Ladies and gentlemen, please take your seats. Our session is about to begin. Please welcome your moderator, Dr. Kwadwo Wusu-Achow. So again, I'd like to go back and I'd like to introduce Kojo. Kojo is a very, very good friend of mine. But this is an innovative session that he's kind of come up with to really give some people some things to think about. Kojo, I've known for quite a while. He trained at Duke. He was an HSS fellow. He's currently in Richmond. And he's a hip arthroscopist. He is very busy. He also works with the Gladden Society on the board. And he's an editor in core. So I go ahead and introduce Kojo, a very good friend, and start this innovative session. All right, I appreciate you all having me today. Thank you for being for this session. Thank you to the AOSSM for its attention to this important subject matter. So my highest respect and acknowledgment to the J. Robert Gladden Orthopedic Society for their support in this presentation. Now, any disclosures relevant to this session can be seen via the app or the website. So we're going to begin with a brief case presentation. A 16-year-old African-American male presented to my clinic. He had a three-month history of knee instability after an awkward landing while playing basketball. Now, he's an elite level player. He has college aspirations. He has considerable attention from recruiters. He was told by the initial evaluating staff it was just a knee sprain. He just needed to take his time, rest, and things would get better. But he continued to have instability over the course of those three months, swelling and difficulty with those lateral movements that we know are prerequisite for elite basketball playing. So his mother, concerned, sought a second opinion and, of course, advocated strongly for an MRI. On my examination, he had a positive Lachman and a pivot shift examination. He had an apprehensive and compensatory gait, well-maintained range of motion, negative for any other ligamentous injury, and neurovascular intact distally. And what should be no surprise to any of y'all, by this point, his MRI was positive for a full thickness anterior cruciate ligament rupture. So what we have is a situation of delayed diagnosis of an ACL tear in a young, athletic, functional individual. We can all agree this is an unacceptable situation. We discussed the diagnosis with the patient and his mother in detail and came to a plan to put together a patella tendon autographed ACL reconstruction. Now, we're gonna come back to this person's story in a bit, but there's a few things we need to talk about via detour that we need to dissect. The situation at hand is that we have a delayed diagnosis of an ACL, leading, therefore, to delayed treatment of the ACL in a young person, again, something we don't wanna see as someone that age. There are a few different components that we need to dissect and look into in detail. There was an initial delay in diagnosis, based on his initial presentation by the presenting staff. This was exacerbated and compounded by the fact that his initial concerns and complaints of him and his mother were ignored by the staff he was working with. All this culminated in a failure to correctly direct him in terms of his next steps for the clinical pathway, according to his functional treatment goals, right? And so the situation at hand is that a young, minor patient with a serious ligamentous injury was told repeatedly that this was just a sprain. Unacceptable. If only this was an isolated occurrence, but unfortunately, there's a more systemic problem that we need to break down. And more unfortunately, the patient's race is material to the discussion here. An interesting study from 2020 that I'll show you all briefly, a psychological survey of collegiate athletic staff found that said staff was found to have an overlying perception that black patients, when compared to white patients, feel less pain at the time of initial knee injury, specifically for ACLs. Now, aside of the baseline concern with that, the critical issue here is certainly you can understand that an underestimation of pain at the initial time of injury may lead to a lower urgency of diagnosis and therefore treatment, potentially even for a miss of treatment in the first place. This is unfortunately something that's bigger than just orthopedics. This is something that we have to take a historic lens to look at to understand how we can improve the future for our patients, all right? We have to unfortunately look at the uncomfortable history about America, knowing that misconceptions related to black pain perception trace all the way back to the transatlantic slave trade, where the pseudoscientific beliefs were propagated about the biologic differences between races in order to justify atrocities committed. Now, certainly that was centuries ago, but unfortunately, aspects of that have taken root in the American consciousness and in the medical American consciousness, unfortunately, such that to this very date, there persists in some providers a notion that there was a biologic difference between blacks and whites, particularly as it pertains to pain perception and resilience. These are false narratives that we have to see change for us to change the narrative moving forward. Taking the next step, we need to really dissect the concept of the social determinants of health as it pertains to delay in treatment and care. In 2020, our colleagues at the Children's Hospital of Pennsylvania showed us that race and insurance status significantly affected the time from diagnosis to treatment for ACL ruptures. There was a significant delay seen for patients who were of black and Hispanic background, and you might imagine a higher rate of irreparable meniscus tear for said patients. Even after surgery, those patients averaged a fewer number of physical therapy visits and a significantly lower strength at nine months, protective strength, as you might imagine, with less PT visits. What we're seeing is both a delay and a limitation of access to initial care and delay in access to follow-up care, which I'll argue to you are two sides of the same coin. The concepts of the social determinants of health are far larger in scope than I can talk to you about today. It's a complex interplay of factors, as you all know. The CDC has given us kind of a way or a tool to talk about it empirically, if you will, known as the Social Vulnerability Index, which takes into account a multitude of different factors, including minority status, socioeconomic status, housing type, and other housing characteristics. This allows us to look empirically and to evaluate this and see how it affects care for patients. At our institution, we did a preliminary evaluation utilizing the Social Vulnerability Index, the SVI, to look at if there was a delay in treatment from diagnosis of ACL to actual treatment. So utilizing a popular electronic health record, we looked at 130,000 patients at 1,400 institutions, and we actually ranked the institutions based on the average SVI of the population treated at said institution. Preliminarily, what we found is that those patients at places with a higher SVI had a longer delay to treatment from injury to ACL. Black patients were statistically more likely to be treated at an area with a higher SVI. This is congruent with some recent studies by Dr. Chang and colleagues from 2024, this very year, showing us that another critical index similar to the SVI, the Deprivation Index, which is more of a geographic understanding of access to care, was also tied to a delay for patients from ACL diagnosis to ACL treatment. This highlights a geographic notion or background as it relates to access to care and deprivation. Unfortunately, these concepts or this geographic notion of area deprivation is not arbitrary. We once again have to take a historic lens and evaluate how we can change the future and improve how we can treat our patients. Looking back all the way to the 1930s, concepts such as redlining, where state-sanctioned vehicles used to keep certain demographics out of areas of high access to care. Now, while these practices are now highly illegal, they have created, by corollary, these areas of great deprivation around the nation, wherein patients are more likely to be socially vulnerable and therefore have decreased access to care. The point that I need you to take from today, though, is that although these areas were created on the basis of race, at this point in time, every patient in said areas with deprivation are at risk for delayed care and loss of access. So we need to understand that health disparity is an issue of value-based quality of care to every patient that we see. What happens to some of us happens to all of us. Now, this patient so far has a happy ending. Here he is, about to win his local slam-dunk contest so far. But there's some learning points that we really have to take back as we dissect this further. We need to increase the awareness of sports injury early responders at the ground level. We need to improve community engagement such that access is there. Now, one game-changer for this patient is that his mother was familiar with me via her community connections and therefore was able to assess access where she would normally have had it. We need to take more multidisciplinary strategies to improve post-operative access to care and increase the equity of injury prevention programs in the first place. Thank you. Okay. So Dr. Mosoros is going to begin our formal scientific portion. I'll begin with two papers. The first is lower socioeconomic status is associated with recurrent shoulder instability before shoulder stabilization. Thanks, Kojo. I want to thank the program chairs for inviting us and for having us and thank Kojo and Eric for having us present our research. My name is Bill Mosoros. I'm the chief of sports medicine at Henry Ford Health in Detroit, Michigan, and this study is based out of there. This is on the lower socioeconomic status that is associated with recurrent shoulder instability before surgical stabilization. The second paper is lower socioeconomic status before surgical stabilization. I want to thank my co-authors as well. Again, we have nothing to disclose related to this talk. So as a background, and as we just mentioned, the social determinants of health are the social, environmental, and economic factors that affect health access and outcomes, and there is growing evidence that shows in orthopedics that SDOH leads to disparities in our outcomes. And this study came from myself and one of my previous fellows, Lawrence Mweze. We were seeing a run of individuals who were coming into our clinics that had multiple dislocations, and Lawrence had some concerns because these individuals needed latriges or needed remplisages, and we were wondering, why is that the case, and is this related to SDOH? So we created a study where we wanted to look at recurrent instability before stabilization because we want to limit the issues with increased structural damage or increased arthritis, recurrent instability, and the increased healthcare costs with those who have recurrent instability episodes. So our hypothesis was having recurrent instability events before surgical stabilization will be associated with lower socioeconomic status. And the way we did this, we did a two-year retrospective cohort review from a single health system, the Henry Ford Health System here in Detroit, and our inclusion criteria was really based on those patients who eventually had surgery. So we took their CPT codes, evaluated them, and they had to have at least one shoulder instability event. Our exclusion included no documented instability events, previous shoulder surgery, or those who did not have complete social determinant data. That was less than 3% of our cohort. We collected those who, the date of their first dislocation, the number of instability events, their time from dislocation to orthopedic presentation, and their time from presentation to surgical procedure, and we evaluated their SDOH by evaluating the ADI, which was just mentioned, the Area of Depravity Index. Again, it's focused on your income, your location, your employment status, and your housing quality, as well as the SVI-SE, which is collected in EPIC for us. The ADI, thankfully, has a stratified tier. There's low, moderate, and high, and that allows us to really break down the data to understand who's more likely to have shoulder instability. We used a univariate logistic regression analysis to identify risk factors of those having more than one dislocation, and then a multivariate model thereof. In our results, we looked at 106 patients total, and what was interesting, and what we felt would be expected, is that the ADI, the higher the ADI, the more likely you are to have more dislocation events before seeking treatment. Other key results in this study, which reassures me and my partners, is that there was no demographic or socioeconomic difference from the time to presentation to surgical stabilization in our orthopedic clinic, meaning by the time they got to the surgical side, when we did our evaluations and then did our definitive treatments, they were the same once they got into our office. The problem was getting into our office, so an increasing ADI and SVI-SE was associated with recurrent instability before stabilization. Decreasing age and decreasing BMI also were associated with recurrent instability, and in our multivariate analysis, the increasing ADI, when comparing the most deprived, their odds ratio was as high as 7.5, which is significant, and just shows the amount of disparity that occurs in these populations. Again, this is our univariate analysis showing the differences related to age, BMI, SVI, and ADI, and then really the multivariate analysis is very powerful, showing that if you have an ADI tertile 3, which is the worst from a depravity index, you have an odds ratio that's significant that you are not going to seek care for that injury and have definitive care, leading, again, to these complications of multiple dislocations. So this study demonstrated that socioeconomic status is a predictor of recurrent shoulder instability before surgery. The relationship between SDOH and the number of preoperative instability events are likely multifactorial, so this is related to access to healthcare, it's related to their insurance coverage, it's related to your financial instability, and it's also related to some medical education and bias issues. We have to be able to create an environment for which these individuals will seek their care after their first event, because there are consequences to not having definitive care. There are limitations to this study. We were not able to directly survey our patients. Again, this is a retrospective review. Our inclusion criteria were only focused on those who had surgery, so this does not include those who had nonoperative treatment only or who never presented to our orthopedic surgery clinic. And again, we did not examine preoperative imaging or intraoperative findings or postoperative outcomes. Those are future studies that will become related to SDOH and shoulder instability. So in conclusion, the lower socioeconomic status is an independent predictor of high likelihood of a current instability before surgery. For those of us in this room, recognizing this relationship can allow us to change the way we practice. It can create better systems to get these individuals to be assessed in a more timely fashion and understand the consequence if disparities are needed to examine what leads to these disparities and if these disparities also lead to a poorer outcome since they have weighted in terms of treatment. We're excited. I want to thank everyone again for having us. Applause Thank you. Next paper, Dr. Shalem. Race and income influence patient outcomes after multiligament knee injuries. Hello. My name is Isabelle Shalem and I'm with the sports medicine research team at NYU Langone. I want to thank AOSSM for inviting us to present in this session and I would like to also thank all of my co-authors. The author's disclosures are listed on the AOSSM website. Multiligament knee injury involves injury to a minimum of two out of the four primary ligaments resulting from low or high energy mechanisms. These injuries are rare, representing approximately 0.2% of all orthopedic cases. They have the potential to cause long-term functional impairments including vascular and neurological damage. The rehabilitation after this injury requires an extensive amount of coordinated care and follow-up to achieve reasonable outcomes. Socioeconomic research is critical to developing more equitable and effective healthcare delivery strategies. In the realm of sports medicine, previous research has underscored the link between lower socioeconomic status and worse outcomes following orthopedic injuries. Social factors may influence the time between injury and surgery, a patient's ability to complete physical therapy, or the ability to take time off from work to recover. It is unknown the extent to which differences in socioeconomic status variables contribute to different recovery outcomes after MLKI in a diverse population. The purpose of this study is to assess the influence of socioeconomic status variables on patient reported outcomes at intermediate follow-up after multiligament repair-slash reconstruction. This study was a retrospective review of patients in our MLKI database who were initially evaluated for treatment for MLKI between 2013 and 2023. Their diagnosis of MLKI was confirmed intraoperatively or via MRI. We included patients who have provided at least one year of clinical data and patient reported outcomes. All procedures were performed by one of three fellowship trained orthopedic sports medicine surgeons. The data used for this study gathered from the electronic medical records included age at the time of surgery, sex, date of index surgery, rates of post-op irrigation and debridement, manipulation under anesthesia, and re-tear data. PRO data were used including International Knee Documentation Committee scores, Leishman scores, VAS pain scores, Tegner activity scores, and return to work and return to sports status. The SES questionnaire asked questions about race, ethnicity, marital status, household size, household income, education level, and employment status. For analysis, descriptive statistics were used to characterize patient demographic and socioeconomic variables. We used binary categories. For example, white versus non-white and Hispanic versus non-Hispanic. Patients reporting a yearly household income of under $40,000 were classified as low income. Linear regression analysis was performed to identify the ability of income and ethnicity to predict IKDC scores. The final cohort consisted of 45 patients. Most patients were male, English speaking, and did not identify themselves as Hispanic. The median age of the patients was 41 years old. Roughly half of the patients were married and slightly more than half of the patients had sedentary jobs. Income was widely distributed with one patient earning less than $5,000 yearly and eight patients earning $150,000 or more. Lastly, about half of the patients had a college degree or higher education degree and the other half had a variety of educational backgrounds ranging from an incomplete high school education to a partial completion of a college degree or technical program. At the median final follow-up time of four years, the median IKDC score was 66% and the median Lysholm score was 77%. Of the 25 patients who worked prior to injury, 20 patients had returned to work and 12 patients had returned to work at the same level. Of the 26 patients who played a sport prior to injury, nine patients had returned to sport and four patients were able to return to sport at the same level. Eight patients required manipulation under anesthesia after the index surgery, one patient required irrigation debridement for infection, and one patient sustained a ligament retear. Differences in patient reported outcomes by socioeconomic variables are shown in these figures. Return to work was calculated for the 25 patients who completed the return to activity survey and worked prior to injury. Patients who were nonwhite and did not have a college degree had significantly worse IKDC scores as well as patients who identified as Hispanic and those who were classified as low income. There was no difference in IKDC or Leishman scores by marital status or by the nature of their job, sedentary versus non-sedentary. There were no differences in VAS pain scores or change in Tegner activity scores by socioeconomic variables. On linear regression analysis, controlling for Hispanic versus non-Hispanic ethnicity, low income was predictive of a 25.7% lower IKDC score. Significantly fewer Hispanic patients returned to work as compared to non-Hispanic patients, but there was no significant difference when examining the rest of the variables. The most important findings from this study are that patients with lower incomes, those who did not graduate from college, and those who are Hispanic and nonwhite had worse patient reported outcomes following surgery for MLKI. Located in a large urban center, we were in a unique position to include patients from an extremely diverse racial, ethnic, and socioeconomic backgrounds. Our results paralleled those of other orthopedic studies in which IKDC and Leishman scores were worse for nonwhite, Hispanic, low income, or non-college graduate patients. Most of these studies have been conducted in the setting of total joint arthroplasty, but socioeconomic status studies in the context of ligament injury have also been performed. For example, a large cohort study by Jones et al used a neighborhood SES index based on US Census data and observed worse PROs, including IKDC, at two years post-ACL reconstruction based on lower SES index. Another large study of pediatric ACL injuries found that black and Hispanic children averaged fewer post-op PT visits and significantly greater strength reduction than patients who identified as white or Asian. Further studies may expand upon our work by examining the interaction of multiple socioeconomic variables in larger cohorts, as well as testing interventions to improve outcomes in disadvantaged populations. In conclusion, patients who identified as nonwhite or of Hispanic identity or were classified as low income or low education level reported worse outcomes. Surgeons should work to mitigate the risks associated with treating patients who have limited resources and be able to support diverse backgrounds. We look forward to seeing what changes are made in the future that aim to address these challenges. Thank you to my mentor, Dr. Alaya, and the NYU sports medicine research team for your support. Thank you. Thanks to both of you for very thoughtful, insightful papers. In the interest of time, we're going to go ahead and move on to our guest speaker. All right. Thank you very much for your presentations. All right. Introducing Mr. Billy McMullen, my brother, a native from Richmond, Virginia. He's an alumnus at University of Virginia and retired from the National Football League. He's the founder of the SPART Talk Mental Health Equity Platform and joins us to share his perspective on access to care. Hello, everyone. So I'm a little change of pace. I am not a doctor. But I do want to share a perspective of some things that I've experienced in my progression as an athlete from the state of Virginia all the way up into the National Football League. And I want to just say thanks to Dr. O for having me here to share this perspective. And I think hopefully you all can glean something from it as you continue to grow your career and grow your practice and give care to different people from different backgrounds. I'm really excited to share and here's a reason why, because I view you all as healers. At the end of the day, this is what you do. You heal people. It is imperative and it's efficient and it's well needed in the space of just living and playing sports that you guys are the healers. When we have an ache or a pain, we come in and see you guys. When we have a dislocation or a tear, we're coming to see you. And we are putting our full trust in you all that you can get us back to the status that we once were on the field or the court or the baseball field. So I'm celebrating you. You're amazing at what you do. I actually saw some of the videos of the surgeries and I had to walk out. So it was pretty tough. After having my knee scoped before and some other things done, I didn't know it looked like that. So salute. We are in Denver, so you guys get the Milehouse salute. So with that said, I want to just share, like I said, what I think will be a great idea to start to incorporate in as you go through the process with your clients and as you find different solutions for your patients from diverse backgrounds, as myself, as a black man. And I think the biggest piece comes down to storytelling. You guys may say, what does storytelling have to do with my practice? Well, storytelling is a wonderful way to bridge gaps, is a wonderful way to see the person pass the injury, is a wonderful way for you, both you guys, to interact and learn something that you probably didn't know about your patient, they probably didn't know about you. But storytelling is a way to humanize the process and not make it so transactional. And I've had many instances for myself, but also guys that I played with in the National Football League and in college and in high school, where the process was very transactional, that there was no relationship building, there was no storytelling. And in that relationship building process, there is a story. And so with that said, the world moves fast. And as the world moves fast, of course, I know you guys see patients all day long. After talking to Dr. O as he grew his practice in Richmond, I couldn't believe how many patients he saw on a daily basis. And so it's tough to even have the chance to say, hey, athlete number one, please tell me a little bit more about who you are. Please tell me a little bit more about what you think your injury is. Give me your perspective on how you feel. Because you got a patient waiting. And there's only so many hours in a day that you could actually see patients. So the world moves fast. But if you don't take time, judgment, you can quickly do a knee jerk judgment on a person, and that leads to a transactional interaction, which can have negative outcomes for both you and the patient, the client, patient client. So I want to tell you just a little bit story about myself. And I'm going to put this all together so you guys can see where my perspective comes from. And maybe like I said earlier, you can glean something from it and start to apply this to your daily practice. So Richmond, Virginia is where I was born and raised. And my background, my roots run in Jackson Ward, which was like the Harlem of the South. They had the music industry there. They had banking industry, black-owned homes, black-owned companies. It was a very sprawling place to be back in the early 30s, 1930s, 40s. And my family, my father's family is from that place, from that side of town. And it was really disheartening when I actually learned the story about Jackson Ward. Dr. O brought up redlining. He brought up other systematic ways that we were divided from other parts of the city. So that happened in Richmond, Virginia, as it happens everywhere. The Highway 95 was basically built straight through Jackson Ward and destroyed it. Destroyed homes, destroyed jobs, businesses, destroyed families. I'm second generation from that. And that was in 1956 or 1952 when it first started. And my father was a young man seeing a reconstruction of his neighborhood. He was three or four years old, and he remembers that. So you can only imagine what type of energy that passes down to your kids as you see that. And so there was the largest projects also in Jackson Ward. It's called Gippincourt. And so that's where my father and his family lived. And we were raised in that area. And one day, we went to one of the rougher schools in the neighborhood. And one day, my mother's niece who worked at the school, she said, hey, if you can get your kids out of this neighborhood, you should do it. And so my father and my mother, they bootstrapped us, and we moved to the county. Which, by the way, wasn't much better, but it was better than the city. So with that said, my perspective was always around black and brown people. And I caught wind of sports. And football was my main sport. It took me to a new height. I would say I was a late bloomer. I was a tall, skinny kid. Couldn't run fast. You know, glasses, two left feet. And it took me a while to develop, 10th grade. And 11th grade is when I really hit my stride. So I had a lot of colleges, universities coming to see about me. And it took me to a 4K military, one of the best prep schools in the area, where I had a stellar career there. And here comes UVA, comes to recruit me. And mind you now, in this process, I'm a kid that doesn't know, really, the other side of the coin. All of my interactions were with black and brown people. A few people that are outside of my circle that were not black and brown. But I was a very shy kid, very quiet kid. So I only trust who I trusted, and that was black and brown people. And so UVA comes calling, which was a big culture shock for me. And in that process, I became a very, very good player. Became an All-American. Broke all the records at University of Virginia as a receiver. And had the NFL come calling maybe a few years later. My point is, well, I should say this. This story right here changed my life. And this University of Virginia changed my life. And I'm going to tell you why. I was introduced to other people outside of black and brown. And my trust factor started to arise. Now, my last game of my college career was versus the University of West Virginia. And I was picked to be a high draft pick in the NFL draft in 2003. But I just had to complete this game. And the story goes, as it was maybe three or four plays into the game, quarterback threw me the ball. I caught the ball, and I just wanted to get that touchdown. I wanted to run until you saw me on ESPN. I'm running. One guy jumps on my back. Another guy jumps on my back. By the end of the play, it's about nine people. My mind is telling me, Billy, you need to go down. But I got to get on ESPN. I got to make this play. Well, I go down, and I dislocate my left elbow. It was horrendous. I'm laying on the ground, and I'm like, something's not right. I know something's not right. But the other team screams out. This is how brutal football is. Oh, we heard him. And they're cheering. We heard him. We heard him. Wow. So I'm like, heard who? Who'd you heard? So I look over to my left elbow, and it's pointing this way. And I try to get up and almost faint. And my buddies had to help me to the sideline. Well, I don't know how many of you guys know this doctor's name. His name is Dr. Frank McHugh, a University of Virginia legend. So Doc takes me to the sideline, and he says, he whispers in my ear, he said, hey, Billy, your arm's dislocated. I'm going to try to put it back in. Just like that, real calm. I said, all right, Doc, I trust you. Go ahead and do it. So he takes my elbow, and he jerks it. I'm looking away, right? This big football player, I don't want to see any of this. I'm looking this way. He jerks my arm, and I was like, OK, it's back in. He leans back over and he says, hey, Billy, I didn't get it in. I'm going to try one more time. I said, Doc, you got one more time, dude. And I'm going to walk around with a dislocated elbow. So he puts it back in. And I'm like, good, we can start the rehab process. But the moral of the story is this. Because I knew and he knew each other's stories, we created a relationship over a four-year period. I knew about Dr. McHugh. He knew about Billy McMullen. Doc took time to learn us. He would sit next to us, maybe say two or three things. Say, hey, Doc, how'd you know that? He said, he'll just shake his head, and we'll have conversation. Or walking through the halls, hey, Billy, how you doing today? I'm pretty good. I'm a little tired, man. It's two a days, but I'm here. Things like that, hey, Billy, how's your mom? My mom's fine. She's coming up. Make sure you introduce me to her when she gets here. So when the moment was vital for me in my career, mind you now, I'm projected first to third round in NFL. This is a vital period in my life. I have a dislocated elbow. In a few months, we have the NFL combine, which is prevalent in the process of getting drafted. My life is on the line, and I trusted it with Dr. McHugh because, sorry, I trusted with Dr. McHugh because he built relationships. He shared stories to me and our team. He allowed me to see past this face that I had no clue was. This is a man from West Virginia, born in 1930. I'm a kid from Richmond, Virginia, inner city, born in 1980. And because I trusted his story and he trusted mine, I gave full respect to him and full trust at that moment in my career. My point is this. Let me just share something before I get to my point. This is Coach George Welsh. When Dr. McHugh passed away, Coach George Welsh, who's also a legend at University of Virginia, he said this about Dr. McHugh. He was such a great guy and so caring and such a great surgeon. Another coach, Coach Mike London, who coaches at William & Mary right now, he said, Doc had a great passion for helping people no matter the social status. So my point is this. If you really dive into storytelling, if you really dive into finding out about your patients, in the minimum time you have, and building that relationship, it goes light years. It spreads across the table to generation after generation. We could change the status of how black and brown people view these opportunities in healthcare just based off learning the backgrounds and allowing them to learn you. So share and listen. It's gonna foster better relationships, better results, and of course, better bottom lines. Thank you. All right, Billy, thank you for that. That was thoughtful and thought-provoking, absolutely. So we're going to finish up with a panel presentation. We have Billy. We have Dr. Williams of HSS, head doctor for the Brooklyn Nets, and Dr. Eric Carson also of HSS, head orthopedic for Harlem Hospital. So Dr. Williams, I was your fellow a few years ago, and I got to tell you, I don't think anyone engaged athletes like you do. Can you speak to where that comes from, and what are the points that make that work so well for you? Well, being a former athlete, I naturally empathize. And I think that's just my style. I was fortunate to have a lot of great teachers, and I just felt, starting a practice, that I just liked a more informal style to take the volume down. And in the context of this panel, I just cannot echo the chasm there is between a patient who maybe is not as well-resourced, coming up to the Upper East Side of New York into this fancy building where there are not a lot of people that look like you or dress like you, so it's a little intimidating. So I just felt like, well, that's a strategy that's going to play regardless of who I'm talking to. And I just like to know, or excuse me, I like the patient to know or the athlete to know that I really care. I was a marginal athlete, but I consider myself a pretty good doctor. So when they come into my orbit, I want to convey that genuine sense of empathy, because I really think, I really get it. I did what you did. I'm really good at this thing that I do. And it's not necessarily surgical, it's like you're trying to usher treatment. I'm already thinking, all right, this person's got this thing, they're going to need therapy, they live in the Bronx, they can't really get here, there's no good therapy in the Bronx, how am I going to do that? So my AI and my computer is going, and it's really me just trying to source out how it's going to go. And that's just become a habit, not just obviously with patients that look like us, but just with everybody. So I think there's just a genuine baseline respect, I feel it's such an honor to be a physician and to take care of people, especially now after COVID when we couldn't take care of each other. And we were all, I think I feel more passionate about it now, but this athlete, taking care of athletes thing, I think it's a privilege. There's some other specialties that look at us like we're a little frivolous because of it is. But it is a big deal to these kids and to adults, the way that we process being active and being athletic as a life extender and a life quality enhancer, the stakes are very high. So I always feel like at this point in my career, I want to create a bridge so that they know, not only do I know what I'm talking about, but that I care. I think I just want to add one thing. Bradley, just comment just a little bit about just the responsibility of a young black professional athlete. This is the first black physician they've ever seen before and responsibility that goes with that. Thank you. So I have daughters and I love my daughters. And I have a cachet right now, I'd say my primary tertiary group of athletes are these kind of basketball tracked, NBA tracked athletes just because of my position. And they're like your children, right? And I feel like a pediatrician because I have the patient, I have the mother, I have the agent, you know, and everybody in there. You're really sort of engaging a wide variety of people. But I think in that group in particular, I feel super passionately about it because I've seen these athletes become commoditized, they're not often able to process kind of this whole thing that they're, this construct that they're stepping into. So I like to be the one person who doesn't want anything from them, and I just want to, I just want to, and I'll say things like, hey, listen, this is what I think, and, you know, when you go home and talk to your stockholder, just remember that I feel it's my job to help you maximize whatever the experience is going to be. Is it going to be my college career, is it going to be how much money can I make doing this thing that I do, that is, that's my purview, that's what I try to convey, and I think that's probably why people like coming to me. I think there's no doubt about it. Billy, I'm going to flip it back to you. On the other side of the coin, because you're seeing it from the other end, when you see youth athletes, what do you think they need to see to help them feel that comfort level for the storytelling? They cut my mic off. Okay, so, yeah, the question is the youth athletes, what they need to see from guys that have been there before? Okay, yeah, it's the youth athlete just want, what they need to see is someone who has, first of all, open and honest with them about the process in terms of how to get to the next level, and then secondly, putting them in position to ask the proper questions to whether it's their agent or the people who are around them, and then thirdly, we always harp on taking care of your body. That's number one, because it's a commodity for you and then those who are your partner with, I'll say it like that. But we always want to have them in a position, their parents included, to ask the proper questions to sort of start the storytelling process, because if I say this about my, or I've asked the proper question, then the surgeon or the orthopedic surgeon is going to give you some information back, and then you can relay, it becomes this two-way conversation and not just a dictatorship. So what I'm hearing is an emphasis on the back and forth, right, a repertoire that has to be developed. Dr. Carson, from your standpoint, you've seen both sides of the locker room, you've seen the community engagement, your position at Harlem Hospital, what do you think are the keys to moving forward? Well, sometimes I think I'm a little crazy. I left a great job at Wash U working under Regent O'Keefe, who I got really involved in diversity, equity, and inclusion, which I would say was my past life, and I then took on this venture, and I'm not sure exactly how this happened, but it's, I call it my science experiment. I essentially have been, I was an HSS fellow, there's been a lot of interest in me coming back for many years, and then it was like, well, come up with something creative, and, you know, very easily I could have come and worked next to Riley and kind of been doing the same thing, but I've always been kind of on a little different edge, per se, and sacrificing a bit of myself for others, and in short, I called it my legacy move, and moving to Harlem Hospital, which I'll call an orthopedic desert, a rehab desert, there's a fence at 110th Street, where people are so loyal to Harlem, they won't leave Harlem at all, and it's become a passion of mine, and not that I'm trying to reinvent the wheel, but, you know, some of the people that we truly look up to, Riley and myself, that we've reached out to, so Clarence Shields, back in 1994, started his program, HEAL, and it was helping enrich athletes' lives, and Clarence was far ahead of his time before we even used the word health equity, and he essentially was looking at schools in Crenshaw that had no athletic trainers, that had no fields, no nothing, no resources, and he essentially was, you know, been, this has been a passion of his his entire life, and I hope Clarence is in the audience, and I did see him earlier, but it's, I'm essentially trying to emulate something very similar to what he's doing, so for me, I'm living in the neighborhood, I'm definitely interacting, my partnership with HSS has been absolutely incredible, there are so many passionate people there that are concerned about my science project, how do you take an under-resourced, financially-challenged hospital, and improve clinical outcomes, and improve care, so some of the things we're doing right now is I'm working with Dan Green, and we're working with the Public School Athletic League, essentially looking at how we can improve care for the kids in the public school. I've reached out to the Harlem lacrosse program, which essentially is in four cities, these kids are playing lacrosse on hardball courts, on tennis courts, and they're essentially, the who's who's are on their board, and these kids are giving out over 400 or 500 scholarships per year going around the country, so, but they have no athletic trainers, and so I'm in the midst of trying to create a program for something like that. There's a young woman who's here, Camilla Thomas, who is an Olympic fencer, who is involved with the Peter Westbrook Foundation, Peter was the first African-American to go to the Olympics, I reached out to Peter and said, you know, how can we be involved in what you're doing? Not that Peter needs our money or any other support, but I think it's just something that is a passion of mine. So, in short, the last thing I'll say is as AOSSM has taken responsibility for looking at, you know, various programs such as the STOP program and other programs, I think this is something that, between myself, Joel Boyd, and Tim Johnson, and all of us, I would really kind of take it upon the leadership of AOSSM of looking at, you heard two fantastic papers about the healthcare disparities that are going on. This is an initiative that I think we need to take to the next level from the leadership of AOSSM. Just a passing comment, if you'll indulge me. I'll call out Gabriella O'Day, who's at our institution, who does a lot of work on this, and one of the things that resonated with me that she talked about was the tax of the African-American or minority physician. So follow the bouncing ball. More access to care when there are more people that look like you who are physicians. So how do you increase the number of physicians that are administering care? So there's always, I will tell you guys, I probably get conservatively 30 to 40 emails a month from kids who find me and they want me to mentor them, and I can't. I can't do it. I can't do it at all, and I feel terrible about it. You all are all former athletes, so I suspect, or I say that most of you, that the comfort level with dealing with people in other races and backgrounds is probably, in this group of people, probably more widespread than most groups, I would suspect, which is why I enjoy this body so much. So the point of that is, I look at people who played a big role in my life in terms of kind of allowing me to think big, and these were people, these were not black people. These were majority folks who just found me to be worthy of their time, and it had a tremendous effect. So in your faculty responsibilities, in your practices, you know, when there's a brown face, it may not feel comfortable, but it'd be so helpful to lean in on that because it does. When you reach across like that, because you're larger than life, we all forget who we are and how we come across. It's a big thing for them to ask, and the more available you can be, I think that's what I think the take-home message is. You know, more is better, and more diverse is better. There's going to be more health access for everyone, and we all have a responsibility at seeing that that becomes more of a reality and more of a diverse sort of, you know, healthcare administration for, you know, providers. I'm going to piggyback off that, and then we'll take some questions from the audience. I'm hearing a lot about breaking down of boundaries. I think that's a large part of what we're talking about here, be it mentorship, be it community access, and I think increasingly in this day and age, we can use things like social media to kind of further the work that you all have started, Dr. Shields has started, and get that ground level information to patients and their families so they know what they're dealing with. Billy mentioned Richmond, Virginia, where we both live. I've been in practice there about five years, and if you're not familiar with the background, Richmond, of course, was central to, you know, the Confederacy and what have you in the past, so there's a long legacy of kind of racial inequality, and so kind of building up what Dr. Carson's doing up in Harlem, kind of trying to follow that same footprint, or blueprint, rather. We're trying to set a situation where students can come through and mentor, where they can be, you know, get access to the field of sports medicine, and that's a two-way street. That's a double-edged sword, really, so they have more information about injuries they may have, and they have more information what they can achieve in the future. Do we have anything from the audience? I see someone coming into the mic here. Rick Wright, Nashville. So, it's easy to think, well, this disparity in care doesn't, you know, it's not happening in my practice, or it's not happening in our hospital, but we collected 1,234 revision ACLs with MARS, 83 surgeons, 52 sites, and we couldn't do analysis based on race, because there were so few blacks in the cohort. So, this is real, and so that's just a comment, and then I would say, Riley, I think you're right, that we're the people seeing the black athlete in the clinic, and when you're reading Vanderbilt or HSS or wherever you are, when you're reading the applications, there's so many times that the person that's applying in orthopedics was inspired by the physician that took care of them during an injury. So, you've got to lean in and offer that black athlete a chance to shadow, come to the OR, get interested, just like all the other athletes do, and we can make a real difference, because we're seeing these kids. So, I would just challenge everyone in the room to do our part. Thanks, Rick. Hey, I'm Larry Bowman from Clemson. So, y'all stole Gabby back. She came to work and was about to take over all the basketball care and was our shoulder person, and I know she just had a baby, and we went, what's up? Sorry, she's not here, but one of the things that I think we can do, we started a 501c3 to put athletic trainers in the high schools. South Carolina does not have a way of funding the athletic trainers, and so by putting trainers in the schools, they really have a connection and then helps access, too. So, the student athletic trainer system is a great system. Yeah, I definitely agree with you. As we look at the social determinants, access being one of the big issues. I think in regards to Kojo's presentation, it was very clear that there was definitely a falter in the system in regards to access. So, yes, we go to the private schools in New York City. Every single one has an athletic trainer on the sideline. Everyone, there's literally probably more doctors on the sideline than there are players. So, those are the scenarios you deal with, whereas you go to an inner city or a public school athletic league game, there's no doctors, there's no ambulance, there's nobody there. There's no athletic trainers. So, yes, this is something that I think we need to take more of an initiative on. Yeah, Joel Boyd, Minneapolis. So, we can put a pin right in that point for one thing with regard to athletic trainers, and there was a great, great point brought up. I was going to say the same thing, in that there's an opportunity. Obviously, what Clarence has done is awesome, but there's an opportunity not only to increase the number of athletic trainers, but also to increase the number of minority athletic trainers that are involved in inner city schools. And it's every city. It's not just one city. If you just look, it's all the cities. There's no one there. Most athletes, when they get hurt in a city, they go home. They get hurt, they leave the field, and you just don't see them for a while, and nobody knows what happened to them. And so, there needs to be someone there to help guide and mentor them when they have athletic injuries. I know Bill's paper was really good. I wanted to also bring up the economic part of that, and I was wondering if Bill had any aspirations of actually looking at how much, what was the cost in terms of delayed surgeries, or what they had to do. Was it an increased amount of surgery that needed to be done because it was delayed? Because the reality is, I mean, the only way you're going to get any kind of insurer to look at this is if they understand they're paying more because these people are getting their services later. And so, if you can point that out, that would be... I'm right here. Hi, Joel. Hey, Bill. Hi, hey. The answer is we are looking at that, and the expenses are much more significant when you have a multiple dislocated individual needing treatment because the level of surgery of what we're doing typically is more complex. Oftentimes, it can be a surgery that's more of an open surgery, takes much longer. So, if you integrate OR time, it's, again, much more expensive. So, we haven't done anything to publish that yet. That's just at the beginnings of this. The hope is that if we do, that insurers will look at that and understand the importance of us trying to take care of people in a quicker, more appropriate fashion. Excellent discussion, y'all. Really appreciate it. I think we have time for maybe two more questions, and then we need to wrap up. Comment, just not a question. Jim Zakasiewski, Mass. General of Brigham Health Care and Supervisor of Athletic Training Services for Boston Public Schools. So, when you're talking a large urban environment, MGB had an initiative using KSI money, DEI money with Boston Public Schools, where for the last three years, we put athletic trainers into the BPS system for the first time in history. It went over extremely well with the parents, extremely well with the kids and the coaches, and it went from, who are you, an athletic trainer, really? To, why aren't you here at my game? So, it's recognized by the parents. It's helped us move kids through the system and access care with the parents, working with the coaches, working with the nurses that are in the school, working with all of them, and we've got a care coordination team that helps do that. It's a large project, as you said, and I applaud whoever set up the 50C3 to support the ATs in the school. As you know, they are all very hard to find right now, and there's a paucity of athletic trainers, and everybody, at least in the New England area, is scrambling, and you can't find them, and you cannot find athletic trainers that have come from HBCU colleges or elsewhere to find that role model for that student-athlete in a multilingual, multicultural school system like BPS. So, it can be done, but it's a large amount of work, and you've got to be very creative in how to do it. We've set up the equivalent of a group practice, where no one has one high school, and we sit every Monday and look at the calendar for the week and figure out where we're going to be, and then we have to do a lot of communication. So, there are ways to do it, and it's paying its way on dollar delivery down the road, depending upon where the kid goes, and we will send the kid back to their PCP, back to their healthcare institution, if they have a history. If not, obviously, we can get that quickly into the MGB system, and we expedite that referral. Mom or dad doesn't have to wait. They're in within 24, 36, 72 hours, and if they need surgery, they need everything else. That goes through insurance, but we jumpstart the system, which is oftentimes the frustrating point for the parent of not knowing who to call, where to call, why to call, and now they're scheduled six weeks out because of the wait. So, the AT in the school system can jumpstart that for you. All right. Two questions left. Thanks. I'll take that presidential priority. I'm Dean Taylor from Duke University, and I'm the president of the AOSSM, and Eric, to your point, we're listening, and I want to hear some good proposals on how we can move this forward because it's important, and I want to thank you, and I especially want to thank you for helping us learn how we can do this better, and COJO, thanks for organizing it. This has been a fabulous session. I think there's opportunities for us to partner with the STOP program and our affiliation with the National Council on Youth Sports, and I think we can do better, and the AOSSM is committed to that. So, thank you all for this. Thank you. I just have a comment, and I would say that this is outstanding. No one individual has exclusivity. No one provider has exclusivity, regardless of race, gender, sexual orientation, religious affiliation. I'm providing the optimal care, and no athlete has exclusivity. I'm receiving that care, but to think that every athlete in the United States receives it is just not the reality. It's not the reality, and I think that how do we go through this process? I have been honored to be able to work with Joel and with Riley and Eric and Tim and Connie to go through this process, and I think that number one, we have to collectively acknowledge that it exists, and number two, we show in an evidence-based fashion, like we did today with the ADI and the SVI data that shows this is the degree of the disparity, and then we have to work collectively together, and that's at a national, at a regional, at a local level, and to come up with programs, and Eric, you identified it. What Clarence and Dean very well pointed out last night, Barbara Shields have done in L.A., and what you're doing in Harlem, they're templates that we can use going forward, and obviously there will be differences depending upon geographic locations, but using those going forward and having the momentum that a society like AOSSM can provide is really essential, so we have to keep doing this and being brave enough to say that the problem exists and having the fortitude to really come to an optimal solution, so I thank all of you for putting this together. All right. I think that's our time, so a round of applause for our panelists. We appreciate y'all's time. Shout out to Dr. Toth, Allison Toth, for helping us put this together. Thank you all.

Kwadwo Owusu-Akyaw, MD

Eric Carson, MD

Vasilios Moutzouros, MD

Isabel Chalem, BS

Billy McMullen (Guest Speaker)

Riley J. Williams, III, MD

healthcare disparities

African-American athletes

ACL injury

racial biases

delayed diagnosis

low-income patients

community engagement

diversity in healthcare

mentorship

AOSSM initiatives