Thank you Dr. Brummer for that kind introduction, I appreciate that. The title of my talk today is Innovation, the Triumph of Improbability. Okay my disclosures in your program, I can't seem to advance with this, okay. A number of authors have written about the improbability drive of innovation, probably foremost among them is Matt Ridley in his book How Innovation Works. And I'm sorry this thing is not working, I guess I'll ask you to advance each one I guess. But for those of you who might have seen this ad in the early 2000s, improbable does not mean impossible. This was the Rosetta Stone ad about this hard working farm boy, I said he was a hard working farm boy, she was an Italian supermodel, he knew he would have just one chance to impress her. So improbable but not impossible. There have been some improbable innovations in transportation, you have to remember that before 1820 the fastest any human had gone was the speed of a galloping horse. By the mid to late 1800s we had railroads that had far surpassed that, by the early 1900s we had automobiles, and by the mid-1900s we had aircraft that could go 500 to 600 miles an hour. But not all innovation is speeding up, let's look at transportation versus computers in that regard. In the 1950s cars could go 70 miles an hour, today cars go about 70 miles an hour. In the 1950s planes could go 600 miles an hour, they still go about 600 miles an hour. Computers were massive machines in few places, but now computers are everywhere, everyone carries a computer in their pocket or their purse, and they're more powerful than the 1970s computers that NASA used to get men to the moon and back. The rate of improvement differs also, and if you look at cars versus computers, if the rate of improvement in cars had equaled that of computers, cars would get 4 million miles per gallon a day, and have to go to the moon and back 100 times on a single tank of gas. We also know that innovation surges occur in sectors, and in the late 1900s the biomed biotech sector began to surge. So you'd think that by the 1980s the world would have been ready for shoulder arthroscopy, but you'd be wrong, there was some powerful opposition to shoulder arthroscopy. Thomas Kuhn in his classic work, The Structure of Scientific Revolutions, defined paradigm shift and coined that term, calling it a fundamental change in the basic concepts and practices of a discipline. And I think a great example of paradigm shift is the transition from open shoulder surgery to arthroscopic shoulder surgery. Kuhn went on to say that the initiators of paradigm shift were typically young and naive, they were outside the power structure of their discipline, and they weren't discouraged by the long odds against success. And this was certainly the case in the early days of shoulder arthroscopy. See here's an early picture of myself with Dr. Esch, Dr. Wolf, Dr. Snyder, and Jim Esch and Steve Snyder are still my best friends to this day. Conflict was certainly a consequence of paradigm shift. At that time, Charlie Rockwood was probably the most powerful shoulder surgeon, maybe most powerful orthopedist in the world, and he was calling the arthroscope the instrument of the devil. If you think cancel culture is new, it's not. This is Dr. Rockwood's 1988 editorial in JBJS, which was basically a diatribe against shoulder arthroscopy and the practitioners of shoulder arthroscopy. So the message was clear. They wanted us to go away. But by the late 1980s, we were doing things like side-to-side cuff repair. I was doing these using homemade custom suture passers and knot pushers that were made to my specifications by a local aircraft machinist because I couldn't get any companies interested in making the devices for me. And I was doing this in San Antonio, across town from Charlie Rockwood, in what was probably the most hostile point in the universe for shoulder arthroscopy at that point. We had our early radical books. We had this great arthroscopic shoulder anatomy book by Dave Dietrasek and Lanny Johnson. Dr. Esch had his black shoulder arthroscopy book. Dr. Snyder had his red shoulder arthroscopy book. And I followed on later with the cowboy trilogy of shoulder arthroscopy books. Clayton Christensen wrote in his book, The Innovator's Dilemma, that there are two types of technology that can affect change. One is enhancement technology. The other is disruptive technology. Enhancement technology can cause incremental improvements over time, but it takes disruptive technology to cause drastic changes and paradigm shift. This term, burden of craft, has intrigued me for years. And I got this term from this book by Edward Tenor, Why Things Bite Back. And he described the surgeon's burden of craft as being the surgeon's obligation to use his craft for the patient's greatest benefit. But in the early days of shoulder arthroscopy and in this quest for paradigm shift, there were other burdens that had to be assumed for that paradigm shift to occur. So what were these collateral burdens? First of all, there was the burden of arthroscopic identification. We were seeing things from the inside out for the first time, and things looked a lot different and new. We'd have to decide what was normal, what was pathologic, what's important. What are these new structures we're seeing, like the rotator cable crescent complex? There was the burden of developing the language of arthroscopy. We were seeing things that we had to describe that needed to have names. We needed to have names for the repair techniques and the constructs that they were using to arthroscopically repair things. Dr. Snyder coined the term slap lesion. Gene Wolfe coined the term haggle lesion. In this paper that I did with Jim Esch and Scott Jolson, we coined the terms rotator crescent, rotator cable. In 1995, I did this paper on the mechanics of suture anchor insertion and stresses within the suture, and coined the term dead man angle. In 1996, I wrote about this concept I had for margin convergence, which was a method for reducing strain and repairing massive cuff tears. In 2003, Ian Lowe, who had been my fellow, he and I did this paper on the comma sign and coined that term for subscap. Joe DeBeer and I did this paper in 2000 on traumatic glenohumeral bone defects and developed a treatment paradigm based on the bone defects, and we coined the terms inverted paraglenoid and engaging heel-sax lesion at that time. And then in 2014, I got to continue this treatment paradigm for bone defects with Drs. DiGiacomo and Itoi, where we coined the term on-track and off-track heel-sax lesions. It was the burden of disseminating arthroscopic knowledge. At that point, we were boxed out of mainstream journals, so we thought the best option was to start our own journal, the Arthroscopy Journal, in 1984. My hat's off to Gary Poehling, who almost single-handedly elevated the Arthroscopy Journal from a very rudimentary type of journal to a high-impact, internationally acclaimed journal that it is now, and to Jim Lubowitz for continuing that tradition of excellence today with his editorial staff. There was the burden, once again, of disseminating arthroscopic knowledge from the podium. We were boxed out of those presentations as well, so we formed our own organization, ANA. The first meeting was in 1982. First president was Jack McGinty. There was a burden of development of safe instruments and implants. There were just a few surgeons working with even fewer companies. Companies generally weren't interested. There were very rudimentary, early, straight, retrograde suture retrievers that gradually, over time, developed into the more complex and ergonomically optimized suture passers we have today, as well as other instruments. There was the burden of proving biomechanical and structural equivalency between arthroscopic and open repair constructs. At that point, bone tunnel repairs were the gold standard. We knew that if we were going to do arthroscopic repairs of all types, they would need to be done with suture anchors. Having had an engineering background, I took it upon myself to do cyclical loading studies, comparing the constructs we could do each way, one with arthroscopic suture anchor repairs, one with the open transosteous bone tunnel repairs. What we found was that anchor-based repairs were actually stronger than bone tunnel repairs. The fact that we had then shown that biomechanical equivalency, not only equivalency but superiority of the arthroscopic constructs, meant that we could then go ahead with the ethical advancement and conscientious advancement of the arthroscopic techniques. There was the burden of teaching the craft, not just from the podium, but also the cadaver lab and through our publications. Now, if you're going to talk about burden of craft, I think you need to define craft. Craft is a skill that relies on and maximizes manual competence. It has two components, expertise and problem solving. So as such, it has two faces. Let's look at the expertise face. The expertise face optimizes execution, whereas the breadth or the range actually optimizes the possibility of combining knowledge from different domains to obtain a creative solution. Malcolm Gladwell, in his best-selling book, Outliers, talked about the 10,000-hour rule for developing expertise. And he said that typically people that obtain elite status in either athletics or in music have practiced at least 10,000 hours at their field. Obviously, we can't do each operation. We do 10,000 hours before we're qualified. So I would highly recommend this book by Dr. Chris Ahmad that many of you know. It's called Skill, and he has a number of targeted drills and practices that can help you obtain excellence in your field. And our goal is excellence, not perfection. In fact, the famous football coach Vince Lombardi said, perfection is not attainable, but if we chase perfection, we can catch excellence. And that's what we want to do is to catch excellence. So when we talk about breadth or range, this is another book that I would highly recommend by David Epstein. It's called Range, Why Generalists Triumph in a Specialized World. In this book, he talks about this technological trend towards specialization, not just in medicine, but in large companies, academic institutions, where there's actually elevation and narrowness to an ideal. And research is done in groups of individuals with expertise in a single area, and this is called vertical thinking. And you can have enhancement improvements, but not really drastic improvements with that. Dr. Arturo Casadevall, who is head of immunology at Johns Hopkins, has this theory of parallel trenches, and he talks about the danger of narrow expertise with this theory. He says, we keep digging deeper into our own trench, not realizing that the answer may lie in the trench next to ours. So clearly, there's this need for broad experience or from outside collaboration. The case for breadth, I think, is best made by Robert Heinlein, the noted science fiction author, when he said, a human being should be able to change a diaper, plan an invasion, butcher a hog, con a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a table, cook a tasty meal, fight efficiently, die gallantly. Specialization is for insects. So clearly, breadth is something we have to develop just to get along in our modern world. But I think it's also the basis of creativity. It's lateral thinking instead of vertical thinking. Thinking outside the box, meaning that you apply a solution from one domain to a problem in another domain. And I think one of the greatest examples of this is Einstein's thought experiments for his theory of special relativity in 1905. So there is a human engine, though, behind depth and breadth, and that's tenacity. I was lucky to grow up in a small rural area in Texas where I had lessons in tenacity from the Texas range and from my parents, their generation, their friends. So when I would bristle about some of the hard work, they'd say, well, hard work never killed anybody. No man ever drowned in his own sweat. As far as teamwork, they said, if you ain't pulling your weight, you're pushing your luck. They wanted us to show grit and determination. Said, with horse bucks you off, then get back on and ride them again. People use grit and determination as if they're the same thing, but they're really not. Grit begins with determination and then adds a layer of courage, resolve, and strength of character to give it an ability that determination alone does not possess. Grit actually manifests itself through tenacity, which is a relentless refusal to give up. So the paradigm shift to arthroscopic surgery occurred, and it required depth and breadth, but it really never would have happened without grit and tenacity. So there was a thrill of paradigm shift against all odds and after long struggles, and it was a thrill almost too great for words. But the words that best described the thrill of paradigm shift had been written decades earlier by Mahatma Gandhi when he said, first they ignore you, then they laugh at you, then they fight you, then you win. And so we won. But even so, advancement continues, and I want to offer my heartfelt encouragement for a new generation of lateral thinkers whose improbability drive of innovation will continue. And remember, the next improbable breakthrough is right around the corner. The future is yours. Happy trails.

innovation

triumph of improbability

computers

paradigm shift

arthroscopic surgery