( 1998 ASHT INVITATIONAL LECTURE J

Looking to the Past for the Future

John W. Madden, MD Director, Tucson Hand Surgery, Ltd. Tucson Arizona; Clinical Professor of Orthopedics University of New Mexico Albuquerque, New Mexico

G ood morning, everybody. It is early in the morning, and I am glad you came. I really

want to thank Judy Bell for inviting me. It is a great, great honor to be here. I feel it a privilege to be given this podium. Actually, I might consider it a pulpit, although it is 8 o'clock in the morning!

I am pleased to address you this morning, be­cause I am worried about you. I have known many of you all your professional lives. Watching you grow and become my teachers has been one of the greatest joys of my life. At this point in history, however, I am very worried about you. I am not sure your profession is going to remain viable in the new climate of American medicine, and I think the solutions to your current problems may be in the past. What I would like to do today is review a little history for you, and see if solutions to our current dilemmas are in the past.

Hand surgery as a specialty that originated during the Second World War. If you are interested in the history of this endeavor, there is a wonderful book, edited by Sterling Bunnell, describing hand surgical efforts during that war. * The book was pub­lished in 1954. The war had ended almost ten years before that. A great many of the things in this book are comments in retrospect, and of course retro­spectoscopes are always more accurate than bin­oculars! This volume does, however, describe the process of the formation of the specialty beautifully.

At the beginning of the Second World War, Colonel Condict W. Cutler, Jr., Surgical Consultant of the First Service Command, and Dr. Bunnell,

This paper is a slightly edited version of the Invitational Lecture presented at the 21st Annual Meeting of the American Society of Hand Therapists on September 18, 1998, in New Orleans, Louisiana.

Correspondence and reprint requests to John W. Madden, MD, Academy Medical Center, Suite 302, 310 North Wilmot Road, Tucson, AZ 85711.

"Bunnell S (ed). Hand Surgery. Washington, DC: Office of the Surgeon General, Department of the Army, 1955.

special civilian consultant to the Secretary of War, recognized immediately that 75% or 80% of the in­juries being seen initially were extremity injuries. They also recognized immediately that the hand in­juries were really different from injuries to other parts of the body. They convinced Norman T. Kirk, Surgeon General of the United States, to establish nine separate hand centers in the United States. These were hospitals and facilities where people who had upper extremity injuries could be treated when they were sent home from the war zone. The units were set up in hospitals where all the recog­nized surgical specialties were represented. The units themselves were usually wards in larger hos­pitals, staffed by junior officers. Consultants in or­thopedics, neurosurgery, plastic surgery, etc., would come to these units, evaluate the injured soldiers, and make plans for care with the junior officers, who would assist in their surgical procedures and continue their ward care. This organization really concentrated the experience in hand injury man­agement.

Because of the numbers of injuries, the medical personnel in these units had an opportunity to learn enormous amounts about how to care for fractures, how to re-establish bone integrity, how to manage soft-tissue problems, how to test the dogma of the day, and how to develop new and exciting ways to manage specific problems. Unfor­tunately, very little true reconstructive hand sur­gery could be accomplished. These injured soldiers were brought back to the United States after a rel­atively long delay. When a soldier was injured in Europe, it could take two or three months to get him back to the United States and begin this spe­cialized care. As the medical staffs of these centers learned, the secondary changes that occurred as a result of immobility, abnormal positioning, etc., made specialized care much more difficult. Every­one associated with these units felt that the earlier the patients could be seen, the better the results would be.

January-March 2000 19

The most important thing that came out of this effort was the training of the junior officers, the ones who really were doing the day-to-day care of injured soldiers. The attending surgeons had an op­portunity to polish their skills in neurosurgery, orthopedics, plastic surgery, etc., but the junior of­ficers were exposed to all these specialties inten­sively. Although there were some pioneer special­ists in upper extremity reconstruction prior to the Second World War-including Dr. Bunnell and Drs. Deryl Hart, Henry Marble, Hugh Auchincloss, Leo Mayer, Sumner Koch, Michael Mason, Vilray P. Blair, Walter Graham, William Frackelton, and Lott Howard, among others-the junior officers on these wards were the ones who became America's second- and third-generation experts. They learned by personal experience that you cannot reconstruct hands by committee!

The junior officers on these specialized units were the ones who really developed the expertise in long-term planning. Dr. William Littler is prob­ably the most famous example. Dr. Littler came into the armed services after an internship in general surgery at Johns Hopkins. He had been accepted for a neurosurgical residency but was taken into the armed services at that point. He was taken ill and actually became a patient at the Cushing General Hospital. As he was recovering, he began making anatomical drawings for his pleasure and for the doctors at the center. Dr. Cutler saw some of Dr. Littler's beautiful drawings, and Dr. Littler was reassigned to the Cushing General Hospital, when he recovered, to document some of the surgical pro­cedures that were being performed.

The real advances in long-term upper extrem­ity reconstructive planning started during the Ko­rean War. When the Second World War began, the medical corps was small and composed of career army personnel. As the war effort got started, people were drafted and volunteered quickly. The doctors who were recruited, of course, came from private practice. They were pediatricians, gen­eral practitioners, obstetricians, and allergists who found themselves manning frontline evacuation stations, really serving as surgeons. Their individ­ual skills as surgeons were frequently learned on the job! The difference between the Second World War and the Korean War was that, between them, the draft was still in effect. A great number of phy­sicians and paramedical people were actually in school, deferred from being drafted because of their studies. All were eligible for military service but were continuing their education. When the Korean War started, this large pool of highly trained spe­cialists were available for duty almost immediately. Many of the surgeons manning the M.A.s.H. units in Korea had been residents in surgery practicing in civilian hospitals 48 to 72 hours before they were in Korea! These personnel were highly trained and very skilled. Those of you who are familiar with the original movie M.ASH. are aware that the book from which that movie was taken was actu­ally based on the Korean War. As you will remem-

20 JOURNAL OF HAND THERAPY

ber, Hawkeye was a resident a couple of hours be­fore he ended up in that M.A.S.H. unit! Rather than having physicians who were trained in other spe­cialties taking care of triage and acutely injured sol­diers, we had specialists, expert in triage and expert in acute-care, making decisions.

In addition, another difference between the Second World War and the Korean War was the evacuation schedules. Injured soldiers were seen quickly by experts, and if they needed further care they could be evacuated quickly. Because of the specialized nature of hand problems, the Depart­ment of Defense reopened one of the original Sec­ond World War hand centers in Valley Forge, Penn­sylvania. Patients with injuries that were deemed to involve principally upper extremities were sent immediately to Valley Forge. Suddenly, hundreds of healthy men with severe upper extremity injuries began appearing in Pennsylvania within 48 or 72 hours after they had been injured halfway around the world. Several physicians that I have talked to about this experience described removing "Korean dirt" from wounds in Pennsylvania less than 48 hours after the original injury.

By the beginning of the Korean conflict, Dr. Lit­tler had gone back into civilian life. He became a resident in general surgery. In 1949, he became a resident in plastic surgery at Columbia University in New York. They had arranged his schedule, however, so that he could go to the Roosevelt Hos­pital a couple of days a week and continue his up­per extremity reconstructive work.

ErIe E. Peacock, Jr., a North Carolina native, was graduating from Harvard Medical School at that point and was looking for an internship. He obtained an internship at the Roosevelt Hospital. Early in the internship, Erle was looking over Bill Littler's shoulder and really became fascinated by what he saw. Erle traded his days off and arranged to help Bill when he was doing his private surgical cases. ErIe became so fascinated by hand surgery that he wanted to continue this interest clinically.

When the Korean War conflict started, Dr. Pea­cock, who had been an enlisted man in the Navy at the end of the Second World War, volunteered to join the Army again. He felt that if he could be assigned to the Valley Forge Hospital, he could ob­tain an invaluable experience with traumatic hand injuries. Dr. Peacock was assigned to the Valley Forge Hospital.

Dr. Littler was not certified by any American board at that point and, as I understand it, could not be appointed as a consultant for the effort at Valley Forge. Unofficially, Erle and Bill consulted over the telephone, and then Bill began coming to Valley Forge on weekends, evaluating the cases that Erle was seeing, designing reconstructive pro­grams, and even, I am told, helping with the sur­gical procedures. This interval, from 1950 through 1952, marks the next step in the development of modern reconstructive hand surgery.

During the Second World War, because of the multiple specialties involved in upper extremity care, it was difficult for any single person to visu-

alize the final results. These two young surgeons­Dr. Littler was, I believe, 37 and Dr. Peacock was 26-passionately involved in upper extremity re­construction, suddenly were presented with hun­dreds and hundreds of healthy young men who had catastrophic injuries. There were 48 beds in the Valley Forge Hospital and 150 places in a holding company. For the first time, experts in all the spe­cialties associated with upper extremity reconstruc­tion could look at the initial injuries and plan staged upper extremity reconstructions over what could be months or years, and the philosophy of modern reconstructive hand surgery was born. The wonderful techniques of handling soft tissue, bone, nerve, tendon, and joint that had been developed during the Second World War could be focused on individual problems with a single team. Dogma from the past could be tested, and new procedures or variations developed. The details of pedicle flaps, including the very first pollicizations of index fingers as neurovascular island pedicle transfers, nerve grafting, joint protection techniques-all of the things you take for granted-were tested and developed during this period. Essentially, all the surgical techniques now used in modern recon­structive hand surgery, with the exception of free tissue transfers, were polished during this interval.

Although it would be rational to assume that hand therapy, so vital in modern hand reconstruc­tion, developed hand in hand with this intense two­year effort, nothing could be further from the truth. All of you who have not read Judy Bell's Nathalie Barr Lecture, which was published in the Journal of Hand Therapy in March 1989, need to read it! That little book I introduced you to, describing the his­tory of hand surgery during the Second World War, does not have much to say about hand therapy. Hand therapy was discouraged by the surgeons during the Second World War. Sterling Bunnell makes a statement in the book that might shock you, in fact. He said hand therapy was a waste of time! He observed that patients were always better if they were sent home on leave for six months than if they stayed in the rehabilitation centers and worked with the ward staff! Splints were used for muscle substitution, but there were effectively no splints for therapy. The rehabilitation units were designed for paraplegic and tetraplegic patients, not for those with extremity injuries. Again, during the Korean conflict, hand therapy was seldom men­tioned, let alone practiced. These injured soldiers were young, they were evacuated immediately and were under the care of experts within 48 or 72 hours from the time of their injuries. Stiff joints, tendon-gliding problems, and the common second­ary problems you and I see every day were simply not there. The surgical staff worked on fresh inju­ries, and because of their expertise, secondary prob­lems were avoided.

In 1952, although the efforts at Valley Forge continued, Dr. Littler went back to his private prac­tice and Dr. Peacock went back to getting an edu­cation! Erle went back to Chapel Hill, North Caro-

lina, became a general surgeon, and then went to St. Louis, where he became a plastic surgeon, al­ways interested in upper extremity problems. After completing his residency in St. Louis, he joined the faculty at the University of North Carolina's med­ical school. When he went back to Chapel Hill, he started a private practice in hand surgery. The op­portunities for reconstruction, however, were en­tirely different than they had been in Valley Forge. If he could see acute problems, then the same kind of excellent results could be expected, but the pa­tients he began seeing did not have acute injuries. What he was seeing in Chapel Hill reminded him of the Second World War experience. Most of these injured people had been treated elsewhere for months. When the treatment plans went awry, some of them were sent to Chapel Hill. What he saw were stiff joints, tendons that did not glide, and neglected soft-tissue injuries with contracted ele­ments, making reconstruction impossible.

By 1959, Erle had concluded that he might never have an opportunity to continue his recon­structive efforts. Chance and fate played a great role. If Erle Peacock is the father of hand therapy in the United States, then Paul Brand is certainly our godfather. Again I urge you to read Judy Bell's Nathalie Barr lecture. Paul Brand had been working in the south of India for years, teaching medicine and practicing orthopedics, particularly among pa­tients with leprosy. Dr. Brand had developed new techniques to replace paralyzed intrinsic muscula­ture and new methods of restoring sensation. In 1959, Dr. Brand was invited to Pittsburgh, Penn­sylvania, by Dr. Willie White to share his informa­tion with a small group of invited participants. Dr. White invited ErIe Peacock to this meeting. Dr. Brand and Dr. Peacock met but did not spend much time together. Erle was terribly impressed by what Paul presented and by his description of the New Life Center in Vellore. In January 1961, Paul Brand was invited by Dan Riordon, another great friend and teacher of many of you, to come to the Amer­ican Society for Surgery of the Hand meeting in Chicago. Erle also attended and had the opportu­nity to spend an afternoon with Paul, who invited him to visit his unit in India. Erle obtained a small federal grant and spent four months with Paul. This visit really changed hand therapy in America.

I will tell you just one story that Dr. Peacock has told me many times, and I am sure is as accu­rate as he can remember it! The second day Dr. Pea­cock was in VeIl ore, one of Dr. Brand's assistants brought a patient to Dr. Peacock. The patient had classical median and ulnar nerve paralysis. Dr. Pea­cock observed that the metacarpophalangeal joints had only a few degrees of motion, and the proximal interphalangeal joints were fixed in 90° of flexion. Dr. Peacock's comments were to the effect that it would be wonderful if they had been able to see this patient earlier: These joints would never move again, but if they did, there would be a variety of things that could be done. Dr. Brand's assistant smiled at him and left. One month later, Dr. Brand's

January-March 2000 21

assistant brought the patient back to see Dr. Pea­cock, again, and the patient demonstrated fully mobile passive and active motion of the metacar­pophalangeal and interphalangeal joints of all fin­gers! Using the mobilization techniques developed by Dr. Brand and his colleagues (gentle passive stretching, serial casting, and patience!), tissues could be remodeled and brought back into rea­sonable position. Patience and slowness were, of course, the keys. Any of you who have heard Dr. Brand discuss these problems knows what empha­sis he put on patience and slowness! He has always stressed not stirring up inflammatory problems by injuring tissues using too vigorous approaches. To Dr. Peacock, this was really a revelation.

Erle Peacock came back from India determined to try to put these techniques to use. Again, chance played a critical role. Dr. Howard Rusk invited Dr. Peacock to come to New York City to give a talk at the Rehabilitation Center at New York University. Dr. Peacock talked about his experiences in Vellore and demonstrated some of Dr. Brand's techniques. Dr. Rusk, who also happened to be the medical ed­itor of The New York Times, was impressed enough to write an editorial in The Times about this work. Mary Switzer, who was the head of the Federal Di­vision of Vocational Rehabilitation, read the article. Two years before this, in 1960, Ms. Switzer had been given the Lasker Award. The other Lasker Award winner that year was Paul Brand. Ms. Swit­zer and Dr. Brand had spent time together when they were receiving this award, and Ms. Switzer was very impressed by Dr. Brand's experience. Af­ter The New York Times article appeared, Dr. Rush arranged a meeting between Mr. Switzer and Dr. Peacock. Less than a week later, a grant to establish the first hand rehabilitation unit in the United States was given to Dr. Peacock by the Division of Vocational Rehabilitation, to be used to establish a unit in Chapel Hill, North Carolina.

The grant monies were used to rent a small house in Chapel Hill. The bottom floor of this small building was turned into an occupational and physical therapy department, and the top floors were dormitories for male patients. Female patients were housed in the community. Erle began recruit­ing staff, and again fortune played a key role.

Irene Hollis had been working as a field rep­resentative for the American Occupational Therapy Association. She was finishing her tour in that po­sition. She had been inspecting occupational ther­apy schools and had decided to take a year off. She was looking for a job at that point. Dr. Peacock had placed an ad in an occupational therapy journal, and because Ms. Hollis was free at just this time, she accepted the job. Ms. Hollis, who is 81 years old and still lives in Chapel Hill, has been an enor­mous influence on all of us. Many of you owe your interest in upper extremities directly to Irene's teachings.

The next appointment was George Hamilton, as the chief of the physical therapy unit. Mr. Ham­ilton, in addition to being a physical therapist, had

22 JOURNAL OF HAND THERAPY

a master's degree in physiology. Ms. Gloria DeVore joined the staff in 1966.

Surgeons were recruited from the resident and surgical staff at the University of North Carolina. Most of their names are very familiar to you. Dr. Paul Weeks was the first surgeon associated with this unit. Dr. Joseph Eades, from St Louis, was a significant member of the early staff. I joined the program in 1965 and became the medical director of the hand rehabilitation unit in 1966.

We also had, associated with the clinical activ­ities, a very large laboratory program. Dr. Peacock and I were able to get an NIH grant to continue some of our biological work. We were able to hire biochemists, get some monies for our basic science work, and begin looking at tendon-gliding and joint problems from a laboratory point of view. That laboratory ultimately ended up being one of the two or three largest connective tissue research lab­oratories in the world. The laboratory ran for about 20 years and attempted to teach us the biological basis for what we are doing.

The next important element in this mix was students! The hand unit was used as a place of ed­ucation for students of all varieties. There were medical students, physical therapy students, psy­chology students, and residents in orthopedics, plastic surgery, general surgery and even, occasion­ally, ear, nose, and throat! The final element was patients, and these patients were unique as well. As noted, most of the local care for hand problems occurred elsewhere. The patients who found their way to this unit had been out of work for years, had problem5 that had been operated on or seen in consultation many times, and had been given up for lost. The patients were the library from which we all learned.

The educational activities of the hand rehabil­itation unit involved mixing all these elements. For four hours every Wednesday, every individual as­sociated with this unit met with the others-all students, all therapists, all patients, biochemists, psychologists, kinesiologists, and just interested on­lookers. We talked about every patient, everyone of their specific problems that we could define, and asked as many questions as possible. The interest these talks generated spilled out into all our activ­ities. During the four or five years I worked in Chapel Hill, I never sat in an operating room, op­erating on a hand, without a therapist looking over my shoulder. I never looked at a patient or exam­ined a patient in the clinic without a biochemist asking me why I was doing that! Splint makers, biochemists, and engineers arguing over how a pa­tient's hand manipulated the environment was ex­citing stuff!

Dr. Peacock had selected the people involved in this effort not only for their expertise but also for another important factor. Everyone associated with the original unit was there because they had a will­ingness to be open-minded; a willingness to give up their preconceptions, if necessary; a willingness to discuss things, to defend things, to debate ideas,

and, most important, to argue! Finally, all the staff had a willingness to prove that their ideas were correct or, even better, that another idea was wrong, using the scientific method. Everyone had projects going. From 1964 through 1969, we had psychology graduate students getting master's degrees and PhD students trying to work out methodology to answer our biological questions. During this inter­val, we actually gave four master's degrees and parts of two PhD degrees in nonmedical depart­ments! By 1967, we did not have answers to prob­lems, but we had at least some idea of what the questions were!

We worked on some fundamental questions first. We tried hard to make it possible to do repro­ducible measurements of power, range of motion, and functional achievement. Accurate measure­ments and accurate numbers, of course, are the key to all objective studies. We needed accurate end­points. By 1967, we had developed techniques that reproduced measurements of range of motion, vol­ume, and strength. We had developed, through Irene's constant efforts, cheap and effective thera­peutic splints. To my knowledge, this was one of the first times that people worried about splints as therapy rather than worrying about splints as sub­stitutes for minor imbalances or paralysis. Con­trolled studies were set up to find out whether spe­cific protocols were effective or not. Irene Hollis was not only working on specific protocols with the unit but had initiated field follow-ups. She wanted to make sure that the results we achieved in the unit were sustained in normal living. Gloria DeVore was working on developing functional diaries as a way of evaluating activities of daily living and at­tempting to analyze the specific psychological and anatomical abnormalities.

At this point, Ms. Hollis decided that we needed to share this information. The first meeting devoted to hand therapy was held in 1967, and many of the founders of your organization were there in Chapel Hill with us. We had visits by Jim Hunter, Evelyn Mackin, and Bob Beasley. These in­dividuals, of course, took this tiny, tiny flame from Chapel Hill and built huge bonfires in Philadelphia and New York! The laboratory and surgery units were very successful at this point, so successful that we all trucked on to Arizona and started a new adventure. That was a different chapter in our lives.

Now, why the lecture on history? When we started all this effort on Chapel Hill, we had some very specific goals. Have we met these goals? Orig­inally, we wanted to develop measurement tech­niques and correlate these techniques with func­tional outcomes. Were we measuring things that actually made a difference? Could we combine the techniques of occupational and physical therapy to make coordinated programs? Could we work with each other effectively, setting specific clinical goals for individuals and then determining whether our techniques were effective using scientific method­ology? We were attempting to focus the informa­tion about basic science, biology, engineering, bio-

chemistry, pharmacology, and genetics to develop therapy programs that really worked. Now, after 36 years, have we achieved these goals? Although we certainly have not solved the problems, we have come a long way, and we have an enormous amount of hard information now about the effec­tiveness of what we do. The efforts continue, and I am very proud of those of you who are continuing these studies. Watching members of this society be­come clinical scientists and teachers has filled me with joy. Members of this society have produced major advances in basic hand biology and engi­neering. You have contributed to everyone's life. You have become my teachers, and the goal of every educator is to have your students become your teachers. I thank you from the bottom of my heart.

Having said that, however, I am not sure that these achievements are enough to keep your spe­cialty viable! Economic considerations are currently the key, and I am going to share some material that may shock you. The hand center's budget for the first year was $850.00! This included room and board for resident patients and all staff salaries! The first time I showed these figures to a therapist, her comment was "How did you make any money?" The answer, of course, was that we didn't. Every single person associated with this endeavor was simply an interested bystander. We were making our livings doing other jobs, with the exception of the small paid staff, and we entered this endeavor because of our fascination with the problems. We were all volunteering our time.

The second thing that shocks people is that, even with these costs as low as they were, we could not support patients coming to our unit, and of course patients were our library, our life's blood. In 1963, we started a campaign in North Carolina to get support for our patients. The Chairman of the Board of Trustees of the University of North Caro­lina, Mr. Watts Hill, arranged meetings with our local business people, with insurance companies, with Blue Cross, and with Blue Shield, and the sur­prising thing is that we could get essentially no support from any of these agencies. The only group that supported patients in our unit was the North Carolina Division of Vocational Rehabilitation. I think the reasons were straightforward. Those of you who remember the great days of DVR will re­member that DVR was charged with taking people who were out of work and getting them back to work. They could supply education, tools, and medical treatment, if necessary, but the goal was to get nonworking people back to work. About three years into our efforts, the North Carolina DVR be­gan looking up some figures. The patients who had gone through the hand rehabilitation unit were go­ing back to work. Seventy-five percent of the pa­tients with open files at DVR who were sent to our unit actually went back to work. Some of these peo­ple had been out of work for ten years, and all of them had been out for an average of 18 months. The DVR in North Carolina was so impressed by

January-March 2000 23

that, that they wanted to support our unit. They could not provide monies, it was not a budgetary possibility, but instead they gave us a full-time DVR counselor to use in any capacity we could.

I begin recruiting for this position, and fortune again played a great role. Mr. Nelson Parker was working as a field counselor for DVR in West Vir­ginia. He had a master's degree in psychology. I recruited him to come work with us full time as a DVR counselor. In addition, he became the business manager of the hand unit. As Mr. Parker began tak­ing over these duties, he did the things that most DVR counselors do. He began collecting social and economic data from all the DVR patients and, as an extension, from all the patients associated with the unit. These data showed that about three quarters of all the people who went through our unit went back to work doing full-time jobs, at the same rate of payor better than they had prior to their injuries. Permanent physical impairment ratings were de­creased by more than 50%, and that was only among the chronic patients. Of the patients whom we saw acutely following their injuries, 90% went back to work doing productive jobs.

In 1969 and 1970, the units began to break up and move elsewhere. Many of us went to the Uni­versity of Arizona. Again, chance played a role. When Jim Hunter and Evelyn Mackin decided to have the first therapy meeting in Philadelphia, in 1971, they kindly asked me to come and talk about some of my laboratory work. In addition, however, they asked me to bring a small movie that we had made about the hand rehabilitation unit in Chapel Hill. The movie contained a lot of the financial in­formation that I just gave you. The fact that we were getting so many people back to work, and to productive work, impressed the next speaker on the program, George T. Welch. Mr. Welch was an executive with the Insurance Company of North America. After the meeting, Mr. Welch cornered me over a cup of coffee and talked about the economic data I had presented. From that point on, our lives changed. For the first time, a national insurance company began supporting patients for specialized care in hand rehabilitation. Mr. Welch convinced his company that spending extra monies on these patients with their specific problems would be an economic advantage in the long run, and he was exactly right!

Now back to your current problems. When we began this adventure in 1962, we had in the back of our minds the great American dream: If you build a better mousetrap, people will beat a path to your door! The fact is that people did not beat a path to our door. That happened by chance in Phil­adelphia. Now that we are in the era of managed

24 JOURNAL OF HAND THERAPY

care, when the bottom line turns out to be the key figure, everyone has lost sight of the economic ad­vantages of expert care. If you look at the criteria that managed care programs use to select field peo­ple, leadership and excellence in your field are not high on their list. The real criterion is how to do it inexpensively. Cheap is the key word. You and I know that these are very shortsighted goals, and in the long run, society profits economically from your efforts. Unfortunately, the data to prove this are difficult to come by. Unless hand therapy proves that what it does really works-not only by increasing ranges of motion, power, personal grat­ification, and satisfaction but also economically­you are going to be shut out of this endeavor. Prov­ing that your protocols and management programs make a biological difference is not enough. That is all we were interested in 40 years ago, but unless you prove that what you do is an economically vi­able enterprise, you are gong to become extinct. Those of you who have been doing this for a long time need to look at your current hand surgeons to see this developing. Hand surgery in the United States is now being done by more and more people who have inadequate training, and although some of them have boards, you are not impressed by what they do! You need to prove that what you do is biologically effective, but in addition to that you need to prove that what you do is effective econom­ically.

As I was preparing this speech, someone showed me Elaine Fess's letter from the American Hand Therapy Foundation.t Again, coincidence is wonderful. Those of you who have not read that letter need to read it. What Elaine says is exactly the point I have been trying to make. Hand thera­pists need to get together and find some way of proving that what you do works scientifically and economically. You need to start cooperative studies. You need to start volunteering your time, sharing budgets and sharing patients throughout your net­working, to create controlled scientific studies that will prove your value. You certainly will not get paid for this endeavor, but your daughters and sons may! Volunteer your time; more important, volun­teer your patients for these studies. If you do prove that what you do works biologically and econom­ically, you will be around for another hundred years. If not, it certainly has been a pleasure know­ing you.

Again, many thanks for the pulpit. This is very early in the morning for a sermon, and I am glad that you sat through it.

tLetter of Aug 26, 1999, available from AHTF, PO Box 512, Zionsville, IN 46077.