Fifty Years of Innovation in Orthopedics
A lot can happen in 50 years. Organizational restructuring, new leaders, scientific advancement, and changes to medical care have been rapid and continuous at the University of Minnesota in the last half-century. The Department of Orthopedic Surgery has persevered, adapting and innovating to better serve patients and the state of Minnesota. While orthopedic surgery at the University has a history that spans more than a century, the department itself was established 50 years ago in 1969. Through the leadership of John Moe, MD, first department chair, the University of Minnesota Department of Orthopedic Surgery became an independent department within the Medical School. Prior to 1969, the department was a division in the Department of Surgery, as were many other specialties that are now independent. Moe, a renowned spine surgeon, helped establish the department as a leader in developing safe instrumentation for spine surgery. His legacy put the department on the map, and made the U the epicenter of spinal surgery and research.
After Moe’s retirement in 1972, James House, MD, was appointed interim department chair and served until 1974. “That transition time is certainly vivid in my mind,” he recalls. New department Chair Roby Thompson Jr., MD, came to Minnesota in 1974 with the objective of improving resident education through community partnerships. While observing the example of universities in Toronto, Thompson was impressed with how they had organized their community hospitals into an educational consortium with components of resident education delegated to each individual hospital. One of the things that attracted him to Minnesota was that there was only one medical school, which is unique for a metropolitan area as large as the Twin Cities. This would mean no educational conflicts at affiliated sites. “During the first year I was there, I attempted to partner with community hospitals, and I had great reception and support from all the hospital division leaders,” Thompson said. “In 1975, we created a curriculum for orthopedic residency training with educational objectives for each rotation.”
At the time, division leaders included Robert (Bud) Premer, MD, at the Veterans Affairs Medical Center (VA), Donald Lannin, MD, at Shriners, Wayne Thompson, MD, at Gillette Children’s Specialty Healthcare, Ramon Gustilo, MD, at what was then Minneapolis General Hospital and is now Hennepin County Medical Center (HCMC), and Thomas Comfort, MD, at what was then St. Paul-Ramsey Medical Center, now Regions. “Fortunately, it worked out very well, primarily because we had such great people running the hospital programs throughout the Twin Cities,” Thompson said. “Everyone recognized that this was an excellent opportunity to make a better program.”
Subspecialization Emerges
Another objective emerged for Thompson in the seventies: the trend towards subspecialization. While the program had strong leadership in pediatrics, trauma, spine, and hand, Thompson recognized that there were gaps in educational disciplines. For example, there were no leaders for programs in sports medicine or adult reconstructive surgery, which he chose to focus on developing. “We were doing occasional arthroscopies, but sports medicine was really open surgery in the seventies, and while most orthopedic surgeons could do some of it, we didn’t know enough about it as a discipline at that time,” he said. “Expansion of surgical disciplines and the development of specialization led to a good educational program.”
Thompson accomplished this by recruiting outstanding faculty. With the addition of Robert Hunter, MD, in 1981, it became evident that sports medicine was emerging as a critical subspecialty. “When I first came here, there were only a handful of sports medicine physicians using the arthroscope,” recalls Elizabeth Arendt, MD, professor and department vice chair. “The early sports medicine orthopedists really led the way in transforming the arthroscope from being a purely diagnostic tool, to becoming a tool to do surgical techniques inside the knee.”
Although the spine program was already well established, it expanded substantially throughout the seventies. Starting with four spine surgeons, David Bradford, MD, John Lonstein, MD, John Moe, MD, and Robert Winter, MD, it grew into a big program over the course of 20 years. Spine was not the only subspecialty that emerged. Lowell Lutter, MD, brought the foot and ankle subspecialty to the U. In addition, although House specialized in hand surgery, he traveled to England in 1970 to observe John Charnley, MD, who performed the first total hip in the world. He brought what he learned from Charnley back to Minnesota and did the first cemented total hip and knee replacements at the University.
Keep in mind, 1974 was the beginning of the joint replacement era. While a number of faculty, such as House, had a different subspecialty, they began performing joint replacements out of necessity. Thompson hired Harry Robinson, MD, who was fellowship trained in total joint replacement to further promote subspecialization in this emerging field. Ramon Gustilo, MD, also entered the joint replacement sphere during this time. He was chair of orthopedics at HCMC from 1968-1990 and is considered a pioneer in trauma as a subspecialty, having founded the Orthopaedic Trauma Association. Apart from being at the frontier of the joint replacement era, House led a rapidly expanding hand program, which included Matthew Putnam, MD, in 1995, and Ann Van Heest, MD, in 1993. Under their leadership, hand surgery also expanded at Gillette in the care of congenital and developmental disorders, cerebral palsy, and spinal cord injury.
“With an expanded faculty, there was better subspecialty education,” said James Ogilvie, MD, interim department chair from 1995-1997. “When I was a resident, you learned what your professor was good at. Now, there’s a broad spectrum of high-quality subspecialists in the department.”
Community Partnerships Enhance Resident Education
Strong community partnerships are a hallmark of the department and make the residency program well rounded. It is widely recognized that graduates from the U of M Department of Orthopedic Surgery are equipped with the knowledge and skills needed to provide excellent care on their first day in practice. “I think one of the beauties of this program is that if you want to go out and practice as a general orthopedic surgeon, you can walk out the day after you graduate and you’ll be prepared to do that competently,” said Terence Gioe, MD, chair of orthopedics at the VA from 2009-2015. One of the longest standing relationships has been with HCMC. Although residents began rotating there in the early sixties, real transformations in resident education took place when Gustilo became chair of orthopedics in 1968. Gustilo recalls that at that time, residents had no supervision at the Minneapolis General Hospital and frequently took care of patients independently, as there were no paid orthopedic surgeons. Gustilo, recruited by Moe, knew firsthand the lack of structure because of his experiences rotating at HCMC as a resident.
“Once, there was a patient in need of an emergency laminectomy for severe back and leg pain,” Gustilo recalls. “I couldn’t get a consultant to help me, so I decided to bring the patient to surgery in the middle of the night. I had never performed one alone. The patient did well, but at the time I said to myself: ‘If I ever become head of this department, this will never happen to a second-year resident again.’” Gustilo carried out this resolution during his tenure and improved the quality of resident education at the site exponentially. He hired his own orthopedic staff, mentored three to four residents at a time, and made daily patient rounds and weekly conferences an expectation. Given his experience performing an emergency laminectomy, Gustilo’s rule was that no surgery would be performed without a senior physician present or involved in the decision making. As a result, he helped residents perform emergency surgeries in the middle of the night on countless occasions.
“Very early on, there really wasn’t sufficient staff at nighttime, and you were pretty much on your own,” said Richard Kyle, MD, chair of orthopedics at HCMC from 1990-2014. “Now, thanks to the leadership of Dr. Gustilo and many others, the residents are always supervised, there is always someone available day and night, and the teaching is much more effective.” HCMC was not the only institution that had developed a more organized and consistent educational experience.
“The University of Minnesota Department of Orthopedic Surgery became much more organized under Thompson,” Gustilo recalls. “This improved teaching, supervision, and organized weekly conferences. The residency program was on the upswing, and we had many more applicants.” Prior to 1988, there were two orthopedic residency programs in the Twin Cities, one at the University of Minnesota, and one at the VA. Thanks to the strong relationship between Bud Premer and Thompson, the programs merged that year.
“It was advantageous for both programs,” said Gioe, who completed his orthopedic residency at the VA. “Traditionally, the VA was a very strong program, and it was known as a program where you had a lot of autonomy and got to do a lot of procedures. For residents, that’s very appealing.” After the merger, residents at the University had the added benefit of a much broader and deeper operative experience as they spent more time at the VA, HCMC, and St. Paul-Ramsey Medical Center. The VA residents, on the other hand, were exposed to a greater variety of musculoskeletal tumors, spine, and pediatrics. To this day, the VA provides an excellent opportunity for residents to have more responsibility and to gain exposure to adult reconstructive surgeries. House noted that in the seventies and eighties, residents typically consulted with a faculty member and performed the surgery independently. Today, the VA schedules supervisors very carefully while providing ample opportunity for residents to do handson surgery.
“Because of the large volume of arthroplasties being conducted at that site, combining programs meant that we practically trained all of the orthopedic surgeons in the upper Midwest to do total joints,” said Marc Swiontkowski, MD, department chair from 1997-2007. While 1988 brought about a combined and enhanced residency program, St. Paul-Ramsey Medical Center lost most of its educational faculty. As a result, the hospital became increasingly service based. Thompson decided to suspend resident rotations until educational faculty could be recruited, which would take several years. Gillette is a cornerstone in the pediatric orthopedic residency experience, and is noted for its focus on academics. James Gage, MD, completed his orthopedic surgery residency at the VA and joined the staff at Newington Children’s Hospital in Connecticut after graduation. While he was there, he convinced United Technologies Research Center (UTRC) to build a computer-automated motion analysis laboratory. Steven Koop, MD, medical director of Gillette from 2001-2018, was Gage’s fellow in 1983-1984. When Koop returned home to Minnesota and became a full-time orthopedist at Gillette, he worked with Gage to talk UTRC into building a second lab in Minnesota.
Because Koop knew the advantages of gait analysis in the treatment of cerebral palsy, he single-handedly did much of the fundraising to build the lab. The James R. Gage Center for Gait and Motion Analysis opened in 1987 and was the most advanced in the world. Gage was recruited to be Gillette’s medical director in 1990 and served in that role through 2000. “We’ve changed the way cerebral palsy is treated,” Gage said. “Before the gait lab, it was very hard, particularly when we started to do multiple things at once, to see what was correct and incorrect in the surgery. That’s how I got into gait analysis in the first place.” Gillette is one of the preeminent complex pediatric orthopedic programs, and attracts national and international patients. “I recall very well being at Gillette and having patients come from all over the world,” Gioe said. “You would have patients who had traveled from Brazil with a 160-degree curve and were having their scoliosis operation done. It has had a tremendous impact all over the world.”
The department has had a unique town-and-gown experience between the University and community healthcare systems. “There were many surgeons who were previously in private practice that contributed significantly to the teaching program,” said Gioe, who himself came from private practice. “The connection between the community and University teaching faculty was always strong.”
Revolutions in Research
Orthopedics as a specialty has experienced monumental changes in care delivery, largely due to dedicated research aimed at improving the lives of patients affected by orthopedic conditions. Initially, the Department of Orthopedic Surgery focused on basic science research, but with time evolved to focus on patient outcomes research across all subspecialties. “On the world stage, we would be recognized for our enormous success and contributions in spine surgery, our history of seminal contributions in trauma surgery, and we would be recognized internationally in the realm of injuries in the female athlete,” said Denis Clohisy, MD, department chair. The residency program gained a robust focus on basic science research under Thompson, who received his first National Institutes of Health (NIH) grant in 1980. During that time, Jack Lewis, PhD, and Ted Oegema, PhD, were hired as primary researchers, and Thompson invested in basic science labs.
“One of my basic research interests during that time was understanding why articular cartilage failed and developed arthritic joints,” Thompson explained. Thompson’s laboratory won an NIH Specialized Center of Research in Osteoarthritis Award that funded research progress for six years. In addition, Thompson, Oegema, and Lewis all had individual NIH grants that were supporting research at that time. Gustilo also recruited Joan Bechtold, PhD, in 1984, to serve as the director of the HCMC Biomechanics Lab that was established in 1979. Over the years, Bechtold collaborated with the University of Minnesota researchers, and has been supported by the department as the vice chair of research since 2014. “When I started, there was a really strong basic science focus,” she recalls. “Lewis had incredible work examining ligaments in the knee, and Oegema did strong work with cartilage. Their research was internationally known and helped put us on the map.”
Collaboration remains a crucial aspect of orthopedic research in the Twin Cities, and scientists have actively worked together for decades. “One of our strengths is our partnerships,” Bechtold said. “It opens up a lot of opportunities because one person can’t be an expert in everything. The educational impact of this is that residents have opportunities to work with experts from a variety of fields.” Biomechanics had an increasing influence on orthopedics, because implants used in the sixties and seventies would sometimes break. “During my residency I probably worked with 10-11 different designs of total knee and hip, many of which are no longer on the market,” Arendt recalls. The era of modern total joints started in the mid-eighties, thanks to continuous quality improvements made in conjunction with biomechanists. “I realized early on that to advance joint replacement, we had to have a biomechanics laboratory with engineers and clinicians working together,” Gustilo said.
To achieve this vision, Gustilo independently raised money to found the HCMC Orthopedic Biomechanics Laboratory, where he conducted the first clinical research study on open fractures, published in 1974 and 1984. This study still provides the standard classification and treatment of open fractures across the world. “When we started as orthopedic surgeons, there wasn’t even a classification system for fractures,” Kyle recalls. “The classification system has been a huge advancement, because now we understand how to treat the fractures based off of what is proven to work. It has been a giant step forward and has made a huge difference in my career over the last 35 years.” Apart from this seminal work, Gustilo co-developed the Genesis TKA with James Rand, MD, of the Mayo Clinic, a total shoulder replacement, the fibular screw, the BIAS ingrowth system hip prosthesis in partnership with Kyle (the first FDA-approved hip for cementless use), and the flexible acetabular plate. “Another thing that has evolved as a major advancement in trauma has been the development of new implants that allow us to fix unstable fractures,” Kyle said. “Because of sophisticated new implants, patients can get out of the hospital two days after a fracture, whereas when I started this would have taken two to three months. We have to thank the engineers and surgeons partnering to develop these implants and improve care for patients.” Kyle’s fellowship in biomechanics led him to develop the first hip and fracture repair system made of titanium. He also developed an interlocking nailing system for the treatment of long bone fractures as well as multiple total joint implants for the hip and knee. He holds 16 patents.
At the VA, Gioe encouraged and mentored resident research. He was instrumental in creating a community-based total joint registry at HealthEast in St. Paul, which proved to be a rich database for residents to use. In fact, the database is one of the founding pilot registries of the American Joint Replacement Registry. During his time as chair of orthopedics at the VA, 28 of his 76 publications had a resident or fellow co-author, and often, the resident would be listed as the primary author. “One of the things that I am proudest of as an educator is that there was a period of about ten years in a row where a resident doing a research project with me won the Gustilo Award for Best Scientific Paper,” Gioe said. By 1990, the Department of Orthopedic Surgery received the highest level of external grant funding of any orthopedic surgery department at a public university, and the fifth highest overall. “We had some of the leading work on the basic understanding of why people develop osteoarthritis and why articular cartilage fails in the joints,” Thompson said. “We had a lot of external funding for a small department like ours, but it was all around understanding joint failure and osteoarthritis.”
Arendt’s research related to better understanding how orthopedic conditions impact males and females has gained international recognition. In 2018, Arendt became the first woman from a surgical specialty to receive a plaque on the Medical School’s Wall of Scholarship for having more than 1,000 citations of her paper “Knee Injury Patterns Among Men and Women in Collegiate Basketball and Soccer.” She is also the first from the department to receive this honor. “She’s an international expert and is highly sought out for her contributions,” Bechtold added.
Changes in Orthopedics
In the mid-eighties, more women began pursuing medical degrees. Thompson sought to attract the best and brightest students regardless of sex, favoring skills and motivation. “My reaction was that we should have people who were bright, interested, and wanted to be orthopedic surgeons,” Thompson said. “Secondarily, it became obvious that we were going to miss a lot of great students if we didn’t have an attractive program for females. One of the keys to that is having faculty that are women, that students can relate to.” In 1978, the department accepted its first female resident, Jean Eelma, MD, into the program. Shortly thereafter, in 1985, the department gained its first female faculty member, Elizabeth Arendt, MD. “Thompson sought out qualified women,” Ogilvie noted. “I think he was proactive and I never perceived that he was giving women an advantage, he was just giving them an equal footing.” Arendt similarly recalls Thompson’s allegiance to fairness, and was even offered a position in the U of M residency program prior to joining the faculty. “I really did not have warm reception when I interviewed at other residencies across the nation,” Arendt said. “In fact, the only warm interview that I had was with Roby Thompson.” Arendt has been an instrumental leader, serving as the vice chair of the department since 2003, and as a professor since 2006.
When Thompson retired in 1995, Ogilvie stepped in as interim department chair. Typically, a department chair commits to roughly a decade of service, which Ogilvie preferred not to pursue. Still, he was not a passive caretaker and actively worked to maintain the vitality of the department. “I felt the responsibility to educate well trained, ethical surgeons very acutely,” he said. Marc Swiontkowski, MD, was appointed department chair in 1997, a time that was fraught with uncertainty. This was because the same year, Fairview Health Services purchased the University of Minnesota Medical Center. “I was recruited with the idea that we needed a place that had high volumes of patients with common orthopedic problems, which you don’t see in the university environment,” Swiontkowski explained. Typically, patients who are seen in a university hospital have complex, severe, or unique problems that require specialized care. Swiontkowski recognized that it was vital for residents to be exposed to more common orthopedic procedures to have a well-rounded education. That’s when the concept of TRIA Orthopedic Center was born.
Swiontkowski, along with six private practice community collaborators, worked from 1998 to 2003 to find a partner and get the doors open at TRIA. Ultimately, the TRIA team was able to convince the CEO of Park Nicollet that it was a worthy risk to take. “I started it with the primary goal of improving student education and doing clinical outcomes research,” he said. “Our residents were graduating with less arthroscopic experience, and nowadays they are exceptional when they leave.” Swiontkowski and his team also ensured that along with TRIA’s dedication to clinical care, unparalleled resident education laboratories were established. The TRIA skills lab does not have a research focus, rather, its sole purpose is for skills assessment and teaching. “There’s no other place in the healthcare system that’s going to fund a space like that, which is solely dedicated to furthering the surgical skills of residents and trained orthopedic surgeons,” Swiontkowski explained. “That was a very expensive investment, which was a major advancement for this community.”
In 1997, HealthPartners purchased St. Paul-Ramsey Medical Center and renamed it Regions. Within two years, Swiontkowski was appointed chair of orthopedics at Regions, with the intention of recruiting faculty interested in academics and education. He interviewed and hosted 11 potential candidates spanning a three-year period to take over as chair of orthopedics at Regions. “He needed someone willing to come to an environment in which there was no education program in orthopedics, no residents, no students, and no fellows,” said Peter Cole, MD, professor and chair of orthopedics at Regions. Cole was the only surgeon willing to take on the challenge, and shortly after, in 2002, rotations resumed at Regions. Seventeen years later, Regions has six orthopedic fellows and has become a primary teaching site for the department’s residents. “A lot has changed in 17 years, and it goes to show what can be done with strong department chairs who have worked faithfully to grow opportunities and find resources between our two great organizations: HealthPartners and the University of Minnesota,” Cole added.
Expansion into additional sites had other advantages. In 1999, Swiontkowski asked Ann Van Heest, MD, to step into the role of residency program director. “One of my first initiatives was to expand the residency from six to eight residents per year,” Van Heest said. “One of the ways that we got authorization to increase the complement of our residency program was that we opened TRIA Orthopedic Center and re-established ourselves at Regions.” The addition of both rotation sites and resident positions was highly attractive for medical students looking for diverse subspecialty training. Research was also undergoing a transformational period, as Swiontkowski opted to focus on clinical outcomes research. This, of course, reflected the advances made in basic scientific research in the previous decades.
“Research is incremental — whether it’s Dr. Clohisy’s research around pathologic fractures in patients with metastatic disease, or the research we did with carpal tunnel syndrome that showed you don’t need electromyograms for a diagnosis, or simplifying rehabilitation protocols after distal radius or ankle fractures — the department has been at the forefront of focusing on patient-related functional outcomes across the board,” Swiontkowski said. With the addition of Clohisy in 1991, the tumor program became a leading center of research for childhood and adult cancers. Contrary to the commonly held belief that cancerous tumors ate at the bone, his research found that osteoclasts were what destroyed bone at the site of the tumor. This improved how bone cancer is treated. Clohisy leads an Academic Health Center National Institutes of Health musculoskeletal training grant for graduate and doctoral students that has had NIH funding for 28 consecutive years. “Besides contributing to the literature, which this department has done a fair amount of, we literally changed the way orthopedic care is delivered in this part of the world,” Swiontkowski said. “Before, care was doctor-focused, and we changed that. It’s now patient-focused and educational programs have been the benefactor.” Swiontkowski accepted the department chair position under the condition that he would commit to holding it for ten years, and in 2007 stepped down. He remains an active professor and mentor within the department.
Innovation into the 21st Century
Since his appointment as department chair in 2007, innovation has been a focal point of Clohisy’s leadership. “Innovation in care delivery and quality is what our partners are interested in,” he said. “We’ve really focused on that over the last 10-15 years.” Examples include the geriatric fracture program, which has been developed collaboratively with HealthPartners and Regions Hospital, and spearheaded by Julie Switzer, MD. TRIA Orthopedic Center also brought together three groups to form a musculoskeletal outpatient comprehensive center, which opened the first immediate access walk-in orthopedic care center in the upper Midwest. The Sports and Orthopedics Walk-In Clinic, located in the Clinics and Surgery Center, opened its doors in 2017. Clohisy has also embraced technology’s increasing role in healthcare. “Right now, we are innovating through a phone-based app that allows real-time submissions of suggestions to improve our performance administratively, clinically, and from a research and work culture perspective,” he said. The app, called ImproveWell, is a digital solution to drive quality improvement, innovation, and engagement.
In education, there has been tremendous progress. Alicia Harrison, MD, associate professor and assistant residency program director, completed her residency here in 2009. “Our department is really focused on being innovative in terms of education,” she said. “The residency is very different now than when I was a resident, in a positive way. I think there’s more resident involvement and input into how the program runs and what works best for our residents.” Another facet of innovation in education has been adjusting curriculum to adapt to simulated surgery. “To me, the most exciting part is the research arm of our education group, where they are leading the nation in innovative educational techniques and assessing the performance of learners,” said Clohisy. “We now have surgical simulation programs where residents practice surgical techniques on artificial bones using real orthopedic implants.” Van Heest concurs that a significant portion of operative learning can now take place in a simulated environment.
“We have established simulation programs through Gillette, the TRIA Arthroscopy Center, and James House Hand Skills Day,” she said. “Other simulated teaching is done through Excellen Biomechanics Lab at HCMC, the VA arthroplasty simulation, as well as ongoing anatomy labs that are carried out for our junior level residents.” The department is recognized as a breeding ground for leaders in academic orthopedics, and has faculty and alumni that have been presidents of essentially every subspecialty orthopedic group. Department leaders have served in the Dean’s office, on both University of Minnesota Physicians (UMP) and M Health’s board of directors, and have led major initiatives within the organization. One notable example is Thompson’s leadership role creating UMP. In addition, Clohisy was appointed associate dean for surgical and procedural specialties in 2018. “We have significant local recognition, and it’s because of the leadership roles that the department heads and senior faculty have taken,” Clohisy said.
Clohisy has also recruited 32 high-quality additions to the department’s faculty. In Thompson’s days, there were only a handful of faculty. “There certainly has been a lot of growth over the last 50 years,” Clohisy said. “Right now, we have 87 faculty, and 50 are full-time University employees.” What is more, the department has continued to be at the forefront of promoting women as leaders in orthopedics. “In the last ten years, 25 percent of our trainees have been females, and currently 30 percent of our faculty are females,” Van Heest said. “This has been a major advancement and we have been a leader in the country as far as increasing diversity by gender.” To put this into perspective, data from the Association of American Medical Colleges found that 14 percent of orthopedic residents were female in the 2016 academic year. The same data showed that women account for roughly 18 percent of orthopedic faculty in the U.S.
During the 21st century, medicine has faced increasing challenges, and it is likely that technological innovations will further disrupt traditional care delivery processes. “The greatest challenge, by far, is the economics of medicine,” Clohisy said. “We have so many wonderful things to offer patients and so many patients in need, but determining how this care is delivered in partnership with those that are paying is the single biggest challenge.” Another challenge is balancing patient and physician expectations across multiple generations. Older patients are generally more comfortable with face-to-face conversations with their healthcare provider, while millennials increasingly prefer healthcare delivery that has an electronic component. “Managing those two populations of patients in consecutive clinic visits is a real challenge,” Clohisy added.
In 2018, signing of the definitive agreement creating a joint clinical enterprise between the University and Fairview positions us to further enhance research programs and faculty recruitment in the Medical School, according to Clohisy. Over time, the agreement situates M Health Fairview to become an academic health system unlike any other the University has established. “In terms of the success of the department, we have to keep in mind one of our partners that is not always mentioned - the University,” Clohisy said. “The University is a wonderful organization — it has been supportive of the health sciences, and it’s behind the success of the Medical School and the department.” To think back on the progress that the department has made in patient care, education, scholarly work, and research over the last 50 years is exciting. The leaders throughout this half-century have made an invaluable contribution towards the field of orthopedics.
“Despite a continuous-change culture in medicine over the last 50 years, we have stayed true to the mission of the University,” Clohisy said. “We are focused on serving the citizens of the state, providing top-notch education, and advancing care through innovative research and clinical work.”
