Portal de Periódicos da CAPES

2016 ASSH Presidential Address: Teaching Hands—Pass It On

2018; Elsevier BV; Volume: 43; Issue: 7 Linguagem: Inglês

10.1016/j.jhsa.2018.04.019

1531-6564

Neil F. Jones,

Musculoskeletal Disorders and Rehabilitation

Editor's Note: This is the Presidential Address given by Neil F. Jones, MD, at the 71st Annual Meeting of the American Society for Surgery of the Hand, Austin, TX, September 29, 2016. Previous presidents of the American Society for Surgery of the Hand (ASSH) have stood on this podium before me and begun their speech, "When I began my career in hand surgery, never in my wildest dreams did I expect to be giving the presidential address." That introduction would certainly apply to me, having been born in Wales and trained in England, before immigrating to America permanently in 1984. In September 1983, my fellowship director Richard Smith, MD (Fig. 1), gave his presidential address with the theme "Education of the Surgical Specialist."1Smith R.J. ASSH presidential address 1983: education of the surgical specialist.J Hand Surg Am. 1983; 8: 509-515Abstract Full Text PDF PubMed Scopus (1) Google Scholar I was Dr. Smith's senior fellow at the time and my photograph was the last to be projected on the screen behind him. To my horror, it remained for several minutes, so in a way, I have already been involved in a presidential address 33 years ago. However, it is unusual for someone such as myself to become President of the ASSH. Only 3 hand surgeons initially trained in Great Britain have become presidents—Adrian Flatt, MD, from England, Graham Lister, MD, from Scotland, and myself from Wales. Serendipitously, both Dr. Flatt and Dr. Lister played a part in my early hand surgery career. During my residency, I asked Dr. Flatt for his advice regarding hand fellowships in the United States. His response was that, if you had trained in plastic surgery, you should do a hand fellowship with an orthopedic hand surgeon and, conversely, if you had completed an orthopedic residency, you should train with a plastic and reconstructive hand surgeon. I will return to this very important interaction between orthopedic surgery and plastic surgery later in my talk. Graham Lister entered my life, when as an Assistant Professor at the University of Pittsburgh, I was informed that I was to give an Instructional Course with him at the upcoming annual meeting. I replied that I would be happy to help, but the attendees would want to hear from him and not from me. However, he insisted that we would select the best cases from his practice and from my practice. A few months later, I met with him at 5 o'clock in the morning and in 4 hours we selected the best examples from both our practices and arranged them as alternating cases for dual projection on 8 carousels. That night, I practiced my commentary, removing each slide and pointing it toward the light with both carousels perched on my knees. You can work out what happened next. The phone rang, I jumped, both carousels tipped over and 160 slides lay in a pile on the floor. I spent the next 3 hours reorganizing them into what I thought was the correct order. The following morning, Dr. Lister wanted to practice before the course and I had got 1 slide in the wrong order. Tongue-in-cheek, I told him that it was lucky that we had rectified this 1 small mistake! I then learned another very important lesson from him. With absolute confidence, he pronounced the exact slide number we should reach at 8:15, at 8:30, and at 8:45 am. To this day, I use his advice, but my lectures are now on the computer on Keynotes. Malcolm Gladwell's2Gladwell M. Outliers: The Story of Success. Little, Brown & Company, New York2008Google Scholar concept of 10,000 hours did not apply to Dr. Lister—he was the complete master. I was subsequently invited to give other courses with him, as well as being appointed to his program committee. This is a classic example of mentorship, which I will speak more about in a few minutes, but by someone who played no part whatsoever in my training. Perhaps he did it because I was a fellow countryman? Several years later, Dr. Lister was nominated to be Vice President and I congratulated him, only for him to respond something to the effect "I shall now lie awake every night for the next 3 years thinking of what to say during my Presidential Address." Other past presidents have told me this same worry, the proverbial 16-ton weight of Monty Python hanging over your head. That being said, the Presidential Address is perhaps the only time in your career when you are not restricted by time limitations—the lights are not going to be switched on, the microphone isn't going to fade, and the music won't suddenly become deafening! With that convoluted introduction, I want to focus on 6 areas of hand surgery that have been important to me during my career and that I believe will continue to be important in the future of the ASSH.1)Inspiring excellence in hand fellowship education2)Mentorship3)Fostering collaboration between orthopedic surgery and plastic surgery4)Increasing the profile of microsurgery5)International education6)Outreach Excellence may be measured in seconds and financed but not inspired by millions of dollars. To "inspire" is defined as to "influence or guide by divine or supernatural effect." Put into context, how do we as fellowship directors activate interest, create excitement, cultivate passion, or "light a fire" in our hand fellows? This excitement may have already been predetermined by the fellows themselves based on the unique characteristics of our subspecialty:1.The detailed anatomy of the hand or brachial plexus2.The ability to see perfect anatomy in a bloodless field3.The intricacies under the operating microscope4.The variety of pathologies and operations5.The sometimes dramatic restoration of function to allow a patient to resume an independent life6.And finally, the concept of hand surgery being "anything you can get your hands on" Having been a fellowship director for the past 30 years at 3 separate institutions—the University of Pittsburgh, UCLA and UC Irvine—I believe the 3 most important areas that we can inspire excellence in our hand fellows to be:1.Surgical technique2.Surgical judgement3.The surgeon-patient relationship That is not to say that I do not think that teaching hand fellows to critically evaluate the literature or to supervise basic science research are not important. In fact, 1 of my past hand fellows once told me that he was most inspired by the fact that I was still involved in looking at histology slides of rats who had undergone limb transplantation! Teaching the best surgical technique is absolutely fundamental—from the simplest suturing to the most complex implantation of a prosthesis, exploration of the brachial plexus, or microsurgical reconstruction. Personally, I do not favor the Socratic philosophy of "see one, do one, teach one" and then leave the fellow to get on with it. Hand surgery is a detail-specific specialty and so much can go wrong if the attending leaves the room. Don't get me wrong, I let the fellows do the surgery, but I am there from incision to placement of the splint, just like the conductor of an orchestra. Because most hand surgery is now performed under regional anesthesia and because my pronunciation of the English language is rather distinctive, the patients always know when I am not in the operating room! An equally important, perhaps an even more crucial, skill we can impart to our fellows is surgical judgment—which patients to operate on, which patients to treat conservatively, and most importantly which patients to never operate on; and second, when is the best time to intervene and operate. This is a quotation from the father of scientific surgery John Hunter (Fig. 2) in the 1700s: "No operation should be carried out unless absolutely necessary… nor should a surgeon operate unless he would undergo the same operation in similar circumstances." Still completely true today. Surgical judgment can only be learned by osmosis—by direct observation of the fellowship director and other faculty. That is why it is so important for fellows to attend clinics and office hours and see long-term follow-up. Finally, the fellow can observe various patterns of surgeon-patient relationships and hopefully piece together the best practices for themselves. Our fellowship programs are the gateway to the ASSH and, therefore, we have an obligation to continue to inspire excellence in our fellows. In the future, external factors may negatively impact our hand fellowship programs such as accreditation and funding. That is why this year I instituted a Fellowship Directors' Retreat at the annual meeting, to proactively discuss and address some of these issues. Seventy-five fellowship directors attended this retreat along with Pamela Derstine, the Executive Director of the Accreditation Council for Graduate Medical Education, and Gerry Williams, MD, President of the American Academy of Orthopaedic Surgeons. I hope this retreat will be repeated next year or every 2 years to ensure the continuing viability and excellence of our hand fellowship education. Those of you educated in classical Greek will be aware that the term "mentor" is derived from the character Mentor in Homer's Odyssey. A mentor is someone who provides wisdom and shares knowledge with a less experienced colleague. The concept of a surgeon being trained 1-on-1 began in the 18th century in England under John Hunter, but in the United States, William Halsted, MD, introduced the concept of trainees spending a defined time in 1 institution, learning from several different surgeons—the forerunner of the surgical residency. In the past, mentors have been distinguished by having a flamboyant or buccaneering charisma; or a reputation for being a master surgeon able to perform operations other surgeons were unable to perform; or surgeons who continued to push the boundaries; or who had a stellar reputation in research; or had an encyclopedic knowledge of the literature. The most frequently cited qualities of a mentor are that1.They are a leader in the field.2.They serve as a professional role model.3.They are compassionate, kind, and supportive.4.But they also act as an evaluator and critic. The 2 most important influences on my life and career, apart from my parents, wife, and son, were my university years in Oxford and my hand fellowship at the Massachusetts General Hospital in Boston. As you probably know, teaching at Oxford and Cambridge is very different to other British and American universities and is known as the tutorial system. The undergraduate is assigned 1 or more tutors for a specific subject. He or she, either alone or with 1 or 2 other students, meets with their tutor for 1 hour every week and is assigned a topic to research and write a position paper for the following week. So the usual scenario was to party for 6 nights and on the seventh night stay up all night writing your paper in the library. But there is no escape from the 1-on-1 interaction the next day, and it rapidly forces you to formulate a logical argument and defend your position. So the tutorial system is similar to mentorship and perhaps to the relationship between a fellowship director and a hand fellow. In Boston, I was incredibly lucky to be mentored by the late Richard Smith, MD, a true renaissance man and by Jesse Jupiter, MD, certainly charismatic and by James May, MD, all of whom instilled in me the essence of hand surgery and guided me into the start of my academic career. It is imperative that we all strive to mentor our hand fellows and cultivate their excitement and passion. That is not to say that we should neglect mentoring residents and even medical students. Two of my most successful mentees started their careers doing research in hand surgery as medical students, progressed through residency, completed hand fellowships with me, and are now established in academic hand surgery. Because of the enthusiastic mentoring from Richard Smith, Jesse Jupiter, James May, and others such as Graham Lister, MD, and Peter Stern, MD, I am totally committed to the concept of "giving back" or "passing it on" to the next generation of hand fellows. Of the 35 original founders of the ASSH in 1946 (Fig. 3), 14 were general surgeons (40%), 13 were plastic surgeons (37%), and 8 were orthopedic surgeons (23%). However, 50 years later in 1995, the proportion of plastic surgery–trained hand surgeons had fallen to 23%, and even further to 16% in 2016 (Fig. 4).Figure 4Percentage of orthopedic surgeons, plastic surgeons, and general surgeons in the ASSH, 1946–2016.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Of the 83 successful applicants for active membership in the Hand Society in 2016, 58 were orthopedic (70%), 13 were plastic (16%), and 12 were general surgeons (14%). This decreasing interest in plastic surgeons subspecializing in hand surgery and joining the Hand Society should be troubling to the leadership and to all of us, given the enormous contributions that plastic surgeons have made to our field—William Littler, MD, Harry Buncke, MD, Graham Lister, MD, and Hanno Millesi, MD, to name just a few. Why has this happened? Obviously plastic surgeons have an alternative "revenue stream" in "cash up front" cosmetic surgery. Hand surgery is perceived as hard work, unsocial hours, and low reimbursement. The definition of hand surgery has been extended to include upper limb surgery and obviously plastic surgeons are excluded from shoulder surgery and fractures of the humerus and elbow. Finally, we are victims of our own exclusiveness. Residency Review Committee (RRC) logs objectively document that 20% of the total operative experience of plastic surgery residents is hand surgery. However, far fewer plastic surgery residents complete a 1-year hand fellowship and are, therefore, ineligible for the Certificate of Added Qualification in Hand Surgery examination, and precluded from membership in the ASSH. Contrast the percentage of plastic surgeons in the ASSH in 2016 (16%), with the percentage of plastic surgeons in the American Association for Hand Surgery (AASH; 43%) and the detrimental effect, of what 1 of our past presidents Andrew Lee, MD, in his presidential address "Power of Inclusion" in 20123Lee W.P.A. ASSH presidential address 2012: power of inclusion.J Hand Surg Am. 2013; 38: 2437-2449Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar referred to as exclusivity rather than inclusivity, is obvious to see (Fig. 5). I myself completed a residency in plastic surgery at the University of Michigan, but I had also completed significant training as a registrar in orthopedic surgery in England. One of my overriding passions has always been to foster collaboration and integration between orthopedic surgery and plastic surgery. I have always worked at the interface between orthopedic surgery and plastic surgery and have held dual faculty appointments in orthopedic surgery and plastic surgery both at UCLA and UC Irvine. How can this trend be stabilized or reversed? Rod Hentz, MD, another past president, introduced the Plastic Surgery Visiting Professor Program. The Hand Society sponsors 2 visiting professors per year—hand surgeons who originally trained in plastic surgery—to "target" plastic surgery residency programs to selectively encourage young plastic surgery residents to consider a career in hand surgery and proceed on to further training in a hand fellowship. I have had the opportunity to serve as this ambassador on 2 separate occasions to 7 plastic surgery programs. At Pittsburgh and UCLA, we developed totally integrated hand fellowship programs with faculty from both specialties; joint hand conferences for orthopedic residents and plastic surgery residents; and reimbursement monies equally divided between the 2 departments. David Newington, FRCS, vice president of the British Society for Surgery of the Hand has told me that the development of Interface hand fellowship programs in Great Britain is now becoming mandatory. Everybody wins with totally integrated fellowships—the patients, the residents, the fellows, and ultimately the relationship between the 2 specialties. I have always tried to select an equal number of orthopedic and plastic surgery hand fellows and all of them have confirmed that this is a great advantage—the fellows learn from one another. An orthopedic-trained hand fellow can show a plastic-trained hand fellow how to apply an external fixator and a plastic surgery-trained hand fellow can show her or his counterpart how to harvest a skin graft, without ever having to look foolish asking an attending. But is this enough? Perhaps future councils and presidents need to proceed even further and consider relaxing the exclusive criteria of length of fellowship training and possession of the Certificate of Added Qualification in Hand Surgery. However all is not "doom and gloom." A podium presentation at this meeting by Patrick Reavey, MD, from the University of Chicago analyzed 500 applicants for active membership in the ASSH over the past 5 years. Even though only 16% were plastic surgery–trained, 48% of these plastic hand surgeons started their career in academic institutions, which is a very optimistic statistic for the future. Perhaps even more troubling than the decline in plastic surgery–trained residents proceeding on to a hand fellowship and membership in the ASSH is the declining interest in microsurgical reconstruction of the upper extremity, but obviously the 2 may be interrelated. In the 1970s and 1980s, America along with Australia and Japan led the world in the exciting new field of microsurgery. It is a personal honor for me to acknowledge Professor Susumu Tamai from Japan in the audience (Fig. 6). He performed the world's first successful thumb replant in 1965 when he was still an orthopedic resident!4Komatsu S. Tamai S. Successful replantation of a completely cut-off thumb.Plast Reconstr Surg. 1968; 42: 375-376Crossref Scopus (327) Google Scholar, 5Masuhara K. Tamai S. Fukunishi H. Obama K. Komatsu S. Experience with reanastomosis of the amputated thumb.Seikei Geka. 1967; 18: 403-404PubMed Google Scholar All the young residents and hand fellows in this audience should be inspired by his achievement. Harry Buncke, MD, a past president of this society, is rightfully lauded as the "father of American microsurgery" (Fig. 7).Figure 7Harry Buncke, MD, ASSH President 1986, performing a great toe–to–thumb transfer.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The best microsurgeons were hand surgeons, many from this society, 15 of whom have served as presidents of the American Society for Reconstructive Microsurgery. I still vividly remember attending a symposium just after I finished my fellowship, organized by Richard Smith, MD, and James Urbaniak, MD, entitled "Microsurgical versus conventional reconstruction of the upper extremity." It was an intoxicating 2 days—every speaker described a new surgical technique or reported a patient or a condition never treated before the advent of microsurgery. It was "hand surgery on megadoses of steroids!" Since then, these techniques have been refined and perfected so that success rates are 97% or greater. Microsurgery is arguably the single greatest advance in hand surgery, other than the introduction of antibiotics. Obviously, internal fixation of fractures and various implant arthroplasties apply only to a selective cohort of upper extremity conditions, but microsurgery has revolutionized the entire spectrum of hand and upper limb surgery including:1.Restoration of blood flow into amputated digits and hands2.Radical debridement and early flap coverage of open fractures of the upper extremity3.One-stage reconstruction of segmental bone and muscle defects4.Nerve repair and nerve grafting5.Brachial plexus reconstruction and nerve transfers6.Thumb and finger reconstruction by toe-to-hand transfers7.Hand transplantation However, I feel that the pendulum is swinging. In the 1980s and 1990s, surgeons from around the world learned these techniques in American fellowship programs and translated their education back to their own home countries. Therefore, there are now many hand centers in other countries that rival or even surpass the volume and complexity of upper limb microsurgery performed in the best institutions in the United States. Even developing countries such as Thailand and Vietnam, because they are still heavily dependent on bicycles, motorcycles, and scooters for transportation, which result in an extremely high incidence of brachial plexus injuries, are developing innovative techniques of brachial plexus reconstruction using nerve transfers. This reluctance to embrace microsurgical techniques may emanate from the hand fellowship programs, the RRC or from practicing hand surgeons themselves—reciting the classic euphemism "If all you have is a hammer, the whole world looks like a nail." The success of the Fellow's Surgical Skills Course on Flaps has paradoxically revealed significant deficiencies in fellowship training in soft tissue coverage and microsurgery. Fellowship faculty may use the excuse "I'm too old," but Harry Buncke, MD, was still replanting digits in his 80s and I am still doing toe-to-hand transfers in 2-year-old children and I don't consider myself any older than 29! The RRC may be at fault—I was astounded to hear an RRC reviewer state that he did not understand why replantation needed to be performed during a hand fellowship! Microsurgery is perceived by many graduating hand fellows to be associated with poor reimbursement, epitomized by the euphemism of a true "free" flap and incompatibility with a comfortable lifestyle. Somehow, we have lost the ability to inspire the excitement and enormous benefits to be gained from microsurgery. Who cannot fail to be amazed by this 8-year-old boy with bilateral metacarpal hands who lost all 10 digits owing to burns and was reconstructed with 6 toe-to-hand transfers and whose function exceeds that of any tested hand transplants or bionic prostheses (Fig. 8). This reluctance to embrace microsurgery is reflected in a general "dumbing down," for example:1.Nerve repairs are performed without the advantages of the operating microscope.2.Nerve grafting is being replaced by expensive "off-the-shelf" synthetic conduits.3.Single arterial injuries, which are simply the best experimental simulation for fellowship training in microsurgery, are not being repaired. In some institutions, composite bone and soft tissue injuries are now being treated by 2 separate teams—the orthopedic surgeons rigidly fix the bones and apply a vacuum-assisted closure, and perhaps later, the plastic surgeons perform a flap. Sterling Bunnell, MD, would be turning in his grave! This represents a complete breakdown of his founding principle that hand surgeons should be capable of repairing every single tissue—the bones, tendons, nerves, vessels, and skin. Every hand surgeon should be an orthopedic surgeon, plastic surgeon, neurosurgeon, and vascular surgeon. How do we increase the profile of microsurgery in our hand fellowship programs? Several established upper extremity microsurgeons are coming to the end of their careers, so young and midcareer hand surgeons proficient in microsurgery need to step up to the plate and start pushing the boundaries. To plagiarize President John F. Kennedy's famous line, "Ask not what the American Society for Surgery of the Hand can do for you, but what you can do for American hand surgery." For example, the treatment of avascular necrosis of the scaphoid may eventually become a microsurgical operation, if it can be proven conclusively that the results of free vascularized bone grafting with the medial femoral condyle osteocartilaginous graft are superior to pedicled vascularized bone grafts or conventional bone grafts. We have much to learn from hand surgeons and microsurgeons in other countries and it is my privilege to announce a new program of International Hand Surgery Fellowships generously supported by Endo Pharmaceuticals and Stryker. In this program, 3 U.S. hand fellows a year will be selected as future "superstars" of U.S. hand surgery, either during their U.S. fellowship year or within 3 years of completion. Two will spend 3 months at several universities in China and 1 will spend 3 months at Ganga Hospital in Coimbatore in India. All these institutions have an extremely high volume of complex hand surgery and microsurgery. For example, Fengcheng Hospital in Xi'an, the old capital of China, is a 200-bed hospital dedicated exclusively to hand surgery and microsurgery and performs over 25 hand replantations per year! Huashan Hospital in Shanghai performs over 1,000 brachial plexus surgeries per year! The U.S. hand fellows will be allowed to scrub in on all operations and will document their operative experience photographically and by video. After they return, they will be required to edit their videos and submit them to Hand-e, so that a unique teaching library can be established, which will ultimately benefit all other U.S. hand fellows and any member of this Society. It is anticipated that these returning international fellows will "pass on" their expertise to a whole new generation of U.S. hand fellows and residents and ultimately increase the profile of microsurgical reconstruction of the upper extremity within the ASSH. The ASSH is the oldest and largest hand surgery organization in the world. It is imperative that we continue to be the global leader in hand surgery education. Under the chairmanship of Kevin Chung, MD, and subsequently Terry Light, MD, the International Relations Committee has1.Embraced the concept of combined meetings with other national hand societies— the Japanese Society in Hawaii in 2013, the Singaporean Society and the Italian Society in 2015, and the Australian Society in 2016.2.We are developing the International Visiting Professor program in which a senior ASSH member visits several institutions in 2 developing countries and lectures to trainees as well as participating in surgery. Seven visiting professors have already completed their visits—Terry Light, MD, Marwan Wehbe, MD, John Capo, MD, Don Lalonde, MD, Rod Hentz, MD, Amy Ladd, MD, and Jesse Jupiter, MD.3.The Hand-e platform developed by Ed Akelman, MD, and subsequently by Michael Hausmann, MD, Ray Raven, MD, Marty Boyer, MD, and Warren Hammert, MD, will hopefully become the premier educational resource for international hand surgeons and trainees. It is already available to all our international members and is provided free for 1 year to members of the International Guest Society and provided totally free to all trainees in developing countries as defined by World Bank criteria. However, international education is not just about the ASSH educating hand surgeons in other countries—it is a 2-way dialogue—we as the ASSH have so much to gain from reciprocal learning from our international colleagues. In an effort to foster international collaboration at this year's annual meeting, I instructed the program chairs that all symposia and instructional courses should include 1 international hand surgeon. Despite protestations from just 2 members, a record number of abstracts were submitted for symposia and instructional courses this year. We will all benefit from learning from our international faculty members' expertise. Second, I have already explained the International Hand Surgery Fellowship program, whereby our young "superstars" will have an opportunity to operate in hospitals with a very high volume of complex hand surgery in China and India. If this pilot program is successful over the next 2 years, there is no reason why it cannot be expanded to include institutions with similar high volumes of complex hand surgery in South Africa, Great Britain, Spain, Italy, and France. Perhaps to provide momentum to these initiatives, all these facets of international education should be promoted under a unifying banner as "Teaching Hands—Pass It On." Outreach is really only an extension of international education. It is the provision of hand surgery services to less developed countries or underserved areas of these countries, which do not normally have such access. But education must become the main component of outreach. Most people think of outreach or volunteer missions as 1 or 2 surgeons visiting a remote hospital, triaging hundreds of prospective patients, operating on just a small number, and then departing. There is always publicity back home, either at the local hospital, professional organization or local newspapers and TV. All very sexy and heartwarming, but not sustainable. First, outreach programs must become sustainable. Surgeons have to take responsibility for a specific program and return on an annual basis, as well as take responsibility for postoperative care. The availability of cell phone cameras and e-mail now allow 2-way communication between the visiting hand surgeon and local physicians, not only to dispense advice regarding postoperative care but also to provide preoperative consultations for new patients. Second, there absolutely has to be a structured educational component—teaching local surgeons to perform the most basic and effective hand surgeries—fracture fixations, burn contracture releases, tendon repairs, and nerve repairs. Again I will plagiarize the old Chinese proverb: "Give a man an operation and you treat him that day. Teach a man to operate and he will be able to treat other men forever." The ultimate success of any outreach program is to educate and train sufficient local surgeons, so that they can treat the local population. Touching Hands must eventually evolve into Teaching Hands. I would like to describe our model in Cambodia that Graham Gumley, MD, our International Lecturer this year, will describe more fully in his talk. Seven surgeons from Australia, America, and Thailand operate at 5 hospitals in Phnom Penh and utilize the existing local infrastructure—anesthesiologists, nurses, and implants. We operate with the local young surgeons, treating them essentially the same as U.S. residents, teaching them how to do simple and then increasingly difficult and more complex hand surgeries (Figs. 9, 10). After the Khmer Rouge "revolution" and Vietnamese occupation, only 8 physicians were left in the entire country of Cambodia, so it has taken time for surgical specialists to develop. Most surgeons in Cambodia are still "true" general surgeons, but orthopedic surgeons are now beginning to evolve and individual residency programs are being developed. We have partnered with the medical school in Phnom Penh and give lectures every afternoon, not only to medical students but also to the emerging residents in general surgery, orthopedic surgery, and plastic surgery. We are confident that this model of outreach is sustainable and will eventually result in the training of sufficient numbers of hand surgeons in Cambodia. Hopefully, this model can serve as a prototype for outreach programs in many other countries.Figure 1012 Hands: 2 visiting surgeons and 3 local surgeons performing bilateral centralizations on a 1-year-old child with bilateral radial club hands in Phnom Penh, Cambodia.View Large Image Figure ViewerDownload Hi-res image Download (PPT) But outreach does not always have to mean a foreign country. "Giving back" or "passing it on" may be applied to volunteering to supervise the resident or fellow hand clinic at the university or county hospital in America. John Seiler, MD, is piloting a program to provide hand surgeries to an underserved population in Atlanta, and this could easily be extrapolated to other large cities or underserved rural areas in the United States. Retired, experienced hand surgeons, especially those members technically proficient in microsurgery, could volunteer their technical wizardry to our military surgeons and Veterans Administration surgeons who are caring for our "Wounded Warriors" from Afghanistan and Iraq. This loose affiliation would dramatically augment the expertise of our military surgeons and mirror the efforts of Sterling Bunnell and his team after the end of the Second World War (Fig. 11). Finally, the outreach pillar of the Hand Society can never compete with the $64 million endowment of Operation Smile or St. Jude's Children's Hospital. What we can do is acknowledge and consolidate the volunteer work of all our members, some of whom have visited the same country or the same hospital for many years. For example, Louis Carter, MD, has been operating in East Africa for over 30 years and has written the definitive practical guide to plastic surgery and hand surgery in the developing world.6Carter L.L. Nthumba P.M. Principles of Reconstructive Surgery in Africa. Pan-African Academy of Christian Surgeons, Bristol, TN2013Google Scholar If we were able to harness the volunteer work of all our members, not just a few, and publicize it under the banner of the ASSH, we may be able to attract substantial financial support from a billionaire philanthropist or foundation. Based on our recent survey, 72 ASSH members participated in 144 volunteer missions to 34 countries over the past 5 years between 2011 and 2016. In conclusion, just like my mentor Richard Smith's presidential address 33 years ago, I would like to thank all my hand fellows from whom I have learned so much. "My Fellows—My Teachers" have gone on to become ambassadors in raising the standard of hand surgery in their local communities, group practices, universities, and sometimes even presiding over their national hand societies overseas. Most importantly, I would like to thank you—the members of the ASSH—for allowing me the privilege of representing you all as President this year. It has been a true honor. Just remember we all have an obligation to teach and "pass it on." As Alan Bennett7Bennett A. The History Boys. Farrar, Strauss & Giroux, New York2006Google Scholar wrote so eloquently in his 2006 play and subsequent film "The History Boys," "Pass the parcel, that is sometimes all you can do. Take it, feel it and pass it on for someone, somewhere, one day. Pass it on boys, that's the name of the game I want you to learn. Pass it on."