareness around work–life balance and the importance of surgeons caring for themselves, and this should continue to remain a focus in the long term. Surgeons with burnout are at increased risk for cynicism, depression, and physical illness such as heart disease.⁶ Several orthopedic surgery studies published in the 2000s reported burnout rates of 40% to 60%.6, 7, 8 In 2016, it was reported that the age-adjusted rate of suicide among Americans was 13 in 100,000, compared with the suicide rate among physicians in the United States at nearly double that: 28 to 40 physicians in 100,000.⁹ Speeches in the past 2 decades have focused more on holistically developing the hand surgeon, as will likely be shared goals among members and leadership moving forward. This included technical skill, research, investment in teaching, giving back, and mental health maintenance.

Hand surgery is a unique and evolving specialty that embodies collaboration, excellence in patient care, research, education, and a profound history that is imperative for all hand surgeons to appreciate. We are currently standing on the shoulders of several pioneers in the specialty, such as ASSH founder Dr Sterling Bunnell and others. This review aimed to reflect on the distance traveled in hand surgery and to understand trends in the goals and composition of the ASSH. Revisiting the history of the ASSH and the goals of its leadership allows us to reflect on the progress we have made, while recognizing likely future trends and common goals that are important to our society moving forward. Over the past 74 years, the ASSH has provided exemplary leadership in the field of hand and upper-extremity surgery. Major strides have been made in the past decade, with advances in outreach (Touching Hands project), a 10-fold return on investment of the American Foundation for Surgery of the Hand’s funding of research, launching of a knowledge platform (HAND-e) that is providing hand surgery education around the world, and a national hand trauma system that protects the public trust. Based on our legacy and the hand surgeons who have served as ASSH presidents, we know that our work is never done. However, our trajectory and momentum are strong, and we hope it will remain so in the years to come.

Recommendation

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