President's Perspective Early November 2014


The 4 As
Thomas S. Roukis, DPM, PhD, FACFAS
ACFAS President

I have a vivid memory of one of the most famous foot and ankle surgeons in the world plunging a toilet in his surgery center. There has been more published on foot surgery with this person’s name in it than any other topic. I also remember listening to the first cardiothoracic surgeon at my hospital talk about sweeping the floors in the operating room between surgical cases. This surgeon was trained in Boston and was known nationally for his incredible cardiothoracic and general surgery skills. But I especially remember begging an otolaryngologist to perform a radial forearm free tissue transfer for coverage of an exposed ankle joint when I was right out of fellowship. He was a professor at a major medical center in Chicago and had written myriad textbook chapters on the use of this particular flap to cover oral cavity soft-tissue defects. He was openly pleased that I knew who he was based on his textbook chapters (only because the foot and ankle soft-tissue coverage sections required skimming through these other chapters). Regardless, he helped me and the patient’s leg was ultimately saved and functional.

During subsequent interactions, he told me I would be a great healthcare provider because I had the “4 As.” I smiled and nodded while I tried to search my brain for what he meant—what was the appropriate acronym? He could tell I was not processing what he meant and so he spelled it out for me.

  • First, you need to be AVAILABLE. This means you answer your pages, phone calls and emails timely and offer to help rather than set up “hoops” for providers or patients to jump through.
  • Second, you have to be AFFABLE. You need to be likable.
  • Third, you need to be ACCOUNTABLE. You have to complete your dictations, consults, patient paperwork requests, workers’ compensation ratings, etc. without requiring administrative intervention or repeated patient requests.
  • Finally, you need to be ABLE. You must have a quality surgical skill set.

We all strive to be the best foot and ankle surgeons we can and the vast majority of our meeting time is spent learning new or evolving surgical techniques, but it is the least important of the 4 As. The first three involve personality traits that are difficult if not impossible to teach. Every student, resident or fellow I have worked with has heard me discuss the 4 As. Whenever I do, I reflect on these characteristics and invariably on my difficulty being AFFABLE. I am someone that you either like or you don’t with no gray area. If you are forced to work with me, then usually over time you will warm to me based on an appreciation of my giving nature, work ethic and selflessness. This is much like an immunization process. I guess the important point is that if you are missing perfection in one of the 4 As' attributes, then you should reflect on them, ask for guidance from trusted colleagues and develop a personal improvement plan to remedy the deficiency. In doing so, you will grow as a person, your foot and ankle surgery skills will benefit and your patients will receive better care.

I encourage every member of the American College of Foot and Ankle Surgeons to avail themselves of our online and print materials available to help you augment your 4 As. Hopefully, you will not need to routinely perform plumbing or hospital house-cleaning activities like the master surgeons I previously mentioned; however, it is an effective visual useful for remembering the 4 As.

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