Dr. William Grana

Perhaps it was divine intervention that steered William Grana away from divinity school…and saved a congregation. Yes, if he hadn’t met the right role models at the right times, he could have ended up in front of a congregation instead of a class of medical students.

Dr. William Grana, the former head of orthopedics at the University of Arizona and now a professor in that department, says, “I was raised in St. Louis by my dad, a second generation Italian American, and my mom, a second generation German American. Neither of my parents was able to attend college, but my father in particular stressed the value of education. I was a good athlete and had my sights set on the University of Missouri or University of Illinois, both football schools. My homeroom teacher ‘collared’ me, however, and convinced me to apply to Harvard, Dartmouth, and Princeton. I applied, was accepted at all three institutions and chose to attend Harvard. The whole family drove me there.”

As for a higher calling, it was a toss up between God and medicine. “In high school I was a member of a Lutheran church where there was a very dynamic minister who had been an athlete. That led me to consider attending divinity school. When I got to Harvard I met my freshman advisor, who played on the football team and was in medical school. After some reflection I decided that my temperament was not suited to life as a minister. I like things done in a certain way, and that doesn’t always happen when you are leading a congregation.”

Medical Training in Sports and War

So instead of going to divinity school, Dr. Grana completed medical school. But it wasn’t long before he heard from another higher calling: Uncle Sam. “At that time all physicians took part in the Berry Plan, something that helped you predict when you would be on active duty. I was in the Air Force as a general medical officer (GMO), and was assigned to Tucson, Arizona. Since I was the first GMO in Tucson, they made me head of the general medicine clinic. Halfway through my first year, I got orders to go to Vietnam.

“During my time there—June ’71 to May ’72—I got an appreciation for working in a Third World environment with no technology. We had to use cone ether anesthesia, which involves dripping ether on paper. And no one knew how to intubate or resuscitate. During my time there an anesthesiologist came to our facility out in the boondocks and taught the staff how to intubate. Overall, my memories of the country are positive ones. I now give a talk called ‘Christmas in Vietnam’ in which I discuss my experiences there and the commonalities between the Vietnamese and American people. I hope to be able to return for a visit one day.”

Returning to the U.S., and to his training, in 1972, Dr. Grana entered a residency program at Barnes Hospital, Washington University in St. Louis. “Those were the days in which residents undertook two years of general surgery followed by three years of orthopedics. It is unfortunate that students don’t have this now as there is no question that the two years of general surgery makes one a better surgeon.”

He then headed to the land of football to “do” football (and other sports). Dr. Grana: “In 1975 I joined the faculty at the University of Oklahoma, essentially because Dr. Joe Kopta, who had been at Washington, was hired as Chair of the Oklahoma orthopedics department. He recruited me to sports medicine, in particular because during residency I had helped take care of the St. Louis Cardinals.”

Like his sports medicine colleagues of the day, Dr. Grana was left to hone his skills without the benefit of structured training. “At the time there were few organized fellowships in sports medicine, and there was no accreditation or certification. A faculty member from OU suggested that I spend six months working with Donald Donahue, the past head of Orthopaedics at the University of Oklahoma and someone who had written the textbook on treating injured athletes.”

I learned one on one from Dr. Donahue, both in the office and the OR; we did an average of 70 to 80 cases per month. He had the foresight to recognize that there was something important about a new tool called arthroscopy, so he had me spend several days with a friend of his to learn the procedure. As a result, I became the first person in Oklahoma City to perform arthroscopy.

A Practice of His Own

Armed with this new skill, and with a bird’s eye view of high level athletics, Dr. Grana had put himself in a good position to build his own facility. “During my time at OU I had my first experience with the U.S. Olympic Committee (USOC) when I went to work with athletes at the USOC Colorado Springs training center. Based on my time there, I decided that I wanted to create an especially organized approach to treating active people. I began to plan for a facility where athletes could come in and get their problems taken care of and have access to all aspects of patient care at one location. In 1983, in conjunction with the hospital on the university campus, we started the Oklahoma Center for Athletics. That facility merged with others in Oklahoma City after I left.”

Expounding on his work with athletes, Dr. Grana says, “Working with the USOC is in a sense like dealing with any other large organization—it is bureaucratic. But when you are at a competition, it’s just you and the athletes and that’s always rewarding. The athletes I dealt with were very professional and understood what they were there to do. I never covered professional teams and my personal experience with them was that they were difficult to deal with and did not bring as much gratification.”

As for the clinical side of things, in-game changes have brought progress. Dr. Grana: “The rules have changed with regard to blocking and tackling because there was a spate of lower extremity and head and neck injuries. There were a number of reports in the media about problems with concussions during football games; now we have concrete ways of evaluating concussions. One of the conclusions we came to was that even minor injuries can create a cumulative effect on the athlete’s cognitive functioning over a period of time.”

And Dr. Grana’s leadership roles didn’t stop there. “In 1983 I began a private practice adventure that lasted 17 years. During that time I had the largest orthopedic practice in town with 7 offices and 17 doctors. In 1999 I began to think that I had missed out on the opportunity to head a department and so began exploring several such opportunities. At the time the University of Arizona (UA) was starting a new department in orthopedics, and I was recruited to start the program. It is a complex task and not nearly completed as of yet.”

Athletes shouldn’t wander aimlessly around the field, and neither should the team physician. Speaking of how things have become less random in the team doctor arena, Dr. Grana notes, “Programs are much more organized now, with every aspect of training and conditioning more regimented. We know so much more than we used to about organizing game day care, setting up practice on the field, court, etc.”

Part of my experience included writing whitepapers on the roles of team doctor and what they should do and should not do with regard to things such as large event coverage, etc. You can’t just walk out on the field and say, ‘I’m here to care for your athletes.’ Prevention, evaluation, and management of injuries are all a team effort, and you must have a plan ahead of time. I don’t walk into the OR without thinking through what I am going to do—it should be the same when approaching game day.

Dr. Grana, who stepped down as head of the UA orthopedics department in 2007, continues to work in the department he built. “My biggest ‘kick’ now is teaching an elective for the second year students. We meet once a week for an hour and do an overview of orthopedic topics such as emergencies, compartment syndromes, infections, and pulmonary embolism.”

Research and Education

Those second year students and other trainees also benefit from Dr. Grana’s expertise in the research arena. “The majority of my research now is on healthcare policy. In one study we looked at the costs related to treating isolated wrist fractures and how those expenses might be modified based on changes in how people are allowed to code and bill for those conditions. We have found that if you modify the way ER docs and orthopedists bill for this—just this single isolated fracture—you can save $37 million annually. I sent this information to my state representative but have not yet received a reply. This work has been submitted to The Journal of Bone and Joint Surgery (JBJS), and we are also hoping to present it at next year’s AAOS meeting.”

Dr. Grana, who encouraged the development of the UA orthopedic laboratory when he arrived as Chair, states, “Our lab, which is focused on the mechanical treatment of articular cartilage problems and arthritis, is now growing cells and working with bioresorbable materials that you can grow cells on and implant to treat the local surface of the joint. We can implant these in an animal model, but we are five years away from clinical trials. While we had a National Institutes of Health grant for $1.3 million, that funding has just run out. Fortunately, we have recently received $300, 000 from the National Science Foundation.”

Dr. Grana affects the future through research, as well as education. “I am the Editor in Chief of Orthopaedic Knowledge Online, the AAOS online education program. Eight years ago I had an opportunity to create an educational program for the members and residents that would be available all of the time. The fact that it’s so comprehensive makes it very unique. And of course it’s backed up by the credibility of AAOS and its history of outstanding educational programs. I hope my legacy is that I have provided leadership and vision for what this kind of educational program can be—multifaceted, and with topics like those you would see in a peer reviewed journal.”

He continues,

The self study structure includes questions from the intraining exams and self assessment exams. There is a great opportunity for Continuing Medical Education, and in fact, we are now approaching 200 credits. My next task is to create a portal for all AAOS online educational programs above and beyond ours. For example, JAAOS has online materials—going forward those will be accessed through this portal. The public will also be able to use this site. I dare say it is likely the single largest repository of orthopedic information in the world.

Retirement: What’s Happens Next?

As he looks toward retirement, Dr. Grana considers the generational shifts in orthopedics. “While I was part of the early move towards subspecialization, somewhere out there we must continue to have general orthopedists. If no one is willing to take ownership of a patient’s problems, we are in trouble as a field. For example, I don’t do back surgery but I don’t turn someone away. I at least evaluate the patient and refer him or her to the appropriate caregiver.”

Now we have people who are only willing to treat one or two joints and won’t even evaluate other problems. I don’t think much can be done about this situation, however, because it seems to be generational. So many people are not interested in the 24/7 approach that doctors of my generation were accustomed to. This trend is happening all across medicine. Some days I wonder who is going to be there for us when we have a problem, and I wonder if it will be the same quality of care that I would have given to a patient.

Although retirement is on the horizon, Dr. Grana plans to stay active. “I will probably quit operating at the end of this year and officially retire from practice in June 2010. My plans are to continue teaching at the medical school and running Orthopaedic Knowledge Online. Some of my peers who have gone through the retirement process find it very difficult while others feel it is a great stress reliever. I will probably be one of those in the latter category because I take surgery very seriously.”

One thing he can’t do in retirement, however, is stay home. “My wife has mandated that once I retire I am not allowed to be home from the hours between 8am and 5pm. I don’t see that being a problem, however, because in addition to my work, I exercise regularly on a treadmill and play tennis and golf. My wife and I love spending time with our children and grandchildren and having everyone over to our house in Colorado. We especially enjoy the summers when we can do lots of hiking and fishing.”

Dr. William Grana…bringing order to the sports world and refining orthopedic education.