Issue: January 2014
January 01, 2014
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Pioneer: Douglas W. Jackson, MD

Issue: January 2014
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Editor’s note:

This month, we introduce Pioneers in Orthopedics. The featured pioneers have distinguished themselves in the pursuit of new ideas and innovations that have changed orthopedics.

How did you decide on a career in orthopedics?

Douglas W. Jackson, MD: I decided I wanted to be a physician during my junior year in high school. My final decision to pursue a career in orthopedic surgery was after a circuitous path. Upon entering medical school, I intended to pursue a PhD-MD program in experimental pathology with an internal medicine residency. However, during the surgical rotations of my third and fourth years of medical school, I enjoyed surgery — particularly “fixing problems” in a short period of time.

 

Douglas W. Jackson

During the first few months of my internship, I narrowed the choices to neurosurgery and orthopedic surgery. My final decision was influenced by my interests in athletics and physical fitness and, that I enjoyed working with orthopedic surgeons. During the Vietnam War, the Berry Plan allowed physician deferment from immediate military service while they acquired training in civilian institutions. Those accepted would later fulfill a 2-year military obligation. I was accepted. I had to decide between neurosurgery and orthopedic surgery as residency programs decisions were being finalized.

Even though I had abandoned my plan for a PhD, I completed a master’s degree in experimental pathology during summers and by taking extra courses during medical school. The training allowed me to establish and be the medical director of a free-standing clinical research laboratory and tissue culture facility.

What lessons did you learn from your mentors?

Jackson: D. Kay Clawson, MD, was instrumental in my choosing orthopedic surgery as a career. His lectures were stimulating and he encouraged students’ interests. I did a clinical rotation with him during my last year of medical school. Later, we published a white paper about the curriculum need of medical students to get more exposure to musculoskeletal care.

Following my residency, I served 2 years in the Army during the Vietnam War. From a career standpoint, I was fortunate to be stationed at the U.S. Army Hospital at West Point, N.Y. During my first 6 months, I worked closely with John A. Feagin Jr., MD, taking care of the cadets and athletic injuries as well as the supporting military community. My time at West Point was like a fellowship in sports medicine. Dr. Feagin left after 6 months for another assignment, so my knee and shoulder consultants at West Point were James Nicholas, MD; Charles S. Neer, MD; and Anthony F. DePalma, MD. We examined patients and I did surgery with them on selected cases. I was also fortunate to do cadaveric dissections with Emanuel B. Kaplan, MD, and discuss difficult spine cases with William Fielding, MD, FRCS(C); and Leon Wiltse, MD.

Following my military obligation, I spent 2 weeks each with Ian Smiley, MD, and Donald B. Slocum, MD, operating and examining patients. I also visited frequently with Leonard Marmor, MD, and observed surgery. The surgeons were instrumental in demonstrating discipline needed in orthopedic surgery and attention to detail, and shared their skills in patient care. I then joined Dr. Wiltse’s group in private practice and we worked for 10 years before I established my own group.

What was your most important contribution to orthopedics?

Jackson: I was fortunate to enter orthopedic surgery at a time when several concurrent advances and specialties were developing. These included arthroscopy, joint replacement, sports medicine, orthopedics research and advances in imaging. I was fortunate to meet, and know, and at times work with leaders in these rapidly developing fields. My interest at the time was new techniques in sports medicine. I developed special interests in ACL and PCL, menisci, articular cartilage surgery and the use of allografts.

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My long-term associate Timothy Simon, PhD, and I started a tendon allograft bank and tissue culture facility. This was early in the use of soft tissue grafts in orthopedic surgery and before tissue bank standards were extensively developed and widely accepted. We screened and acquired the grafts ourselves and performed animal studies. We performed ligament, meniscus and articular cartilage transplants on several hundred goats using both autografts, allografts, xenografts and synthetics. We did extensive testing, and published and presented our results with particular attention to clinical application.

I became more involved in the internal decision making and politics of orthopedics after participating in several specialty societies and committees within the American Academy of Orthopaedic Surgeons (AAOS). I became acutely aware of the changing health policy and reimbursement issues as they impacted orthopedic surgeons and patients. While no one person can change an institution with the tradition, number of talented members, outstanding professional staff and size of the AAOS, I gradually became more involved in policy issues, particularly those related to changing socioeconomic aspects of private practice.

During my early years in practice, I would call AAOS headquarters for advice on specific issues and more often ten not, would not get a satisfactory answer. I would receive phone calls from individuals with similar questions who were referred to me. A group of orthopedic surgeons with similar interests believed that the AAOS should become more involved in changing health care issues. After serving on the board of directors for a few years, I decided I would like to serve longer, particularly in policy making, and pursued the presidential line.

Besides supporting ongoing programs, I wanted to push three specific issues forward. One issue was that in addition to an outstanding history of being a non-profit educational organization, it was time to offer AAOS members the benefits of both a C-3 and C-6 organization. No one organization at that time had the resources and staff to represent orthopedic surgeons effectively in the evolving issues that impacted them and their patients. We needed a stronger voice on the federal and state level, and the ability to join efforts with other groups with similar goals. We established the dual tax structure the year I was president. The change to include both a C-3 and C-6 organization had been narrowly defeated previously, but the process was completed during my leadership.

I also worked to have more clinician scientists as AAOS members. The clinician scientists were among the best teachers and most significant authors in orthopedics. The initial goal in working with the Orthopaedic Research Society was to have at least six of the 600 new members each year pursue a committed academic career.

The third area was AAOS needed a more diverse membership — one that was reflective of society.

How do you envision the future of orthopedics?

Jackson: Two things I see continuing to evolve are the changes I experienced during the last 20 years of my career — less autonomy and reduced potential income. I enjoyed the autonomy, particularly during the first 20 years of my career. I could decide what to charge patients if they were in need and offer financial help at my discretion. At the same time, if my overhead increased, I could pass expenses on in my charges. This type of autonomy as an orthopedic surgeon has decreased significantly. We can donate time in free and underprivileged health care environments, but I enjoyed the freedom to do it in my own office, too.

I also see orthopedic surgeons being even more a part of the musculoskeletal team in working with more ancillary help. The surgeon will still play an important role in the team as the decision maker for certain treatments. However, established guidelines and outcomes will further determine the scope of an orthopedic surgeon’s practice. Reimbursement issues will continue to determine limits on some treatments, and there will be limits on potential income from direct patient care and ancillary services. Orthopedic surgeons will remain among the top physician income generators, but regulations will further limit the income generated from patient care.

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While I believe there will always be some private practice, the pendulum has moved more toward orthopedic surgeons as salaried employees of institutions and large medical organization. Survival and be success in these settings will still be based on the quality of patient care and orthopedic surgeons remaining placing the needs of the patient first.

The field will continue to see innovative technology and treatments. Future outcome studies will continue to document the cost-effectiveness of orthopedic treatments and the measured patient benefits. Improving quality of life will keep orthopedics in the forefront of patient care.

What advice do you have for young orthopedic surgeons?

Jackson: My advice is for young orthopedic surgeons is “repetition, repetition, repetition then reputation.” Be patient and repeatedly offer quality and honest patient care. If one does good work and places patients first, then a good reputation follows. One needs to give peers credit for their knowledge and skills. Young surgeons who want to be immediately recognized for their skills or are focused on income generation may make costly mistakes that limit their long-term potential.

Do not let a starting salary be the sole deciding factor in making the initial career choice. Find a professional position where one can continue to develop their skills and grow personally. This will eventually lead to a more satisfying type of practice. It is also important to choose a place where one can have desired lifestyle, particularly as it relates to raising a family. If one is happy at home, then work is more enjoyable.

A career in orthopedic surgery is an endurance event that takes continued learning, giving back and personal honesty. The lifetime friends one develops along the way are some of the more meaningful long-term relationships in life. The future is exciting and the field of orthopedics offers a satisfying and rewarding profession where one can make a difference.

For more information:
Douglas W. Jackson, MD, is past president of the AAOS and chief medical editor emeritus of Orthopedics Today.
Disclosure: Jackson has no relevant financial disclosures.