responsibilities of the NFL orthopedic team physician and in managing the sidelines and landmines. My disclosure is in the AOS book. So introduction, here's the key. Who are you going to call? OK, you're there. Who are you going to call? When I first started, I was a year and a half out of my fellowship taking care of a major league professional team. Who would I call? I called John Bergfeld. Guess what? He always answered the phone. I called Frank Jobe. Called Jimmy Andrews. I called Russ Warren. So you got to have, you need all these mentors and trusted friends when you first start. They've been through this before. So they can guide you. And you learn an awful lot from them. Then, who are you going to call that's your own peers? So these are my guys that I call. Neil Alatraz, and John Conway, and Danny Cooper, and Walt Lowe. Between the four of us, we usually can figure out what's going on. So these are trusted friends. And these relationships are going to last you a lifetime. Choose your mentors wisely. This is Dan Rooney. If I'm half the guy he is, I'm doing a great job. But Dan was one of my great mentors in how to handle people, and especially handle people in the NFL. So first of all, what does it take to be an orthopedic team physician? Well, these are my top 10. You've got to give a shit, OK? It's showmanship versus substance. It's not how much money you make. It's not the status in your community, or the number of cases you do, or how cool your office is. The idea is not to get your name in the newspaper, OK? So Henry Hillman was a Pittsburgh billionaire. He was an invisible billionaire. He said, the spouting whale gets harpooned. So once you go above the surface in the press, they know where you are, and they're going to come for you. So it's about giving back and passing it forward to your fellows. And I have some of my fellows here. It's about how well the cases turn out. It's about return to sport at the same level. So as Spike Lee says, leave your ego at the door. Do the right thing. I choose fellows on realizing, will they do the right thing when the pressure's on? Trust. Number two thing is trust. It takes years to build, seconds to break, and forever to repair. So once they trust you, you kind of got them. So this is Cordell Stewart. We were playing the Raiders, and Mr. Rooney hates the Raiders. And he got hurt his knee, and we have a good relationship. And I examined him on the sideline, couldn't make a decision, went inside where it was quiet. And he looked at me, and I examined him two other times. And he said, Doc, what do you think? And I said, I think you strained your PCL. He says, can I play? I says, I think you can play. He didn't say one word, walked out, scored three touchdowns. We beat the Raiders. And Mr. Rooney was very happy. But I wouldn't have done that if he didn't trust me. He would have had some discernment. This is another one. This is a patient of mine, a friend. And Jason, they wanted to do some things to him early on in his career when he was young. And they asked me, and I said, absolutely not. This is not. You're too young to have this happen. So the trust is not given. It must be earned through these people. But honestly, you've got to be honest with them. A little situational awareness is helpful. What time of the year it is, is a major coming up. And treat them like everybody else. Number three, what's best for your player, this is really important. What's best for your player is what's best for your team. That's always period. That's no exceptions. So great coaches get that. Great organizations, they realize short term, it may not be best for their organization. But long term, the great organizations embrace it. And that's why they consistently win. So you're not a fan of these guys. You're not their friend. You're their physician. So you've got to act like it. The traits of a good team physician. We talked about AAA, we'll get back to that. And Kevin Plancher was not the first one to say that. Honesty and good judgment, communicate well, compassion, commitment. And you've got to throw in a little laughing at yourself. Players like a little of that levity like that. So availability, you've got to clear your schedule. Sorry, there's no golf. Affability, a dose of self-effacing humor in front of them goes a really long way. Ability, you better upgrade your skills constantly. Honesty, they can tell where you're untruthful. Good judgment, that comes from experience. Communications is the art of medicine. Compassion, I was cut from an NFL team. You need to feel their pain. And finally, commitment. And the quality of a person's life is in direct proportion to their commitment to excellence, regardless of their chosen field of endeavor. And that's Vince Lombardi, I totally agree. Some thoughts about judgment. Good judgment comes from experience. And a lot of that comes from bad judgment. That's from Will Rogers, all right? So you've got to go through some bad times to get good judgment. But this is the other thing from Albert Camus in the fall. People hasten to judge in order not to be judged themselves. So don't feel too bad, because a lot of people judge you real quickly because they don't want to be judged themselves. Communication, number five, communication is key. Always answer your phone. This is Jimmy Andrews, and he taught me this. We were in a golf tournament in Chardonnay, California. I said, he's taking phone calls in every hole. I said, Jimmy, we can win this tournament. He says, no, no, no, no, I got to call these people. He took 19 phone calls in 18 holes, and we came in second. So communication is key. Talk to the player at the level of their understanding, not yours. The difference between college and pro is about five phone calls. The other thing is on the sidelines, just shut up and listen. Do not interrupt them. They will tell you the diagnosis about 80% of the time without an exam, and then you confirm it with an exam. So just listen to what they're saying. Number six, as the team physician, you are expected to be right all the time. It's just the way it is, so you better get used to it. So there's some couple rules, but when you're not right, you apologize, you take full responsibility, and you make no excuses. John knows Bill Cowher. I said to Bill, our defensive back's gonna be ready to play in two weeks with his broken finger. He wasn't ready to play. I got my ass cussed out right in the office for about five or 10 minutes, and then Bill calmed down and came down and said, okay. He was very polite about it, but he was pissed off. So there's a 49-year-old. So on the sidelines, you only get about 40% of the information, and it's easy to be right if you have 90% of the information. So what you do is you do a complete exam, but it may be hard when you have multiple players hurt at the same time and in the same position, but just kind of trust your gut. You've been there before, go with your best trust, and that's the best advice I can give you. You never stop learning. Number seven, when you stop learning, it's time to retire. So you need to feed your brain. So every time I think I've got something, guess what? I don't, it'll bite me in the butt. So this is one of my heroes, Russ Warren. He did the New York Giants for 39 years, and when you would come to these meetings, Russ would be in the front row right there writing things down about what the next study he's gonna do, so he never stopped learning. If you want to change, you have to be willing to be uncomfortable. So if you're gonna do the next procedure in your thing, you've gotta be uncomfortable. You've gotta be uncomfortable because otherwise, you're not gonna be, sooner or later, you're gonna be comfortable, but get uncomfortable. This is Steve Burkhardt, The Burden of Craft. You've gotta constantly challenge your ability with new thoughts and ideas, and you can see the doctor's bed's not in there, but the engineer, the lawyer, and the teacher are. So this is Albert Camus, or sorry, this is Thomas Kuhn, and the structure of scientific revolution. So he says, if on the other hand, no one reacted to anomalies or brand new theories in high-risk ways, there'd be few or no scientific revolution. So if you don't go out of your box, nothing would really move forward. So what I said in a quote to this paper, I said, yeah, that is a problem with large institutions like mine. They do not like people who think out of the box, but they love to take credit for it. So The Burden of Craft, that's attention to detail and patience. You gotta be skilled at working in these virtual spaces, these small spaces. Not everybody has these skills. There's an obligation to learn the skills, to teach the skills, and to perform surveillance of these skills, that's your obligation. And remember, level one studies, they always talk about level one studies, but the major bias of a level one study is that level one studies only reflects the technical skills of the surgeons in the study. It's like, if I have a team from Ohio State playing a team from St. Mary's, well, guess what? It's a totally different comparison. So level one studies don't prove what's possible. They don't demonstrate the limits of a technique. Does not demonstrate the equivalence of techniques. It's dependence on the surgeon's skill. It's dependent on outcome measures that may be not sensitive enough to pick out the small differences that you can see. So beware of level one studies. So this burden of craft is our burden and it's our obligation. The key is to keep asking yourself, are you spending the time on the right thing because time is all you have? As Burkhardt says, we must accept the challenge and responsibility of this burden. I totally agree with him. Next thing, is there a sports gene in my mind? I said, yeah, I think there's a sports gene out there and I think these are some of the qualities. I think people that have this gene, they instinctively think in 3D. They believe in their ability. They're confident. They're not cocky. They have rapid cognition. You gotta read the book by Malcolm Gladwell. When you're in a surgery and all of a sudden something feels not right, guess what? It's not right, so you gotta back away. So you have to have rapid cognition. They don't really get uncomfortable in a crisis. It seems to be like a good quarterback. Everything seems to slow down for them. They always stay beneath their learning curve unless they're gonna get in that uncomfortable position to learn something new. And the theater is never too big. Between whether you're being in a huge game or if you're just doing a practice, the theater never changes for them. And you gotta have some grit. So what's grit? Well, Chris Amad said grit is the mixture of passion, perseverance, self-discipline that keeps us moving forward in spite of obstacles. This is a really good book he wrote. It's called Skill. So number nine, you have to embrace this process because sometimes it's gonna be very painful. So when I first took the job a year and a half out, I had a running back that was giving us a lot of trouble. The press was all over me. It was Christmas time. They were raking me over the coals in the TV and I was doing the wrong thing and da da da. And so I thought I'd ask my mother. My grandmother's crying, you gotta quit your job. I said, mom, I gave her the story. This is what my mom said, suck it up, buttercup. So that's what I got so much from mom. The next thing, like anything else, we talked about a good judgment comes from bad experience. So it's a growth curve and you must put yourself in stressful situations repetitively to get used to it. This is my friend and patient Greg Norman who I take care of and he told me this after I was talking to him about after he lost the masters. I said, he said, this stressful situations has gotta be part of your DNA. If you're gonna do it, you have to do it to the best of your ability and Charlie Earp is the guy that's next to him, was his coach and he said, D-I-N-D-I-P, do it now and do it properly. And he told me after he failed at the masters, he said, look, Jim, I just embraced this failure. I learned from it and I just moved on and that's what we gotta do. You embrace your failures, you learn from it, you move on. Remember, number 10 and most importantly, always remember that sports medicine is a team. It's not you, okay? This is my team, that's my old coach Bill, that's them and that leadership in this is never about technology. It's always about people. So now, just I'll talk about the NFL. So this is my resume, I've been doing it for 31 years, 690 games on the sidelines, 39 playoffs, nine conference championships, four Super Bowls. It's different but the principles between college and high school, the principles remain the same. So I said this back in 2010 to our paper. I said, look, the, and we just talked about this, the equilibrium between intervention needed to achieve accelerated return to play and judgment needs to protect the athlete is the NFL paradox. So return to play versus protection. There are some misconceptions about the NFL. The National Institute of Occupational Safety and Health, you gotta know, found that the true life expectancy of an NFL player is actually longer than the general population, it's not 55 years old. They have lower rates of diabetes, cardiovascular disease, less of them die from cancer, suicide rates, 59% less than the general public. Cholesterol and sleep apnea are actually the same as the general public, but they are three times more likely to die from a neurocognitive disease. The other, oh sorry, the other misconceptions is this. The average career of an NFL player is not 3.5 years. It's not true of a player makes an opening day roster, it's close to six years. If a rookie makes the roster, it's over six years. The average length of a player that has three pension years, credit seasons, is 7.1 years. You're gonna have these guys for a long time in my field. See, he's got them for four years, and their coaches can use them for four years, but we get them for a much longer time. So if you have a first round pick, he's gonna make the league 9.3 years. If they make the Pro Bowl, they're in the league 11.7 years. So let's go to the medical staffs. This is my problem. So when I first started in 91, this is 92's medical staff, we had nine people on the medical staff. This is our medical staff. In 2013, there was 37, and this year, there's 41. So I'm managing, we were managing 41 different people. That's how much it's grown. The wheel, the hub of the wheel, I got it from Tim, and then this is what, I totally agree with this. This is the thing. The head team physician and the certified athletic trainer, and I totally agree that certified athletic trainer is the hub of the wheel. Then he goes to me, but he runs the show. This is my trainer, this is John Norrie. He's been with the team 31 years, or 32 years, I've been with 31. I've never had another trainer, and we work together very well. We yell at each other on the sidelines sometimes, but we work together very well. Extended medical care, okay, we talked about emotional intelligence. What's emotional intelligence? It's social skills, self-regulation, self-awareness, motivation, and empathy. So you got all these personalities on the sidelines, around, you got all these top specialists that are all alpha dogs, and you gotta keep all those balls in the air, and you gotta keep them happy. A couple of things, the extended medical care. So I have one surgical case. There's a, these are the individuals involved in one surgical case in the NFL. There's more than 17 individuals involved in the care of that athlete that you have to manage. There's a lot going on. It's a year-long schedule. I'm not gonna go through it, but when I first started, I said to my wife, look, this is like a six-month deal. She says, well, don't get another hobby. Well, now it's not a six-month deal, it's all year round. So we are going all year round doing something. So if you're gonna do something like this, it's a big-time commitment. Some of the things you should know, that before an NFL game, there's a 60-minute medical meeting. So all of us meet an hour before the game, the team physicians, athletic trainers, the referees meet with us, the NFL personnel, there's a whole group of us, and we go through all the items in the stadium, and all the, review the medical resources, review the emergency action plan. That all goes on before every NFL game. Also, in a game day, there are 30 physicians in and about the stadium on one side that help us. So we have to manage those. Nextly, we have a concussion checklist, just like you do. And if we have a player that we think is concussed, we have to go through this checklist before they can return to play. During an NFL game, any of these people can trigger a stoppage of the game. It never used to happen. A teammate, a coach, the game officials, the spotters upstairs, and the team-affiliated medical staff, we can stop the game if we think somebody's down, which we never did that before. When someone gets concussed in our field, we have to take them not to the sidelines, we have to put them in this tent, and we have to assess them. If we assess them that they have a concussion or have symptoms, they go right to the locker room, and they're not photographed on the sidelines or anything, they go straight to the locker room. Concussion hasn't been a big deal. There's increased scrutiny of head injury, and it's sequela. So we have spotters upstairs. We have a video review system that the Steelers actually put in. They ask us, what should we do? And it went leg-wide, where I can actually say, OK, let's look at the injury. I'll send one of my guys. We'll go over to the video thing, and we get slow motion videos of the entire injury. The big three in the NFL, they're lower extremity injuries, ACL tears, and high ankle sprains. And we've got a whole bunch of task force in the NFL that are looking at those specific things. So what are the lessons I've learned? Number one, like Chris said, this is all about relationships between the players, the owners, the medical staff, the agents, and the press. They can get involved. Trust, the players and the organizations have to realize that you have their best interests at heart. So this is what my owner said to me when I took my job. If someone interferes with you taking care of my players, I want to know who it is, basically. Basically say, look, I got your back on this one. Communication, you got to engage them, being able to explain their issues at their level and understand. So I was quoted in a thing after we were going to Super Bowl. I said, listen, white coated eggheads do not play well to athletes. They don't. You've got to be kind of more than that to them. Compassion, you've got to feel their pain and security. If you've ever played, you know that feeling. Because when players get hurt, other players don't want to be around them. Ego, best and most important. Leave yours at the door, OK? Doesn't matter who gets credit. Just get it done right, and then give everybody credit. Obsess with the little stuff. All the big stuff's going to take care of its stuff. It's that little stuff that's going to torpedo the big stuff. Medical mafia, so the medical mafia and the Pittsburgh Steelers is the ATC, the internist, and me. And we have to speak. That triad has to speak in one voice to the athlete so he doesn't hear multiple things, because they like to fragment sometimes. Media, as Chris said, stay out of it. Their job is to create controversy, usually at your expense. Agents, embrace and engage them. Make them part of the solution. Let them help you and the player. Like, I have very good relationships with my agents, because I call them all the time. And they'll call me at halftime if their players are hurt. And we'll give them information, because they're part of the solution for me. They help me. Free agency for us is a problem, because you invest all this time gaining your players' trust. And when they leave, you get someone who's had a bad experience. And it takes twice as long. And John will tell you, it'll take twice as long to gain their trust. Owners, I prefer football families over corporate guys. I'm biased. But I think the families have the players' best interests at heart. What do the critics say about the NFL? Careful about how hard you hit each other, OK? Well, that's not true. This is what Roger Goodell said. Leadership on the road to a safer game. At Harvard, we embrace our leadership position. We make the right choices for the right reasons, based on science and facts, not speculation. Football has always evolved. It always will. Change does not inhibit the game. It improves the game. And his final statement was, the rule in our league is medical decisions override everything. He further went on to say, I strongly believe that sports can be made both safer and more exciting. These are not mutually exclusive goals. These are the number of safety initiatives in the NFL. I'm not going over them, but there's 48 of them. And I'm intimately involved in a bunch of them. But that's how much we take the safety of the player at the NFL to level. Just one example, this is NFL injuries, or ACL injuries. And what we do is we divide them into evidence-based, excuse me, evidence-based, with good data, and then data-driven, currently limited, and then we need further investigation. So that's how we're studying each of these injuries, especially lower extremity injuries, high ankle sprains, and ACLs. And we've got task forces on every one of them. We have data innovation and technology workstreams in the NFL. We have a helmet technology workstream, integrated mouth guards. We have Amazon Web Digital Athletics, surface innovation, cleat innovation, shoulder pads. All these are streams of which we're studying it to make the game safer. So thank you, but even God loves the Steelers. And welcome to Pittsburgh, the real city of champions, not Boston.

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