Good evening, and welcome to the AOSSM Sports Medicine Fellows webinar series. I'm Jeff Dugas, and it is my pleasure to host two of my good friends, Doctors Bob Arciero and Dean Taylor. Bob is a professor of orthopedic surgery at UConn, and Dean is professor of orthopedic surgery at Duke. I could read you their resumes and their CVs, but you're going to have to trust me when I tell you that that would take the entire hour that we have, and that these guys have held every position there is to hold in every level of what we do in sports medicine. They've been every chairman and president of everything, they've led the world of what we do in sports medicine and orthopedic sports medicine for the last 20 years, and I consider them both very good friends, and I'm really thankful that they're both with us tonight. This is a leadership series, you know, we're talking about transition to practice tonight, and so if you have questions, please submit them on the GoToWebinar panel. Click the questions drop-down arrow and submit your questions, and I'll be happy to ask them of our two guests. The format tonight is going to be 15 minutes for each of them to speak on the topic, and then we're going to have about a 30-minute discussion and do questions and answers. So with that, I'm going to say thanks to you guys, it's good to see your faces, I wish we could meet in person, I miss our golf games and our dinners, and we're going to start it off, I believe, with Dr. Arciero. Well, good evening everyone. I'm going to talk about sort of a framework, a mindset of approaching your practice. I think the first one is to be as good a doctor as you can be an expert. And by that, I mean embracing our craft as orthopedic surgeons. You all are going to have a lot of challenges, not just patient care, but money issues, maintaining your education, performance measures. If you become a team physician, there's a lot of challenges there dealing with athletes, coaches, parents, and anybody else who's associated with a team. And we're going to talk about building a team, and that's in the office, in the operating room, and in the teams that you cover. And Dean and I'll share a few things. Here's a picture of a young Dean Taylor many, many years ago. And I steal this quote from Jesse DeLee, keep your eye on the ball. And that is, make sure that you remain patient focused. If you make patients the center of your practice, you will be an enormous success. And I hope to share a little bit of that with you. A number of years ago, it's probably more than 10 years ago, Don Shelburne, another leader in sports medicine, talked about the art of the knee exam. And what he did was he circulated a questionnaire among patients who were referred to him by other orthopedic surgeons, or had seen other orthopedic surgeons, and found that only a third of the surgeons that had seen these patients had actually done a physical exam with the knee exposed, and only about 20% examined the opposite knee. So that tells me that we're in too big a hurry, slow down, remain patient focused. First thing is to talk to your patient and examine your patient. This was at a Metcalf course, and we had a focus session on the physical exam of the shoulder taught by Buddy Savoie. And here we are in a national meeting, and we're talking about physical exam. And you can see here the inset John Fagan at an AOSSM meeting showing the prone Lachman test on unsuspecting orthopedic fellow lying on a table in the room. My point is, history and physical exam engage your patient, make your patient the focus of your attention, and then you can make a good diagnosis and proceed to good outcomes. And part of this is a continued learning experience. You have to continue to learn. Despite all those pressures that are out there, we need to hone our skills. And this is what Steve Burkhardt calls the burden of our craft. It's not really a burden if you love it and if you enjoy it. But it's just like a golfer going to the range and learning how to, you know, construct and build a swing so he can play better. Here you have Dr. Freddie Fu, former president AOSSM, and Dr. Russ Warren, who's about 75 years old in this picture, at the Orthopedic Learning Center engaged in teaching and continued learning. This is really a prerequisite for starting your practice and maintaining a strong practice. This is, I can't tell you how vital this is because it's something that you have control over. You know, you're going to be, like I said, tugged by in many different directions. But this is a skill that we possess. We're orthopedic surgeons, orthopedic sports medicine surgeons. It's actually something we have great control over, how much we know and the skill that we have that we can engage and treat our patients. So when we look at these challenges of decreasing reimbursements and, you know, having a staff that can help you pull off a successful practice, what have we done? Because we're hardworking people, we jam our clinics with more and more people to try to get around or circumvent this process of continued diminishing reimbursements. This is really not the answer. All it'll do is you'll be one of the 15 or 17 percent that doesn't examine their patient. And when we look at things that patients judge us by, which leads to a vibrant, full practice, because you're going to receive patients through online reviews and from word of mouth and from family members. The things that drive performance ratings are the history and physical exam and actually your ability to not operate on a patient, to actually discuss, engage and educate in non-operative treatment, not just the operative management, but history and physical exam. I can't stress this enough. And continued education and learning. Just a word about complications. They don't go away. They get worse. Always be aware of intractable pain, loss of appetite after you do surgery, patients doing well, and then they deteriorate. And really, this is something I learned in the process of making my own complications. You really need to see these patients twice as often, not half as often. And it's very difficult for us to come to grips with complications that we have with our patients because we inevitably feel guilty and totally responsible. And what we really need to do is to actually step back a second, take a deep breath and manage those complications and be really vigilant and aggressive in treating those complications. Just a word about being a team physician. It's not about you. It's really the athlete. It's about the team. And I think one of the mistakes that many, many young sports medicine surgeons make is they have all this great training, the latest training, and they go into a community and expect a practice to immediately be placed in front of their feet. That's just not going to happen. You have to build that. And the way that you build that is by gaining trust and gaining experience. And you do that by not being aggressive in this regard, respecting your colleagues and people who've come before you, and that practice will grow. And this is another, this is a plaque that hangs at the military academy in our football training room. And this is a quote from John Fagan. We were privileged to serve those who paid the price. That's the mentality we need to have as team doctors to be successful. Again, it's not about us. In fact, the best team doctors, a lot of people don't even know who it is, except for the people that count, the coaches and the players and the trainers. Also, building that team, building that reputation in your community, you got to see people who can't pay you. And you can't fill your clinic with that because you can't meet the bills, but you can tie that experience. In other words, take a couple appointments out a week, a day to see people who can't pay you. And this is an alarming study done that was done in Cincinnati, a fictitious 15 year old with an ACL tear. They called 42 offices. And if the patient could not pay or had Medicaid, only six of the 42 offices gave him an appointment. And the private insurance was within two weeks, 38 out of 42. It's really scary. We just published an article about this in the shoulder. And we found that the uninsured and the underinsured with shoulder instability required so many more major reconstructive procedures, bone grafting, and bone substitutions, much more aggressive open surgery. And that's because care was delayed. So I would urge you to get this, build this practice with tender loving care. It is tough, but I think what makes it easy is to stay with what we do the best, which is being a very good or the best orthopedic surgeon that we can be. And it is supposed to be hard, but it is also what gives us great professional satisfaction. So we talk about team building and, you know, this was the dream team, the Olympic dream team, unbelievable dream team. This is my orthopedic dream team. These are key mentors in my life that I have communicated with as recently as a couple of weeks ago with one of them. And I would encourage you to with your mentors and your residency director, your fellowship director, that you continue to engage with mentors and professionals who have guided you and given you great advice. Stay in touch. You know, as far as I'm concerned, I know I can speak for Jeff Dugas and Dean Taylor and many of us who are in so-called leadership positions, you know, our text messaging is immediately open, email, phone. I actually take great pride in staying in contact with former fellows and residents. The other thing, too, is as you go into practice, try to surround yourself with great people. Another quote from John Fagan, he goes, you got to build a practice or join a practice where there are physicians there who will take better care of your patients than you do. And that's quite a statement. But when you think about it, that's the kind of group you want to be in. And, you know, and unfortunately, and I'm glad that's a small percentage, but you need to be careful of people who have unethical behavior and try to avoid that as best as you can. And unfortunately, you don't find out all the time until you're into a practice. But the people around you that are your colleagues and your partners are critical. I'm blessed to have a fabulous team that helps me do my job. And I think that's another critical piece is the people who work for you are, excuse me, the people that work for you hire good people and then reward them. You have to reward them and they will, you know, stand in front of an 18 wheeler for you. I've been lucky to have three people who work for me who've been with me since I came here in 2000, which is 20 years ago, 21 years ago. And I don't do anything magic. I just try to treat them well and make sure that I appreciate them. That's a very critical thing to building and maintaining your team. You don't want to go through a number of people, a revolving door. And the way to do that is when you find somebody who's really dedicated is you got to reward them. There's another thing that I learned. I learned this from Joe Hannafin is embrace your colleagues. And, you know, this is a competitive world that we live in. We're going to go into towns and cities that where the competition is keen, but be special, be unique in the fact that you try to embrace your colleagues and not be a pitted enemy. Try to speak with them. If you see their patient, it's okay to write a letter to them or forward them a note. This is almost a lost practice now. You see a patient or somebody sees you, you never hear about it, but that's an exchange of information. And any of us who are care about the performance we have, we want to know if our patient is doing well or if there's a change in plan. I think it's important to do that. And we need to take care of ourselves, you know, litigation and the government, they want us fighting each other because that causes disruption and allows them to continue to hack away at our practice. And I would urge you to be as fully a team member with your colleagues as you can. This, I had to throw a picture in here of Gus Mazzocca. He's like the little brother you love, but you want to beat up every once in a while, but he's a spectacular partner of mine. And we don't always see eye to eye, but we love each other. And I would hope that you guys and girls, when you go into your practice, that you can establish these kinds of relationships. It's very, very important. I want to say one last thing, because I don't want to go too overboard here, but I think that being involved in a society like the AOSSM is also critical. That's how you stay engaged with your colleagues. It's how you stay engaged with your mentors and you can volunteer and contribute. And it's a way to really energize your practice and to keep that energy level high. So I would encourage you as you go forward to embrace the society. And I thank Jeff, Meredith, and AOSSM for giving me a chance to editorialize and give an opinion. Thank you. Thanks, Bob. Great job. I'm glad you didn't put a picture of my golf swing in there. And I have a feeling we're going to see a few more pictures of all of our mentors, John Fagan, in this next talk. So with that, I'm going to let Dean take the floor. Have at it, Dean. Thanks, Jeff. And thanks, Bob, for leading off with such a great talk. This is, like both of you said, this is a real joy to be here with both of you and to talk about one of my favorite topics, and that's leadership. And so we're going to talk a little bit about leading within your teams. And Bob touched on teams and the importance of those. And we're going to go through that. And when we're talking about leadership, really we're talking about influencing. And we'll get into that a little bit. These are my disclosures, none of which pertain to this talk. And what I want you to take away is that you all have a responsibility. We all have a responsibility to be leaders in health care. And we can be better leaders if we develop our competencies. And we'll talk about that. And we need to build effective teams to be effective leaders, both professionally and personally. Now, that's easy to say. And so the other thing I want you to take away is this isn't easy. And there's a lot of challenges, and it's continuous learning. We're still learning. As Bob talked about, it's the burden of your craft. And we can learn from others. And sometimes that's preferable, because learning from your own challenges and failures sometimes is learning the hard way. So we'll try and share some things that hopefully will minimize those lessons that you have to learn the hard way. So why are we talking about this? I mean, Bob just said you should be spending all your time developing the burden of your craft, right? Learning how to operate, learning more about anatomy, physiology, all those things. Well, the burden of your craft also includes that human-to-human interaction. And we get to that through leadership. And that's why we talk about leadership. It's not about the people in charge, the people with the positions, the people with authority. When we're talking about healthcare leadership, we're talking about the ability to effectively and ethically influence others. It's about influencing others for the benefit of patients and patient populations. So when you think about that, we all have the ability to influence others for the benefit of patients and patient populations. Everybody in the team does. So if we can enhance our leadership skills, our leadership competencies, then we can make healthcare better. And I'm a firm believer that you can learn to be a more effective leader. Some people say leaders are born. Well, I think, yes, some people have innate skills that allow them to lead effectively. But we can all learn to be more effective in our leadership. And that's by developing skills and also having that desire to accept the burden of your craft. If you want to become a better leader, then you can. It reminds me of the joke of how many psychologists does it take to screw in a light bulb? Well, it's one, but they have to want to change. And if you want to be an effective leader, you have to want to change some of the things that you do and some of your practices to enhance that part of your craft. And it's an important part. One way to do it is by thinking about a framework. And we did some research to look at what were the most important competencies for effective leadership in healthcare. And I'd like to just share a little bit of that with you as an introduction to talking about teamwork. When we looked at the different competencies, one thing rose to the center. To be an effective leadership in healthcare, you need to be patient-centered. You heard Bob talk about being patient-focused. If you are focused on the patient and keep that patient at the center of all your decisions, you're going to make good decisions and you're going to be an effective leader. It's a necessary part, but it's not sufficient. Alone, it can justify really horrible behaviors. And we've all seen those behaviors justified. Well, I'm just taking care of the patient. Leave me alone. Well, you have to understand that the other competencies are important as well in order to be an effective leader. And I think the most important one is emotional intelligence. And that's why it's at the top of the model. It's at the keystone. It holds everything together. Emotional intelligence, the ability to recognize and understand thinking and emotions in yourself and others, and to use this awareness to effectively manage your behavior in your relationships, that is a competency that can be learned and developed, but you have to work at it. And if you do, that will enhance your leadership. It'll enhance your life. It'll enhance your people skills. The foundational competencies of integrity and selfless service, they're at the bottom because they are the foundation. Maybe you can't learn integrity. Maybe you can't learn selfless service. But like Bob talked about, these are important to recognize these qualities. It's not about you as you're going into your new jobs. It's about others. It's about building the team. It's about taking care of the patient. It's not about you. And the more you're thinking about others, the richer your life will be. And I'm not talking about money. So these are foundational competencies. And you'll note that when we talk about selfless service, we're not talking about doing everything at the expense of your entire life. We want to emphasize that you prioritize others' needs over individual wants and desires while maintaining a personal and professional balance. The framework for effective leadership is two competencies. Critical thinking, and that's not knowing everything, but that's using your knowledge base and others' knowledge and input to create appropriate and effective solutions while recognizing that we all have biases. And they're going to affect our thinking. Teamwork, and that's what we're going to spend a little bit more time on, because that's a key part of what you need to do is develop teams as you go into practices, as Bob talked about. Collaborating, maximizing your role in the various teams that you're on to improve those teams' overall performance and cohesion. When we think about those teamwork attributes and why it's included in the model, those attributes include motivating, managing people, optimizing team dynamics, encouraging improvement, innovation, and contribution, and fostering a vision. Those are all key attributes that you can develop and learn about to be a more effective leader and build better teams. Okay, so let's take a step back and talk about teams for a second. So, the dictionary definition is two or more persons associated together in a work or activity, okay? So, with that definition in mind, I want you to think about how many teams are you on, or more grammatically correct, on how many teams are you? And as you think about that for a second, Meredith's going to put up a poll, and I ask you to think about how many teams are you on, Meredith, is it up? Meredith, is it up? Yeah, we have 11 to 100, or greater than 100. Okay, so let's take a step back and think about how many teams are you on, or more grammatically correct, on how many teams are you on? And as you think about that for a second, Meredith's going to put up a poll, and I ask you to think about how many teams are you on, or more grammatically correct, Meredith, is it up? Yeah, we have 52% voted so far. I'll wait till we get to 60, and then I'll close it. Okay, because I can't see it. It is up. Okay, so maybe somebody can tell me what it says. All right, I'm going to close it right now. Did you see it? I cannot see it. Okay, I'm sharing it. Can you see it now? I still can't see it, but that's okay. So how many teams are you on? 41%, there's a tie, 41%, between 5 and 10, and 11 to 100. How many said more than 100? Zero. Well, I would say I'm on more than 100 teams, because if you think about it, for every patient you have, you have a team, because you're teamed with that patient. That's the most basic form of leadership. You're influencing that patient, that patient influences their outcome, and everybody in your clinic, your rehab team, your surgical team is part of that team for that one patient. That's the most basic form. Now, yes, you have, and I think most people are thinking, well, I have my clinic team, or I have my team of fellows, or I have my team in the operating room. Well, what about your family? Well, you have your, or your spouse. That's a team. You have your immediate family. You have all these different teams. Bob talked about being part of a community of orthopedic surgeons. All the orthopedic surgeons in this country make up a team. Everybody in the AOSSM is a team, so you're on a variety of teams, and the more you recognize that you have a role in all those teams, and you can influence all those teams, I think the more you'll understand that those teams can get better with your influence, and if you build those leadership skills, they're going to get a lot better. I'll recommend a great book about large teams, and Stan McChrystal was a general in the Middle East during the Iraq War, and the way he got the complexity of the entire organization was thinking about it as a team of teams, and if you think of yourself as a member of smaller teams and larger teams, you can enhance that large team by enhancing your team while also recognizing the goals of the large team, whether it's your hospital, your health system, whatever else, and I really recommend this book. It's some great insight on how to be a good teammate, and how to influence teams, and how to be the leader of teams when appropriate. Bob talked about how he builds effective teams, and it is, it's about selecting the right people. You want to get the right people on the bus, and for some buses, that's Jack Kerouac, and Ken Kesey, and the Merry Pranksters, and I think those were probably the right people for that bus. They might not be the right people for your bus. If you think about it, you've got to figure out what sort of people do you want on your team when you're building that team in your clinic, in your operating, in your rehab team, and once you get those people on the bus, as Bob talked about, you treat them well. You play to their strengths, and you build trust. It may not be people that you like. Abraham Lincoln, as outlined in Doris Kearns Goodwin's book, Team of Rivals, took his major rivals who all vehemently disagreed with them, and couldn't understand how this guy could be president, because they were career politicians, and this guy coming from Illinois became the president of the United States with only 39.8% of the vote, yet he reached out to them because he recognized that their skills were necessary for him to successfully lead the country in 1860, and so Seward and Chase and Bates became part of his cabinet and made him the successful president he was. I'd highly recommend this book. It's one of my favorite books on leadership, this biography about Abraham Lincoln. Then the last thing we're going to talk about is building trust, and I know Bob's team, he's really treated his people well. He's played to their strengths, but he also builds trust, and one of the things that we do to build trust is we build it over time, and we do it through credibility, so that people can say, I trust what she says, or I trust what he says. We do it by reliability, so I can trust that they're going to do the right thing, because you do it repeatedly. Then intimacy, and intimacy means getting to know your teammates better, and that leads to emotion, so they feel comfortable sharing with you in discussions, and you'll notice the thing on the denominator, the thing that destroys trust is self-orientation, okay, self-centeredness. Your motives, in other words, having the motives for the team and others above your own, are going to build that trust and build better teams, and people recognize right away when your motives are self-serving, and that's going to break down trust, and it's going to break down your teams, and we're going to show a video that highlights some of the things about building teams here, and Meredith, go ahead and try and do this, and hopefully it'll work. Okay, can you hear me now? Yes. All right, so let's get back to that. As a lot of you probably recognize that's from Remember the Titans and it really brings out a lot of things, but especially it brings out that self-serving attitude. And there's no trust between Gary and Julius at this point in the movie. If you haven't watched the movie, you got to watch the rest of it because there's a lot of great, great leadership lessons in there, but you can see how there's no trust with that self-interest, that self-orientation. And I highly recommend that you watch it if you haven't because there's a lot of lessons about how they went on to build trust and create that trust through credibility, reliability, and intimacy and being more for the team. So I hope that that little taste of leadership and physician leadership and talking about how to build teams will help you as you're trying to think about, well, how am I going to build my teams, both in your professional and your personal life? Because, you know, your personal life, those teams are more important than your professional life. And if you think about how you want to build your family, both your immediate family and your distant family, all these things can apply to that as well. But when we talk about leadership in health care, you have to understand that you have a responsibility to influence what happens in health care, both at your local level as well as regionally, nationally, even internationally. And if you build your competencies and skills in leadership, we're gonna have better health care, no question about it. And like I said, it's not easy. Maybe some stories will come out about some of our failures. We fail at leadership every day and hopefully we have that growth mindset and are able to learn and become better leaders through those failures. But it's also good to learn from others. So learn from those lessons of books and movies and what other people can share with you, especially your mentors, as Bob talked about. And I look forward to the discussion. Thank you very much. Thanks, Dean. Great talk. Thanks to both of you. And so, again, if there are questions, please submit them through the website. I'm gonna ask both of you, you know, a couple of pearls for starting in practice. I'll lead off with the one that I always tell our new partners, you know, when somebody joins our group and I tell the fellows this, make sure the first patient you see has a good outcome. You know, the first case you do, make sure it has a good outcome and then carry that to the second one. Get off to a fast start. And by fast start, I mean make sure all the outcomes are good. Focus on the patient. Focus on the outcome. If you're focused on how fast can you get to doing 30 cases in a month, you're gonna have some complications. You don't want quality over quantity. And so, I tell me your first order of business, it's like the statement in the book, The House of God. If you haven't read that book, it's a winner. But one of them is, when you're going to a code, make sure you check your own pulse first. Make sure the patient has a good outcome. Make sure the first patient you see, the first operation you do has a great outcome. And carry that same feeling for the first patient to the second one and so on. So, you guys, give me a couple of pearls for going into practice. You know, leadership quality pearls for going into practice. Go ahead, Dean. Well, I was trying to practice one of the things that I was gonna say. I think as you're going into practice and you're working with teams, especially with athletic teams, try to keep your mouth shut and listen. The more that you can listen and learn and be interested in what's going on and not have to interject, I think the more valued you're gonna be and you're gonna earn that trust as I talked about. You know, Jeff, you stole my first one, really, which was staying patient-focused and being committed to the patient, their outcome, and improving your skill level. That's a big plate of pearls, if you would. And I think that's a recurring theme that our listeners and certainly I continue to learn every day in my practice that always brings great rewards and professional gratification. But the one that I would go back to is hire good people. And you'll know, you need to check on people. You know, like if you're gonna hire somebody to be your assistant, you know, and they've had prior work experience, you know, check up on it. Try not to get burned. And certainly that can happen. But the people that are in your office and in your operating room lead to your success. If you have people who don't answer the phone well or are not organized, you and your patients are gonna suffer. So I would say it's a process. And I'm lucky and I'll be honest. I didn't have any skill in getting the three people. I'm in a state institution. These three people were dumped into my lap. But they happen to be fabulous people. And the only thing that I've done is I make sure that honestly every day they feel appreciated. Simple, you know, thank you for helping me in clinic today. You guys are doing a great job. I'm sorry I'm punishing you with adding 10 more patients to the schedule. You leave the operating room, you say thank you to people for everything that you do. All the time you just embrace and humor. I think our fellows could tell you sometimes my humor is not in good taste. But it does get a lot of laughs. And I think that's a good thing. You know there's a time to really be serious. But if you can provide some levity as well as gratitude. And then you got to reward them somehow. And you know in a state institution that's hard to do. But you know you figure it out how to reward them. But that's important. You know you say thank you, you reward them and they'll they'll think twice about going to another job. And they'll stay more importantly very committed to you. So that's the one that that I would say. Surround your people, hire good people and retain those good people by doing some of the things that have worked for me. Hey Jeff, can I build on that a little bit and tell some Bob Arceo stories? So for those of you who don't know, Bob and I go way back. He was I was the fourth fellow in the West Point Fellowship. And Bob was my fellowship director. And then we were partners together for five years. And Bob talks about you know humor and making things fun. And as as Bob's fellow and as his partner, we had so much fun. And he just has that that ability to to laugh about things and enjoy what you're doing. And the passion and enthusiasm for all the things that we're doing. And if you're sharing that with your team, you're gonna have a team that's gonna love coming to work and love what they do. And then it's it's part of that intimacy. And the more you make it fun, the better relationships you have, the more you build those relationships or that intimacy and the more trust you build. And one of the things that we would always do when we were at West Point is we would also do things outside of work. And when you have the opportunity to be able to do those things and see people in a social setting, whether it's just a meal or an outing or anything, you can build that intimacy and build that team to greater degree. So when you when you have the chance, take those opportunities to to enhance the team by by doing things outside of the work. I love that. I think that, you know, the teams that we work with, especially if you work with the same people a lot, you know, highly specialized people that work for you, they're an extension of you. You know, as you hire somebody, make sure you understand that they're going to be an extension of you and they have to think like you react like you if your nature is to say yes. And, you know, anything I can do to help you make sure you hire people that have that mentality, because if they say no to everything, that's a reflection on you and and vice versus. So, you know, I think the people that you work closely with should be a very mirror image reflection of the way you do things and the way your personality would handle something. And that takes time to build. You know, Bob said something and I think Dean did as well. Turnover will kill you. You know, if you have a team of people, you work with three or four people in your office, you start having turnover. That gets painful. And trying to train somebody to think like you takes time. So the point of rewarding them and making them feel valued is really important. Otherwise, you're never going to build that team. What else? It's that great line. Attitude reflects leadership, right? No doubt. What about, you know, one of the things that Andrews used to always tell us is never be critical of somebody else. You don't know the situation they were in when they did or said what they said. You know, if you if you tell a story to somebody and let it go five, three or five rounds, by the time it gets back to you, it's a completely different story. We see this in medicine all the time. When you see something in your office, the x-ray doesn't look great. And you think, oh, my God, look at how bad that is. But you don't know what the circumstances were. You don't know what the resources were they had. And I think that's a cautionary thing for people as they go in practice. You guys want to discuss that a little bit? Yeah, I if you don't mind, Dean, I'll take the first swing at that one. I think I can't agree with you more, Jeff. In my clinic, I think fellows will will and residents will understand very quickly that if I think something was poorly done, or there was a poor decision made, that is never spoken anywhere near a patient. It's in closed door in my office or in a back room. When we say okay, now, why did that fail? Oh, well, yeah, that's a vertical ACL. It's standing straight up and down. That's probably the reason why this this patient failed. But you and and if the patient asks you, then you say you say simply to them. I mean, this is this is something I say, and it's absolutely true. If I see a vertical graph, for an example, and I'll say, well, you know, 1015 years ago, five years ago, that's kind of the way we did ACLs. We did them that way for a very long time. And now we think that the graph might be in a better spot. But that's I did them just like that. And you know, you diffuse if you not only do you not criticize, but you should do everything you can to diffuse the situation. I'll give you one other story. I had this Olympic level skier from Vermont, 17 year old had this, this severe shoulder dislocation. And the physician who saw the patient scheduled them for an arthroscopic stabilization. And when that surgeon got into the operating room, found out that about 60% of the humeral head cartilage surface had been sheared off. This is a 17 year old boy, that surgeon took the scope out and sent the patient to me. And the paint the parents were hot, because this was putting this kid behind the eight ball another six, eight weeks. And I said, You know what, I got to tell you that that doctor had your son's best interest at heart. That's a remarkable physician that you encountered. They didn't just do something that they know to do, and ignore a major complicated problem, they actually sent you to somebody who might have a clue of how to manage this. So, you know, that that's a kind of mentality. And I would, I think I've, I've heard Jimmy talk about this. And I know he instills that in people who've trained with them, but it's a very valuable attitude to have in the clinic with about your colleagues. Dean, anything to add? Yeah, I would agree with what Bob has said. You know, it works with your partners, too. It works both ways. If I've heard it said, and I totally disagree with this statement to ask for help is a sign of weakness. And that is absolutely wrong. And you can't go into practice with that mindset, or you're going to get burned repeatedly. To ask for help when you need it is a sign of great strength, and, and humility. And it'll keep you out of trouble many, many times. And so if you're not sure what's going on, put that patient first. And like Bob talked about, embrace those complications. And ask your partners to take a look. You know, ask somebody like, in the story you just told Bob, take the scope out. I've had the same thing happen to me with one of my fellows that sent a shoulder patient similar to yours, to me did the same thing. And, and the, the family didn't understand it. But he was doing the right thing. He was asking for help when he didn't need it, because he put that patient first. And to me, that was a sign of great strength. So I would agree with everything that you said. I have a patient that just goes back a ways. This is about 15 years ago, I saw a guy who had a femoral nail in from a mid-shaft femur fracture. And he was having knee pain where one of the screws was. So I get an x-ray and the femur fractures healed. But he has a tibial nail put in retrograde in his femur backwards, upside down and backwards. And I'm thinking, that's, that's the worst looking thing. I mean, by the grace of God, the fracture healed. And that's the worst looking thing I've ever seen. Until I read the op note, and guy had a femur fracture, but the next closest intramedullary nail was 300 miles away. And this guy, instead of looking like he's done something bad, looks like I felt like calling the guy, see if he was still around to tell him what a genius he was. And the surgical skill it took to make that look good, look good. So, you know, think about, you don't know the circumstances all the time. You got to, you got to really dig into those things and try to understand what people's perspectives are. Could I, could I make another comment, Jeff? Yeah. So Dean brought up a good point. And this gets at the heart of, you know, you want to, you want to be able to carry your load as a new partner. And I think the trap is the multi ligament injured knee. So you're in training, you get exposed to these types of cases. And then, you know, sure enough, one of your partners, your older partner is getting tired like me of doing these and stressing out about them. So they send the case to you and you've, you know, scrubbed on maybe 10 of them or 20 of them, but you've never been doing it all on your own. And you feel like, oh, okay, I got to do this. That is an enormous trap. Okay. You will, you will have huge issues. So that was, is a case where you need to ask your senior partner and, or your fellow, fellow buddy who incidentally should be knowledgeable. You can't just take a PA unless that PA has done a hundred of them and go into a room and do a multi ligament. And this is where people get compartment syndromes and pressure injuries and infections and DVTs. And the, it goes, I've had every single complication you can imagine because I was stubborn early in my career. I even had a contralateral limb compartment syndrome after a multi ligament knee that took me five hours. The other knee, the other leg had a compartment syndrome. So, you know, I'm just here to say, get that help. And that's another thing. You got to have a team. You got to have people in there that, that surgical scrub nurse tech, the circulator, anesthesia, the, these are huge traps when you do a fellowship and you're going to take on one of these more complicated cases. Don't be afraid to ask for help. You know, we've all passed the boards at least three or four times, you know, in our careers. You guys are coming up on your, on your, you know, oral boards here in a few years. And I can tell you that we've all been through this process or been part of it. Failing part two of the boards is, is a fairly straightforward thing. And one of the key things that will fail you on the boards is if you ignore your complications. If you do not handle your complications, everybody has them, you know, you know, don't shy away from your complications, embrace them, get better. But you will absolutely look like you're the kind of person that should fail the boards if you avoid your complications or try to avoid them. They are looking for people to do the right thing. They understand that complications happen. It's how you handle them that you're being evaluated on. And that was something that was brought up by both of you guys. Adversity is part of what we do as surgeons. You have to handle it head up. You can't avoid it. You can't try to skirt around it. You've got to deal with it with integrity. Okay, let's talk about the tide rising all ships. So I tell our guys in a group practice, many of you will join a group practice, whether you join an academic group or a private group or a private demic group. Our motto here is, if it's good for the practice, it will be good for me. Not the vice versa of that. If it's good for me, it will be good for the practice. I think that's a key thing for young members of the medical world, whether you're an orthopedic surgeon or not, to realize you're joining an entity and you become a fiduciary responsibility to that and you take on a partnership. And to understand what partnership means, you guys both use that word, you were partners, you know, we're all partners with with our folks. Lyle and I have been partners for 22 years. What does it mean to be a partner? And then, I think that's an important part of leadership as these guys join their practices. Talk a little bit about partnerships. Yeah, well I learned a lot from this guy about that. And I, you know, it goes back to that selflessness. When we worked as a team at West Point, it, like I said before, it was fun. It was always fun to go to work because we knew we were going to work together, we're going to take care of all the work. And that was a true partnership. And obviously the incentives are different and it's hard to reproduce that in the civilian world. That said, I think that both of us in our own environments at UConn and at Duke have been able to work towards creating a more collaborative team environment. And the more that we are effective in doing that, the more we enjoy what we're doing. And having a partner and having great partners, and I have great partners here at Duke, just like I did in the Army, where we have each other's back, where we can talk to each other about cases openly and create that comfortable relationship and that safe space to work together. That's what it's all about. It's hard to get to because orthopedic surgeons in general are the most insecure human beings on the planet. And you'll see that when you interview for jobs and everybody's vying for whatever they're vying for. But if you create the incentives for the team and to enhance the group and work together as partners, you're going to be in a much better situation. So as you're looking for your jobs, you want to look for jobs where you can truly work with people that have similar values that you'll want to spend your time with because you're going to be spending a lot of time with them. And you'll be very unhappy if you have conflicting values and people that you don't want to work with. So that's a great segue to our last minute or two here, the partnership among AOSSM. And we've all spent a lot of time together between committees and boards and meetings and social gatherings and dinners and golf and our families and, you know, our group of people that does these things. The AOSSM has really been a conduit to a lot of great friendships and a great just career path for all of us from the time we all got started to now. Talk a little bit about that for just the last minute or two and how these guys can get involved and how important the society is to their future. I would say pivotal, you know, being a member of the AOSSM at a young age and then being able to see my colleagues and my mentors on a recurrent basis, share cases and share fun, just like Jeff, you were talking about, Dean, you were talking about, you know, being a member of the AOSSM, honestly, has been probably the most significant professional aspect that has enriched my practice and my professional experience. And the key thing, it's not an old boys network unless you let it be that way. The key thing is to volunteer. And once you're a member and all you have to do every year on the website, there's a sheet to volunteer and there's committees that openings are available every single year. And you just have to put your name in. It's not a matter of, you know, Dean Taylor and Bob Arcero was selected from the time they were 31 years old in a path this way, or Jeff Dougas. It was, yeah, we were influenced by people who valued the AOSSM, but we were willing to volunteer. And that's where it all starts. And that's the quickest way for a young person to get involved. And I think the society is really phenomenal with regard to continuing education and collegiality. I won't add much more other than, you know, John Fagan was a mentor to both of us. And what John Fagan has told to many people, a lot of people have told me this, pick one organization and put most of your efforts into that one organization. And your career will be enhanced because of that. And for me, that organization has been the AOSSM because it is filled with wonderful people like Jeff and Bob and so many great mentors and peers and friends. And I've learned so much along the way. It's great professionally. It's great socially. And I couldn't be happier to have been engaged so much with the AOSSM. And I'd encourage all the fellows on this to become fellow members and enjoy this organization for the rest of your professional careers. With that, I'm going to say thanks to you both. Really appreciate it. It's great to see your faces and spend a little time with you. Can't tell you how much I appreciate it and have continued to learn and enjoy you both. Meredith, if you're there, you got anything else to add for these fellows before we let them go? Yes, I'm just going to cover a couple of the closing slides. These introductory and closing slides were included as a handout where you can access the resources and information that I'm going to share. Thank you, Drs. Arciero, Dugas, and Taylor for your time and preparation for tonight's webinar. The AOSSM would like to remind the fellows about candidate membership and the opportunity to join a committee. If you have not already, you may apply online for free candidate membership during your fellowship year by clicking on the membership tab at sportsmed.org. Learn more about applying to join a committee at the AOSSM website at this URL. The deadline to apply is this Friday, February 12th. Open for free registration for current fellows is the Pediatric Sports Medicine Webinar Series. This is in collaboration with PASNA, taking place on April 7th, April 14th, and April 21st. You may follow the registration directions here. And for more online and on-demand education resources, visit the online AOSSM Playbook and Surgical Video Library. And the next two fellows' webinars are listed here. Thank you again for participating, and good night. Good night, guys. Thanks very much. Thank you. Good night. Thank you. Good night.

webinar

leadership

teamwork

patient-centric approach

building trust

continuous learning

challenges

personal anecdotes

starting a practice

professional societies