I guess I'll get started. So Dr. Robert Chase is a revered surgeon, veteran, researcher, educator, archivist, historian and pioneer in the field of hand surgery and plastic and reconstructive surgery. As a longtime member and former president of the ASSH, Dr. Chase's innovative career was the inspiration for the Chase Memorial Library and Museum. The library, which is housed in the ground floor of the ASSH headquarters, was established as a place where history, literature, art and science come together and is dedicated to surgery of the hand and upper limb. The ASSH historian and Chase Library committee members work to document and record important historical events in the society's history. In this past year, the members of the society toiled in the basement to cull the holdings of the ASSH for archival purposes. These holdings consist of audiovisual recordings of the pioneers in the field of hand surgery, artifacts, illustrations, personal letters, brochures, texts and many, many photographs of our members. The mission of this committee is to bring history, art and science of hand surgery to the membership of the ASSH, to provide context for the human side of hand surgery history and to prevent the rich traditions of hand surgery education from being forgotten, erased or to remain unknown to the membership or to the future of hand surgery. To that end, we have some great talks lined up for you by Dan, Seth, Sanu and Amy. These are all inspired by Bill Neumeyer's book, The First 50 Years of the ASSH. We're going to bring some of this history to you today and then hopefully virtually to you for handy in the future. Just a shameless plug, I know we have a giant audience here, but there is an exhibit in the center hall of the lobby on the first floor called the Family Tree. If you haven't already, go out there and put your number in. You can indicate your mentors and your fellowship director and that will help us track the legacy of history of hand surgery. So, with that said, I'm going to bring up Dr. Nagel. Thank you very much. It's wonderful to be here so early in the morning. Okay, so we're ready to go I guess. We're using the mouse, is that what we should do? So, the bottom line is that I'm supposed to talk to you about the founding of the Hand Society from World War II to about 1971. But actually, you don't want to think that hand surgery didn't spring out of nowhere. There was a little history. There was hand surgery in the United States before World War II. For example, there was the Chicago School of Hand Surgery, and I'm obviously biased because I think it's a good one. It was founded in 1901 by Knavel, and you all know about Alan Knavel and Infections of the Hand written in 1912. Sumner Koch and Mike Mason and Harvey Allen were there. And also, there's Sterling Bunnell, of course. We all know about him in the 1930s out in San Francisco. In New York, there was Condit Cutler, Leo Mayer, and Hugh Auchincloss. And in Boston, there was Henry Marvel, and in North Carolina, there was Daryl Hart. So, however, let's move on to World War II. Out of the crucible of World War II, a lot of good things happened. We got penicillin, the flu vaccine, and the ASSH. This is all thanks to the work of Major General Norman T. Kirk, at least his insight as U.S. Army Surgeon General. And he was actually in charge of the Global Military Healthcare System, which is quite a title, I thought. But he had worked with Sterling Bunnell at the Letterman Hospital in San Francisco. And he recognized that Bunnell had a very deep interest in hand surgery and injuries of the upper extremity. So he asked Sterling Bunnell to establish hand surgery services in the nine Army hospitals around the country. And he did this from 1944 to 1947. And to do this, he actually traveled across the country. And what Bill points out in the book, which is interesting, is we think, well, just traveling around the country, that's no big deal, right? You can just get on a plane. No. He had to do this on planes, everything but planes, trains and automobiles. And he'd gone from his practice for a month at a time. And he did that eight times. So we really do owe him a huge debt of gratitude. This is a list of the hospitals. But interesting, this is a list of 10. And I don't know if any of you out in the audience know which one didn't continue on, because I think Letterman did. But you see the chiefs of the hand surgery are all essentially the founders. And here he is making one of his tours to visit one of these hospitals. So the founding occurred in 1946, as many of you know. The first founding meeting was at the Blackstone Hotel in Chicago. That hotel still exists. It's still there. In fact, you can see this picture. This is at the Blackstone Hotel. And that's obviously a modern picture because of the cars you can see down there. And so this is the iconic photo that you've all seen before. This is the dinner. You notice they're all dressed in uniform. Here's Joe Boyes, Sterling Bunnell, and J.W. Littler, and everyone else that actually eventually became a founder. So at that meeting, they elected Sterling Bunnell as president, Sumner Koch as president-elect. And then they did talk about bylaws. They had a constitution. They all signed it. And then they had committees. It's interesting. They thought prosthetics was important, but education was already on their mind. There was the inaugural members-only ASSH meeting, which was held a year later on January 24th in 1947. And this was hosted by the Chicago school that I referred to earlier. That's Mike Mason, Sumner Koch, and Harvey Allen. And so at that point, Sterling Bunnell was the outgoing president. They had 26 of the 35 founding members were there, and they decided they would talk about war experience. And they had a whopping five papers, but they had case presentations back in those days. They actually brought patients in and examined them and talked about them. And there was an open meeting. It was at the Palmer House, and this is actually a current picture of the Palmer House. It hasn't changed. How many of you took your boards at the Palmer House? Yeah, I'm sorry to make you nauseated showing you that picture. Actually, I think that hotel was built, it was supposed to be, after the fire, it was supposed to be fireproof, I think. Anyway, so they had four papers that day, not a big venue. So also during that meeting, though, they talked about journal affiliation. And Tom Stevenson, who is a plastic surgeon, thought that the proceedings of the ASSH should be published with PRS. But Sterling Bunnell said, no, I think it should be with JBJS. And in fact, Sterling stated the following, that hand surgery is primarily an orthopedic specialty. But obviously other people would argue with that. Robert Bodie was commissioned by Dr. Webster to create this logo, which was our logo all the way through the end of the 21st century. So what happened in 1948? Well, this guy, William Shackley at Bell Labs, invented this little device, the bipolar junction transistor, which actually has changed all of our lives and the world, actually. And also William Backman and Howard Scott of CBS created the long play record, 33 RPM. But we in Chicago at the ASSH had a meeting with the AOS, like we did for so many more years in the future, as you know. And this time the outgoing president was Sumner Koch. The scientific meeting was again at Northwestern. Registration fee was a whopping $25. But I did a little math. That was $300 in 2022 dollars. There were 22 members elected. And this is the largest entering class until 1971. And I have a graph to show you a little bit more about that later on. And they had 13 papers that were presented. They talked a little, not really, they didn't talk too much about membership criteria. In fact, this is what they said. You had to be qualified, reputable, a practicing surgeon, active in hand surgery, who had made some worthwhile contributions. Now keep this in mind because you're going to see in the following slides the membership criteria start to crank a little bit. You did have to attend three meetings. That hasn't changed since 1948. They wanted to be exclusive, 75 members. And they created an honorary membership, and we'll come back to that a little bit later on. Annual dues were $5 or $60 in current dollars. And they did discuss the relationship between the ASSH and the ACS Trauma Committee. And that's interesting because 70 years later Scott Levin finally cemented that deal, and he created the ASSH-ACS National Hand Trauma Center Network. So just a little patience and things pay off. The last two presidents of the 40s were Walter Graham and Tom Stevenson. Now I made this little map of the meeting sites. Generally speaking, the meetings were in Chicago. Generally speaking, the meetings were always with the AAUS. But they did occur elsewhere. You'll see in those years the meetings were held in New York, one in Los Angeles, a couple in Miami, and then one in San Francisco. So now I sort of grouped the 1950s together, not going year by year because that would be way too boring. But this is ironic, isn't it? So on June 2, 1953, the queen was coronated, and unfortunately we saw her passing this year. Also back in the 50s, color TV was sold in 1954. We had Sputnik, 1956, and we had Elvis gyrating and making our parents worry for our mental health. And we also had the polio vaccine. So a lot of good things were going on. We had Truman and Ike, and we also had these nine presidents for the Hand Society. I won't bore you with all that, but at least we had photos. I don't have photos of the last three. I tried. I couldn't find them. But here we have the 1957 ASSH meeting in Chicago. Nice, tidy group. In the 1950s, you had 30 minutes per paper with a two-hour lunch, so things were pretty relaxed. Who knows? That's not in his book, so I don't know. But here's the number of papers that were presented over the years up until the 70s. You can see not too many gradually start to increase as you get into the 60s. In the 50s, Mike Mason was appointed ASSH representative of the JBJS editorial board, which is important. Somebody from the society would be on that board until we had our own journal. Membership, they started to get a little more serious about that. They created different membership levels. There was an associate member who was either a former active member who sort of slowed down, didn't want to do as much hand surgery but still wanted to be active in the group. Allied fields, and that still exists in a way, they were not permitted to vote or hold office. Then we had a senior category. You could hold office. You could vote. No dues, and you didn't have to attend all the meetings. And then there were honorary members. Remember, we talked about that previously. And so that was formed in 1948, if you recall. And so 11 years later in 1959, Eric Moberg and Claude Verdain were the first honorary members. So now the 60s, we'll talk a little about a couple of the meetings specifically for the specific years. So this time, instead of having two presidents, we have three, Kennedy, Johnson, and Tricky Dick. And a new wrinkle was introduced by Adrian Flatt. They decided to have a pre-meeting in Iowa, so everybody went off to Iowa City. And then they took the train back to Chicago. The scientific meeting that year was run by Julian Bruner. He was the president. And we had two more honorary members, Guy Polvertaft and Patrick Clarkson, both of the United Kingdom. Also, in 1960, we had a report from the Hand Surgery Training Program Committee. They did a survey that was started in the late 50s because no one knew exactly how many programs were out there. So Posch from Detroit, Littler, and Carroll were on that committee, and they reported that there were 26 orthopedic programs in 1960. There were only four hand surgery fellowships. And the ABOS had actually authorized a six-month hand surgery rotation if you wanted to have one. So let's go forward to 1961. What happened then? Well, Yuri Gagarin was the first man in space. We were a month late with Alan Shepard. And while they were floating around in space, we were floating around in pools in Miami. So our annual meeting was in Miami, and Paul Brand was made an honorary member that year, and he eventually became an active member. And this is a great slide. So Bob McFarlane and Harold Kleiner, both who became presidents of the Hand Society, were rejected by the membership committee. And actually, Bob was actually trained in our office. We'll take a little credit for that from the Chicago school. They increased membership to 100, so they're a little less exclusive than they were before. Now, just a year later, there are now eight fellowship programs, and you'll notice the names, it's all the founding members. And that year, the cash flow through the society was $20,000, a little less than we deal with today. 1963, we'll look at that meeting. That was a tragic year. We lost President Kennedy in Dallas. Our meeting was in Miami, and the membership committee was formally created. It was called the Credentials Committee at that point. And this is sort of a recurring theme. As I said, we worry more and more about who's going to be a part of this august group. The first midyear meeting was held in the Palmer House, and this is an interesting thing because after that, there were midyear meetings all the way through the 90s. I think Graham Lister's meeting may have been the last one. But there was a midyear meeting for members only. 1964, saw the Beatles come to the Ed Sullivan Show. And then continuing on with Adrian Flatt's idea of having a pre-meeting, the Mayo Clinic and Ron Linscheid decided they would have a pre-meeting as well. But that meeting was great scientifically, but then they had the train ride from hell on the way back. They missed their connection at the Winona Junction, and they had to spend the night in the Winona Junction train station until the next train came in. So they had no food, and they got in just early in the morning. They all were able to get dressed and get to the meeting. 76 members showed up at that meeting. Look at this, 1,350 guests. That's pretty good. And 28 papers. Look at that number, 1,350, because this meeting we have, tell me, 2,000 attending. Is that right? So that seems sort of funny. I think those were the numbers. In the same year, 1964, at that meeting, Dr. Seiler proposed the ASSH Memorial Fund, which continues to this day as the American Foundation for Surgery of the Hand. There was a midyear meeting at O'Hare, and that got us through 1964. In 1967, Vietnam was still roaring. And there's a positive note, however. The first heart transplant was carried out by Dr. Christian Bernard in Cape Town. The patient lived for 18 days, but that sort of changed the world as far as heart pathology is concerned. Again, going back to the theme of new membership criteria, this time they're getting more strict. You have to devote 25 to 50 percent of your practice to hand surgery. You have to document your cases. You have to send in a CV. You have to send in your reprints. You have to have formal hand training, and you have to be board certified. So you can see it's becoming a bit more restrictive. And you also have to attend those meetings. That's not really new. That year, Jack Bell, Bill Frackleton, and George Phelan were assigned positions on the American College of Surgery Board of Directors. Also that year, the ASSH and the International Federation of Societies of Surgery of the Hand adopted the classification of congenital differences. And interestingly, the previous year, 1966, the federation was founded at an ASSH meeting in Chicago. That was the year of the first Sterling Bonnell Memorial Lecture, and the lecturer was Sir Herbert Seddon, who eventually became an honorary member. That brings us to 1968. Apollo 8 was circling the moon that year, and while that was happening, we were still worried about membership criteria. Applications were now held for nine months for review. You had to have letters from two members, and Canadians were required to have an American or Royal College of Surgeons certification. And you can see here, there wasn't really a big stress on getting new members in. So you see the first year on the left-hand side, that was the 35 founding members. 1948, we had the 22. And then after, you can see there are gaps in there that were no members at all, new members at all. So the clinical session in 1968 was held again at Northwestern. They talked this time about microsurgery, not about war wounds, prosthetics, and replantation. Tamai had done the first replant in 1965, so this was very modern and up-to-date at that time. And Robert Carroll and Al Swanson started to orient the Hand Society towards international education. And that takes us to the Great Expansion. Thank you. Okay. Good morning, everyone. That was excellent. Thank you. It's good to know that the Palmer House is fireproof, so that all those disgruntled orthopedic surgeons that don't pass can't light it on fire, I guess. Oh, perfect. Perfect. All right, so I'm going to discuss the Great Expansion. I want to thank my fellow who helped me put together these slides, Jane. These are the presidents of the time during the Great Expansion, Curtis Adams, Bell, Enten, Milford, Flatt, Kleiner, McFarland, Omer, Swanson, Bunke, Murray, Smith, Chase, Dobbins, Ashworth, Jabile, Wilgus. A fairly outstanding group of hand surgeons. But as has already been mentioned by Dr. Nagel, there was concerns throughout all of the years up to this point about getting members into the Hand Society and a timely member. As Dr. Nagel was saying, there's a nine-month review for getting into the Hand Society. And so these folks met and decided they needed to make a more drastic change. I'm going to show you a few pictures of members in attendance just so you can get a sense of the size in a pictorial manner. But 1971, not too many members. It's amazing how close they sat to each other. Anyway, so in trying to expand membership, they needed to change some of the rules. They wanted to be less exclusive and more inclusive. And I think they wanted the guests that were there that you mentioned to be part of the society. And still, despite this, very few members are elected to the membership yearly. So they reemphasized this in the membership committee and trying to more formalize the application process. And they started to make progress. You can see here now that's like standing room only in 1973 in Las Vegas. And then in 77, again in Las Vegas. Maybe that's just a popular site. But you can see things have kind of doubled here, which is great to see. No ropes or anything like that also, which is probably good. And then here in 1980 in Atlanta, you can see they've got a much bigger audience and many more in attendance. They're still all kind of jammed in there, which is impressive. We all spread out these days. Another emphasis they thought would be a great idea during this great expansion, which started in 1971, which I thought was great because that's when I was born. So clearly that was part of the great expansion. We can do a bad joke in the morning here. Anyway, they decided they needed more committees to make sure they're addressing all aspects of their mission. And one of them, as mentioned, was also education. And so making sure they had a committee for resident education. They were also interested in fellowship education. At this point in 1983, they had developed a publication, a guide to 36 fellowship programs, so much more than the eight that were previously described. So things have really ramped up here in America regarding hand surgery. And the Hand Society wanted to be on the forefront of that. They also recognized that research support by the society would probably be a really critical aspect of what the society does. And so they wanted to increase that as well. They also made curiously, which is no longer here and maybe we should restore, is an essay committee. It was kind of unclear what the essay committee did, but I think it would be kind of cool to bring back the essay committee and see what our hand surgeons can come up with for a one-page essay or something like that. A little competition maybe, part of the hand meeting. Anyway, the finances are always a problem. These pictures on your right are from this year. Hard to see, but our investments are $29 million this year. So obviously we're doing great now, but back in the 70s, it was in the thousands, if at all. And so they really focused on ways to stimulate their finances. One was more members so they could charge more dues, and then the other was to focus on education and make people pay for things such as the self-assessment exam, which we still do today, exhibitions, other resources, correspondence clubs, these kinds of things. They were interested, and I guess at that time you could get CME credits, but they hadn't completed all the applications for that for the self-assessment exam in the 70s. They also held multiple symposiums, including the mid-year meeting and their own national meeting to help stimulate financial revenue and income. But they still had pretty good money troubles. They were kind of like in this COVID year here for getting revenue rather than up in these higher stacks. So they elevated their dues in 1984 to $300. I don't have the inflationary numbers that we have currently, but I imagine that's probably close to what we're paying. In 1938, their education revenue had increased, but their expenses were at $170,000 rather than the $40,000 that they were gaining in revenue. So they were rapidly losing money and having some real distress. I guess they had a reserve fund and then created an education foundation to protect themselves. They hired a consultant, which in my mind always leads to having less money, but whatever. I don't know how that worked out, but they tried to make their business practices a little better. And one thing they really did was work on our vendors and companies that we work hand-in-hand with. So working on commercial exhibitions to reduce the cost of symposiums and meetings. And you can see, again, in this picture here, we do a wonderful job with that now. This industry revenue is all up in the millions, which is great to help support our education of our Hand Society meeting. So they really succeeded in growth in this period, and they started thinking about some of the principles or the goals or the mission of the society, and they focused on four areas – whoops, sorry – research, quality control, credentialing, and identity. Pretty similar to what we're doing now, but probably we have a little more education bent, but they were still thinking about that. At the time, they were struggling with the identity of the hand surgeon. Is it plastic surgery, orthopedics, or general surgery? And I think that probably led to their goal and mission of simply creating a separate board qualification for surgery of the hand, so that it didn't really matter whether you were plastics or orthopedics or general surgery. If you could get to this board standardization, then you were a hand surgeon, at least in their eyes. They were also getting to the point where, as you saw in the meeting pictures, that they really needed to hire some full-time employees, which obviously helped us tremendously at this time. Despite the financial challenges and membership challenges, I think part of this great expansion period is the fact that they started a number of initiatives which were really outstanding, the first of which that I'm going to talk about is the Bunnell Traveling Fellowship, obviously in honor of Dr. Bunnell and his travels. But this was started in 1981, and looking through this list of people, you can see there are many outstanding members, even some in this room, who did this. And I think this fellowship, even to this day, is really a pride of the Hand Society, and I think it's a fantastic thing that they started and developed and persisted with. Sometimes you come up with these kinds of ideas and they don't persist, so they should be congratulated for it. They also focused on research, and that's certainly continued to this day, and you can see here in this simple chart the research grants given through the Society and the formulation of the ASFH really expanded here in the 90s, but they were really making progress also through the 70s and maintaining it in the 80s, which is important. A next major pillar that they managed to develop is the Journal of Hand Surgery. The first issue was published in July of 1976, with a cover that looks much different from ours currently. This was actually extremely successful over time, and is now British Journal of Hand Surgery with European input as well. Even the Journal of Hand Surgery at that time was publishing papers internationally. The journal, when it first started, had about 3,000 in circulation and doubled within a decade, which is fantastic, to 7,000 hand surgeons interested in reading a compendium of hand surgery every month, which is just impressive. The first editor was Joseph Boyds, and he was editor for, I think, about eight or nine years, and then Adrian Flatt became editor after him. The next thing that they did during this great expansion that was a big step in the progress of the Society was separate themselves from the AAOS. I think many of their meetings were held in conjunction with the AAOS meeting, meaning maybe the day before. They felt like they were still in the shadow of the AAOS. Although they were working closely with them at the time, they wanted some independence. The last conjunction meeting, I guess, was in 1986, and the Society, in severing from the Academy, had an initial drop in membership, which quickly rebounded, which is encouraging. Since then, the Society has been on its own. Again, adding more commercial exhibitions to their annual meetings has helped a lot with their revenue. In summary, the many achievements that they've made during this great expansion, not only increasing their membership and expanding their membership, but doing some of these foundational initiatives, I think, have really propelled the Hand Society forward. Obviously, our journal fellowship and resident education programs have been outstanding. Even the self-assessment exam, we were kind of a leader in self-assessment examinations at the time. Also, the traveling fellowship has been fantastic. They were on the verge. I don't actually know which year the CAQ came out, but they were on the verge of developing it as well. Thank you. That's the Great Expansion. There you go. Perfect preamble. While we wait for this to load up, let's see here. There we go. Perfect. Well, good morning, everyone. Thanks for being here. This is a nice talk we have on the history of the CAQ. I think it's very interesting. I think talking about how a test has come into being is not necessarily the most exciting thing, but actually, there's a lot of back story to this. There's a lot of conflict. It's very interesting to know how everything came about. How did specialization come out? At the turn of the century, we had this urbanization, improved communication, transportation. With the rise of all these specialty hospitals, the medical market widened. There's a lot of people who could treat a lot of different things. Then the AMA came about, and its origins were general medicine, general incentive organization in 1846. By the end of the century, you had 18 specialty paper sections, meaning that it was already getting sub-specialized into 18 different sections within about 50 years. What came about of all that is that experience of different practitioners demonstrated the value of specialization. You had these increased opportunities, and you had increased competition. After the turn of the century, you had the First World War. It showed that you needed specialization, especially with trench warfare. A lot of this is based on Dr. George Ulmer's historical recollection of all of the events of this. He had the medical specialty definition defined as an area of medical practice which connotes a special knowledge and ability resulting from specialized practice and training in the specialized field. He is distinct to being both an ASSH president as well as the president of the American Board of Orthopedic Surgery. It comes down to the why. The traumatic injuries and the Second World War and reconstructive surgery of the hand was important. We learned about the origins of the ASSH itself. The crux of the educational effort of the society has been to create a program of CME for all physicians interested in the care of the hand and upper extremity. That's one of the major missions of what was brought about. The postgraduate fellowships developed because a large number of the general orthopedic and plastic surgeons desired training, specialty training, after completing their residency to improve their knowledge and capabilities in hand surgery. In 1970, the ASSH identified 56 special training programs for hand surgery in the United States and Canada, but there was no standardization. During that decade, committees were developed to study the educational experience of these fellowships, including creating guidelines, credentials, and on-site evaluations. This began the formal certification process. In 1971, there was this discussion of how to create a formal certification for hand surgery. The Surgical Council approached the ASSH of the American Board of Medical Specialties, inquiring about the possibility of a board in hand surgery, perhaps supported by the three societies in a tripartite way, American Board of Surgery, American Board of Orthopedic Surgery, and American Board of Plastic Surgery. The ASSH took this and approached the three boards, and they said no, we're not interested. So then George Omer, who was the ASSH president in 1970, contacted the Liaison Committee for Graduate Medical Education at the time, which was the predecessor to the ACGME, and wanted some guidance on how to do it. So the three boards eventually agreed that recognition of hand surgery was desirable, but then they came to the point, well, how do we do this now? So then Omer presented the CAQ to the American Board of Surgery in 1980, and with Richard Smith he did so to the American Board of Orthopedic Surgery in 81, and both of them, Dr. Smith and Dr. Omer, along with William Graham, to the American Board of Plastic Surgery in 81. So they initially created this ad hoc committee on surgery of the hand. They held their first meeting, and they decided, you know, this doesn't need to be ad hoc anymore. We need to make this a permanent standing committee to move forward with this. So this is interesting. So this is kind of taking some of the information we got from the archives of our Chase Library, and the correspondence, the behind-the-scenes work was interesting. So this is a letter from Dr. Humphreys, who is the executive director of the American Board of Surgery, and I'll read the first few lines here. You know, dear Dr. Smith, thank you for your letter of April 21st and reprint of your article on sub-certification for hand surgery. I have read it very carefully, and I can certainly find nothing in it that I could criticize. While I am certain that a number of people will disagree with your approach to the subject of fragmentation, restriction of privileges, and costs, I believe you are correct. I do not speak for the American Board of Surgery, but I personally believe that it is far better to recognize special qualifications in those subspecialties which have truly matured, and that to try to pretend that they do not exist. So this is kind of the behind-the-scenes. So then, you know, Richard Smith, who got this, sent this to, you know, forwarded this to George Omer, said, Dear George, I thought you'd be interested in seeing this letter from J.D. Humphreys. It looks like we may have a friend. So, you know, there's a lot of this that was going on, so this was not very easy. So the joint committee had, of Surgery of the Hand, had three representatives from the American Board of Surgery, Orthopaedic Surgery and Plastic Surgery, and two representatives from the Hand Society and Hand Association, and they created a directory of, you know, training programs to sort of help guide this. And so the task force was chaired by, you know, Richard Smith to create an application process. The American Board of Medical Specialties approved, and then the CAQ was to reflect additional training, but no less than one year. The exam was ready to start in 1989. So then came this whole grandfather clause. So there was a period of time where you would There was a period of time for about five years that you would be able to be grandfathered in, but they also wanted this to be a time-limited certification, such that when you have this, you'd have to recertify. And this will be a little bit of an issue later on, which I'll get to. And then the American Board of Surgery examination, it was selected by the American Board of Medical Specialties to provide the examination, and there were process goals that were needed so that they could meet standards for eligibility and evaluate cognitive knowledge. So then these committees, these exams were to be, you know, developed and administered with the same standards as your primary board certification, so there should be no less. And so there's this joint task force between both the Association and the Hand Society, chaired by Graham Lister, to have a role delineation study. And like in any process of committees, you need subcommittees, because now the work is becoming great. And so you had committee examinations with Jim Urbanik and Bruce Williams, both from, one from orthopedics, one from plastery, committee on eligibility with Michael Javoli, and then the committee on certification administered by Dr. Chase. And you can see their photos there. So hold on. So now things are going pretty smoothly right now? Not so. So the American Board of Plastic Surgery was concerned that it should not be involved in the hand CAQ, since 25 percent of plastic surgery is hand surgery, and setting the minimum standards would be difficult. The American Board of Surgery was concerned that it should not be involved, since less than 10 percent of the ABS diplomats might qualify. The American Board of Orthopedic Surgery was firmly committed to going forward with this. And they would, and they basically said that, you know, we're concerned that if, you know, if there were separate qualifying requirements, there wouldn't be equivalency. So the AHS had a study which they showed that 53 percent of orthopedic surgeons felt the CAQ was not needed. And their, the leadership within the Hand Association that year and the president-elect opposed it. The ASSH had a different survey which showed that 73 percent of membership supported the CAQ, with 72 percent of those respondents being orthopedic surgeons. So there's a little bit of back and forth here. So the, this goes back to the time-limited aspect of it, because this was not, this was supposed to be for 10 years, but it was not necessarily agreed upon by the American Board of Plastic Surgery, because their primary board was not time-limited. And so when Ermanek started to create the curriculum for this, it was 165 questions, and then Jabalay's committee created a profile for the number of cases. So you had, you had a, you had committees that created the questions, and then you had a committee that created the minimum cases. And then, so Shel Wilgus, who was president of the Hand Society at the time, had strong support for the CAQ. The association president, Ed Strum's proposal to the American Board of Medical Specialties was not acted upon. So, at this time, the American Board of Plastic Surgery withdrew from the joint committee. And at this time, the American Board of Orthopedic Surgery president, Omer, said the American Board of Orthopedic Surgery would withdraw from the joint committee and examine, and administer its own exam unless either or, the surgery board or the plastic surgery board remain in this. And then the American Board of Surgery voted to remain, and the AHS votes to stay associated with the committee. But the committee later, the committee members later exclude both the ASSH and AHS from having representatives. So they wanted to keep it more board represented, to not have society members to keep it more toward curriculum and development there. So, the American Board of Plastic Surgery put a motion forward to reject approval in 1989 of the CAQ, but that was rejected by the American Board of Medical Specialties. And so, therefore, the first exam was administered in 89 in Indianapolis. You can see the numbers here, about 81% orthopedic surgeons, about 20% general surgeons. And you need about two thirds to correct a pass, and the overall failure was not fairly high. And the American Board of Plastic Surgery rejoins later that month. So, let's see here. In 89, they felt the requirements should be altered, based on the first exam, due to the tertiary nature of the certificate. So I think they realized, you know, we need to make this a little more rigorous. So the caseload was increased from 125 to 150, and they wanted to limit common cases like carpal tunnel, trigger finger, ganglions, and fractures above the wrist, which would sort of make it more true hand and not just sort of, you know, doing basic stuff that you may be doing in your general practice. And the American Board of Orthopedic Surgery accepted both. The ABPS rejected both. And the American Board of Surgery rejected the increased cases, but was okay with the limitations. So, the problem is, the boards, so this is, the way I'd sort of liken this, this is almost like a legislative body, and each one of these boards are like almost different political parties. And you're basically having, and these representatives to this joint committee are their delegates, that they are, and you have to basically go with the party line. And so even though the delegates were in this committee to sort of come up with a plan, they were not to deviate from the marching orders from the board. So you're sort of locked in that position. So, any case, in 1990, 307 examinees, and then this time we had a huge number of class surgeons because they didn't take it the first time around. Passing scores of 65% that you needed to move forward. And going back to what I was talking about, the unlimited and limited certificates, the American Board of Plastic Surgery issued unlimited certificates such that if you had the CAQ, you, that was a lifetime certificate. The American Board of, sorry, Medical Specialties confirmed that it has to be time limited. And so then the American Board of Plastic Surgery told their delegates that, you know, we need to develop a more inclusive and less exclusive criteria for credentialing plastic surgery candidates for the CAQ in hand. And I think the, you know, and I don't think there's a good way or a bad way, but the way my perspective on this is I think you sort of, as a board, you're looking out for your membership. If a lot of hand surgery is being done by your membership already, then moving to this would not necessarily be in the interest of your membership per se. So I think they felt that this wasn't benefiting them. Whereas in orthopedic surgery, the folks that were doing hand surgery were sub-specialized and doing more exclusively hand. Whereas I think a lot of general plastic surgeons were doing some hand as part of their practice. So different, different, different, you know, methods. And so the application statement was developed by the joint committee that they want to identify surgeons with special education and experience, increase potential to meet the economic and social needs of patients, stimulate research and surgery of the hand. And so this is also a little interesting, you know, background. So, you know, when we talk about the grandfathering, this is a letter to the editor by Dr. Nguyen, who is a plastic surgeon at University of Arkansas, to the editor. And then it was in a reply by Dr. Omer. He was complaining that he missed his grandfathering by one year because he has, you know, with his training of five years of general surgery, three years of plastic surgery, you know, he missed that window. But that he, during those three years of plastic surgery, he spent six months at Kleiner as part of his training and he did a lot of hand surgical cases. And so this was not inherently fair that, you know, I missed it by one year. And then in the reply by George Omer, he said, you know, a lot of this is created jointly, but there is a clause that you can petition your own primary board to see if you can have an exception for that. But you can see that there's a lot of back and forth here. It wasn't a very smooth, smooth transition. But I think in any type of, you know, creation of anything like this, it's always going to be a little rough waters. So the first five years, pass rate was overall 82%. If you had a formal fellowship, 92% of them passed. If you didn't have fellowship, 65% passed. So you can see the difference. If you had a full hand practice, 97% pass rate. If you had a practice with less than 25% hand, your pass rate was 56%. So, and I think the overall pass rate at this time, during these first five years, the American Board of Orthopedic Surgery Diplomats, 96%, Board of Surgery Diplomats, 72%, and Board of Plastic Surgery, 63%. And I think the way this is being thought about is not reflection of the primary discipline, but more related to your practice. So I think a lot of the people who are taking this in the Board of Surgery and the Board of Plastic Surgery, we're not doing exclusive upper extremity practices, whereas in orthopedic surgery, it was being done that way. So I think that's what you're seeing here. And so, you know, CAQ, so it's all of medicine, is basically redefining its primary boundaries and with special certificates. And, you know, an example is allergy immunology was a certificate of special qualification medicine back in 36 and repeats in 44, but it became its own primary board in 72. So history demonstrates that these certificates will influence and continue to define future primary boards. And a lot of this is from Ormer's and the personal archives from the Chase Library. So thank you. Thank you. Can I make a quick comment? Yes. Excellent, excellent talk. Yes, I did not. He was, he was, he was just fighting. It was like, back and forth. I think he just kept going back and forth. It was amazing. It's in the season. It's not my work. So I, I, I'm the only guy in the room that actually was there. So to that end, so I'm Amy Ladd, and we have our committee here, our historian and Chase Library committee, and many of our members are here, so this is an easy talk for me. But it's great, this reflection. So I took it in 92, and I was trained under Dick Burton, who was president of the Hand Society at the time, and George Omer was good friends. It might have been, Frank Wilson was in there as ABOS president. They were all kind of in the mix, and that was probably his biggest headache at the Hand Society was the CAQ, and how mandated and important it was, and I was a little upset because I didn't get grandfathered in. Did you get grandfathered? No. No. But were your orthopedic boards, were you grandfathered? Or no? No, I didn't. No, you were on the cusp as well. So there was this whole cadre that, oh, I got in, I got in, and we were eligible. So I'm going to talk a little bit about the Chase Library and its origins, and really, you guys have really spoken to much of it, so hopefully we can have a few moments of discussion. So I'm going to start out with a formal mission statement, and Brent gave kind of the big vision of what we're intended to do, but our goal is to preserve, collect, and exhibit an enduring repository of artifacts, documents, and media related to the history of the specialty of hand surgery and the SSH, and you've seen much of the rich history here over the last few minutes. So this arose, so 822 Washington, has everybody been to the headquarters? Has anybody not been to the headquarters? So this was part of the great rift from, you know, you heard about leaving the Academy for the annual meeting, and the headquarters were in multiple places. They were in San Francisco, and then they were in Denver, and then they moved to Chicago, and then they partnered with the Academy at their building in Rosemont, and, you know, with the concept of, well, it is a subspecialty, and it's the first CAQ in the surgical specialties that it's, you know, it's its own home, and Dan Nagel and a few others were really critical to this, and Peter Weiss ultimately found the building that's 822 Washington, and along that was, you know, having your own home and what you could say about history. So a few of us got together and said, well, we need a library to continue this library that turns out has been in different places for years, and I have to say it was a bit of a challenge. I was presenting remotely. It was probably the first remote presentation I've ever done, and counsel was there, and so I have no idea what was going on in the counsel room, but I proposed this library and to create a physical and multimedia resource library at the new headquarters to honor the person I came to Stanford for, Bob Chase, as well as his trainee, Rod Hintz, and as you've heard, an innovative educator, surgeon, archivist, historian, and visionary, and he was indeed the president from 83 to 84. By the way, I was in medical school at this time, and Andy Palmer was my mentor in medical school, and I got to attend the first international meeting, which was in Boston here, and looking back, so Andy was the Bonnell Fellow the next year, so there was a lot of crucible stuff going on at that time when Dick Smith was the president. Well, so there was actually some assets or a library a long time ago, and people like Chase, who was always interested in history, and he was, you know, parallel presidents with Dick Smith, who was here in Boston. They decided that they could have a library, and it was kind of going to travel with each of the presidents, but ultimately, they thought the appropriate home was at the Bonnell Library, Bonnell in San Francisco, where Bonnell practiced, and interestingly, he was a professor of surgery at Stanford because the medical school was up in San Francisco at the time, so the Brown Tolan Building, the hospital, became this place to collect some of these items. A lot of them were donated by Bonnell and by Chase and other people with interest in hand surgery. Well, the Hand Society moved to Denver, so the assets went there, some of them. Some of them stayed with Bonnell Library and are there to this day. I'll tell you that in a minute. And then others, for reasons I'm not totally clear, went to the Curtis Hand Center, and I think maybe because Shaw Wilgus was president, so it was kind of this partitioning of things that, you know, to be honest, only history buffs really wanted, like Bonnell's bag or, you know, something from a sign amputation guy, you know, a lot of archival things from the Civil War. Now the thing about the Bonnell Library, which I'm going to tell you in a second, so there are presents for Hand Library, so the Bonnell Library. So I visited it multiple times before this building was turned into condominiums a few years ago, and to be honest, it's a bunch of photographs and, you know, at the top floor you have to get a key and there's a lot of probably junk in there, but it's a history homage. But now it's somewhere in a shelf in some other new wing near the baseball stadium, which is really sad, because we tried to get some of these, which we thought were Hand Society assets back, but be that as it may, they're gathering dust somewhere. So then there's the Littler Library, which was Littler's collection in New York City, but is now housed in the New York Public Library in a special room, which you also have to get a key for, which is like, oh, couldn't we have this? And it's still something for us to think about. There are other private collections. Many people have things. I've already been to the Mütter Museum in Philadelphia, kind of like Ripley's Believe It or Not, pretty wild. And then, oops, going the other way. So other libraries, and so because of Bob Chase, I've actually visited a lot of them, a couple on my Bunnell Fellowship. The Edinburgh Royal College of Surgeons, which houses many of Sir Charles Bell's items and paintings and drawings and other things. The Hunterian Museum, so the Hunter brothers were great philanthropists, and there's a T-Rex in Glasgow that sits on the lawn and survives all the harsh Scottish weather, if you will. The Anatomical Waxworks, and Dr. Chase and I have photographed several of these in 3D or in stereoscopy. This is in Bologna, but there's collections in Florence, Bologna, Vienna, and I visited recently the last one, which is probably the best, which is in Sardinia in the University of Cagliari. And if you ever, the history buffs, anatomy buffs, these collections are unbelievable. They were sculptures done in the early 1800s, and the vividness of the colors of things like lymph nodes and lymphatics that you can't really even see when you dissect them, but these artists were so skilled. Anyway, so precedents for doing some sort of collection. And let me tell you a little bit about Bob Chase. He turns 100 this upcoming January, which is pretty cool. He's still alert. He visited us a little while ago. He met Bill Littler when he was stationed at Valley Forge, and one of those itinerant hand centers like Norman Kirk had set up, and Bill Littler was a civilian. Bob was in the Army, and great anatomists, as you know, as we've heard. His great mentor was Bill Littler, and it's not by happenstance that Bill Littler was a gifted artist and that he attributes Leonardo da Vinci as the person that taught him most about the emotion and connection and the anatomy. So da Vinci was, it was, you could be excommunicated for dissecting cadavers at that time, but the Jesuits in Florence allowed him to dissect, and it's one of the reasons why there's such an emotive quality to da Vinci's paintings and drawings. Not one of us can escape hand surgery without knowing about the Fibonacci sequence and the beautiful drawings that Littler did and professed. But he also hearkened to Sir Charles Bell as the real founder of hand surgery as we think of it. I have our residents and fellows read the Bridgewater Treatise every year. It's now on PDF freely available, but it's a wonderful little book written in the early 1800s, and it actually became somewhat seminal to Charles Darwin because of his natural history approach to comparative anatomy and evolution. Interestingly the Bridgewater Treatises were commissioned by, I think it was George III perhaps, and it was to extol the virtue of God in man, and Bell took what was in front of him. He did this kind of spiritual thing about thought and vision and the senses and how evocative the hand was in actuating those of the senses. Back to the Chase Library, we were actually able to raise almost half a million dollars in less than two weeks, and that's really an homage to Chase and his vision, and hopefully what we think of hand surgeons of retaining the past and its importance, and also through a generous gift of Stanford. So the ribbon cutting at the building, let's see it was bought what, like September of 2010, and so 2011 was the proposal, and the ribbon cutting for the building was at the annual meeting September 2012, and here's Dr. Chase cutting the ribbon, and with Adrian Flats, some of his archival things from being in the Royal Air Force in World War II. We do have, one of our tasks is having exhibits at the annual meeting. We've been a little bit, you know, laid back if not existent for the last two years for obvious reasons, but we've had a show, a 3D show that Dr. Chase put on in 2014. One of our members, Leo Kiyoshin, who's a great collector of art, had exhibited several of his art pieces in 2015 along with other memorabilia. I particularly love the hands in the middle of the photograph, it's a Man Ray photograph. And now, was this Bunnell's dissecting kit? Was this the one, yeah, that we had 2015, yeah, we were talking about, what were these things, and like, oh that's nice. It's part of this, that's nice, what do we do with this, what's the meaning, but it just harkened to what was part of a doctor's bag one time ago. The second part of our mission statement is that we are an educational resource for our members, and that, here's the hard pole, is maintain relevance and utility in the advancing age of archival technology. I think many members think that everything can be digitized, that's good enough, but to have and touch and feel and to really understand and to pour through archives is its own treasure and we are tasked with, you know, vitalizing that. And as Brent alluded to, in last year, I think most of our first big trips during COVID, it was appropriate that we knew how to mask up because there was a lot of dust down in the basement. Going through, it was like going through your grandmother's garage after she passes, there was a lot of junk, and kind of the wheat from the chaff, but we still are tasked to figure out what to archive, what to bring forth, how to digitize it, how to display it. So just a few projects, the presidential interviews that Roy Meals did before Dan Nagel, Dan Nagel took on the lion's share and Sanu is finishing that up with, yeah, now has the lion's share and fortunately they're skilled videographers and interviewers and have a few of the living presidents of a certain age yet to complete. And in homage to the presidents, I need to give a shout out to Mary Beth Izzaki, the only woman president until now, Jennifer Wolf. And we've partnered with members Lindley Wall and Nikki Schroeder with podcasts of these early giants, much of which you've heard of today, which will be released shortly after the meeting. Well, the family tree, as Brent mentioned, this is probably our next big venture for the next few years is really put the footprint of who we are and why we are connected. So please do fill this out and it will be tied to Dew's membership every year, so hopefully we'll develop a database. So this was just, you know, the skeleton of my own connection, so Chase trained with Littler and Littler's great partner was Dick Eaton. They trained Dick Burton, who was my orthopedic chair. They also trained Rod Hentz, who was my partner and hired me. Raul Tubiana trained Barry Simmons, who was my fellowship director. And I counted up last night since I started the fellowship in 91 at Stanford, we've trained, these included 57 hand fellows. So that diaspora, if we think of all the mentors that you've had, I didn't mention Andy Palmer. He's the person that got me into hand surgery first year of medical school, scrubbing with him. You know, the permutative mentors are going to be extraordinary and I can't wait to see what those cluster maps bring forth. Well, an aspirational goal is exactly that, to mean relevance and utility in this advancing age, but we've never had better tools to do so. So thank you and thanks for coming this morning and now we have a few minutes for discussion among ourselves. So, thanks.

American Society for Surgery of the Hand

Chase Memorial Library and Museum

history of hand surgery

hand surgery education

preserving traditions

Hand Society

history of hand surgery talks

exhibitions on hand surgery history

Chase Library origins

importance of archival resources