Hey guys, well, thank you so much for being here. We are excited to give this, we did it last year and excited to have Beth and Chris here in person and appreciative for the chance to do it. It's a little bit of an unusual topic, obviously, it's not specifically just on how to do an ACL or how to do a Tommy John, but a topic that we think is really important and we want to be super open about things. Part of it is we're going to try to leave time for discussion and things along the way, so if you have questions, feel free to just stop us during the middle of it. It's meant to be open and discussion based and should be, hopefully, an interesting topic. Disclosures are online. I'll just introduce our panel, very, very grateful to these three for being here. So Chris Ahmad from Columbia takes care of the Yankees and NYCFC and has a particular expertise in throwing shoulder and elbow, so he'll be talking about that. Beth Schubenstein at HSS, who is really a renowned expert as far as patellofemoral. I'm Matt Tao, I'm at University of Nebraska in Omaha with a very, pretty much primarily knee heavy practice. I'm still trying to hang on the title of young surgeon, so I'm giving the young perspective for this, so we'll see if I can continue to do that. And then Allison Toth at Duke, who really does a tremendous amount of complex shoulder and knee surgery. She actually did my shoulder surgery, how long ago, 10 years ago maybe? You wouldn't know, I don't have a great use of it, but she really does a fairly good job, so we'll let her talk about that. So if you're looking and going, gosh, one of these four is not like the other, Nebraska is actually a state in the country. It's in the Midwest. And one of my friends the other day said, I don't think I could actually pick it out on a map. I said, well, I think that's an educational failure on the part of the country. But either way, it's actually been a great place. So anyway, we'll get rolling here, we'll do a little bit of an intro. We will talk about some specific things for shoulder, throwing elbow, patellofemoral for Beth, I'll talk about knee. But one of the goals of this really is not just drilling down to specifically how do you do, what do you do if this goes wrong, but kind of managing things intraoperatively, postoperatively in terms of how to deal with complications as well. So we'll draw on some non-medical things, psychological things, other resources. These three are particularly thoughtful when it comes to this kind of stuff. So hopefully, it'll lead for fodder for good discussion. When we think about putting this together, this phrase for me kind of summarized everything. This book is by Jim Mattis, the former Secretary of Defense, and he just said that basically we learn the most about ourselves when things go wrong. And I think certainly for me, that has been very true. I'm just going to put up a couple quotes here, just in terms of perspective. One of the things that I have definitely come to appreciate is that there's a difference between knowledge and wisdom, that we spend so much time trying to gain knowledge as we go through training, and then we get out and there's still something different about time, about things that have been learned in the past. There's something about that perspective that's been gained over time that really should be honored, and some of it is what we're trying to portray here. It's not to say that we have all the right answers by any means, but hopefully just sharing some of the perspective and things that we've learned along the way. These quotes I think are just particularly relevant as far as how we frame some of what we're talking about here. But I'm putting up some pictures of kind of my not top ten, so it's always more fun to look at somebody else's complications than your own, so hopefully you can look at this and say, man, I'm really glad that those are not my own. But I do it just to say that this is hard, right? This happens to all of us. These are not fun to go through, but we'll talk about some strategies of how to manage that as we go. So one of the things, I'm kind of splitting it up in segments here, but one of them is intraoperatively when things go wrong. This is certainly one of the things that I was most nervous about starting practice, and Beth was kind enough to tell me when we finished fellowship, it's not a matter of if, it's just when. So get ready, it's going to happen pretty soon. And she's totally right. Those of you that have operated for a while, you know that. And it's about trying to mitigate that to some degree up front, which we'll talk about, but also knowing how you're going to respond in the middle of it. So this is a book from two former Navy SEALs that now do business consulting. Really good book, Jocko actually has a very good podcast, but one of the chapters they talk about here is when things go badly, that you have to prioritize and execute. Figure out which task is the most important, and address that, and then sequentially move on. I'll kind of litter with books along the way here, but this one is on teams that have achieved historic levels of success, and how they've done that. And they talk about how our role as leaders, and I would argue in the OR, we have to be the captain of the ship, that our role is particularly important when things go wrong, or in decisive moments, and how we handle that emotionally, meaning keeping our cool, et cetera, really matters a lot for the tenor of the team. So this is just something that I do. It really is helpful for me, if something's just not going right, or if something actually bad happens, is just to take a split second and pause. I try to be super intentional about just closing my eyes for a second, take a deep breath, try to relax my shoulders, and then move on. It sounds kind of funny, again, this is not kind of a normal podium presentation, but I think it helps to reset things for just a minute, and then focus. You guys know the OR can be a crazy place at times, maybe the music's loud, maybe the tech's talking to the nurse, or whatever, but eliminate some of those distractions and allow yourself to focus on whatever the task at hand is. And then don't be afraid to ask for help. This was something that Allison, I think, was really good at teaching me, is it's okay to ask for help, and you can use whatever resources you need. Ask the people in the room, call a friend, call one of your colleagues in, even if they're not a sports surgeon, be willing to ask for help. I think what you can't do is you can't let it snowball. You can't let one mistake or one bad thing just start to gain momentum and all of a sudden the case is way out of control. Likewise, you can't let it completely derail your day. This may be the first case of your day, you can't just continually beat yourself up throughout the day. Set aside time at the end of the day, deal with it, you can debrief with the team after the case, but you can't let this just totally wreck your day, because you obviously have other responsibilities going on. So I'll just show a case here. This is a trochlear OCD, just like most of these. The cartilage on the outside doesn't look that bad. She had a couple surgeries before, her bone underneath didn't look great, so we sized it. This is me then sizing the allograft. I took the allograft, then drilled the trochlea here, and then we went to put the plug in and the plug was about three millimeters too small, and so I was like, what happened here? And they handed me the wrong size reamer, and I just didn't look. So there's plenty of times where I've handled things very poorly, so I feel like I have some willingness to speak on that, but this is one where, you know, what do you do? Somebody gave you the wrong instrument, but ultimately it's my responsibility, right? This is my case. I am the captain of the ship here. You can yell and scream and stomp your feet. We have one of my partners that's particularly known for stomping his feet in the OR. They call it the Siebler stomp, but it doesn't ultimately accomplish a lot, right? Maybe you need it to vent or whatever, but ultimately you just have to go in and fix it. So whatever the case may be, in this case the contour wasn't great. I wasn't super happy with it. I took a picture from the side that I can show the family and say, oh, it looked really good here, and she actually did totally fine. Things like that, it's hard in the middle sometimes, especially if you don't have a perfect solution. You still have to kind of figure out what to do, but again, I think the tone that you approach things with really matters a ton for the people around you, for the scrub, the nurse, even anesthesia, et cetera. So maybe we'll wait. I'll have these guys kind of comment at the end, but we'll move through these. This is not just a shameless plug for Chris's book. I would have this up here probably if he wasn't here anyway. But one of the chapters in his book, it's called It's Not the Environment, It's You, and I think one of the things that's really hard for most of us is when things go wrong, we have the tendency to pull away, and I think this is something where if something comes in the clinic or you get a phone call or an email, you have to just be willing to deal with it. It doesn't mean you beat yourself up. It doesn't necessarily mean you assume fault, but you have to not run away from it, be willing to give it the time and the effort that it deserves in terms of trying to deal with it. So similarly, just for me, I hate being behind in clinics. So I really, if something's coming in that's bad, it really stresses me out a ton. But this is something where I do try to kind of stop the clock and just say, look, it is what it is. I've got to sit down and deal with this issue and give it the time that it deserves. And I actually think our posture here matters a ton. So I like to sit. I sit and get on eye level with people and just try to talk to them, assure them that you're in this together, you're part of the same team, we're going to get through this together. And I think that's ultimately what they want to know. They want to know that you're here for them, you're going to help get them through it. And then it's time to fix it, which the fix is not always easy, obviously, but we'll talk about some of that specific to each of these areas. But this is one from my board collection during first year of practice. I do take trauma call, unfortunately, still. So I was doing a HEMI. I thought my intra-op looked good. The post-op and PACU looks good. She comes into her three-week appointment, and I see this before we walk in. Presumably, we had a crack there that we just didn't see, and it subsided. And literally, I'm walking in, going shoulders down, going, gosh, this is the first complication I've had in my collection period. This is terrible. And I walk in, and before I could say anything, they're literally just effusively praising me, the patient and the daughter. We're so thankful for you. You've done such a great job. My hip just feels fantastic. I could not be more grateful. And I'm going, oh my gosh, all right. So I said, well, I'm really sorry to tell you that I broke your femur. So this is not the best situation for us. So one of my joints partners said, hey, I'm happy to fix it. This is why we're here. I'll take care of it for you. So I came back in and said, we're going to have you see Bo Kongsberg. He's great. And she said, I mean, no joke, she goes, is he going to be as good as you are? I said, I got to tell you, he's not going to break your femur. So you will be in better hands now than you were before. And she did well, thankfully. But I think one of the things that I've also really come to appreciate is that this physician-patient relationship matters a ton, particularly when things don't go well. And I mentioned the tendency for most of us to try to pull away. I think that's certainly my tendency. You see these patients that either haven't been happy or truly have had a complication. And my kind of gut level reaction is just, I'm not going to see him that often. Maybe the PA can see him. Maybe instead of seeing him every four weeks, we can see him every two months. But this is something where I think you really do kind of have to press in here and fight that urge. Show these people empathy. Again, it doesn't necessarily mean you have to assume fault or anything like that, but make sure that they know that you're on the same team, that you're going to help try to get them through this. Just a quick word on this. You know, much of what we're talking about is individual things here. But if we really want to have success as surgeons, just like with any sports team, you have to do that as a team. And this article from the New England Journal, if any of you have seen that before, is from the late 80s. It's a really good article. It's very short, but it talks about essentially how we motivate people. So the idea of the theory of bad apples, where you think everybody's doing a bad job and you constantly yell at them and write them and expect that they're going to get better because of that. Or the theory of continuous improvement, where you're trying to motivate people to try to improve with time and help them along the way. And I think to whatever degree you can, it depends on your institution and what your practice setup is, but try to build a team around you of people that share the same goals and then help them achieve those. Because you kind of work through these processes, and if you have a team there, it does get better and better with time. I think you guys know that from even just in the OR. If you have the same surgical team, it makes a tremendous difference. So in terms of how we get better, I'm just going to walk through a couple things here, and then I'll let these guys talk. But one of the things that's interesting, those of you that read Atul Gawande, one of his books, he talks about how as surgeons, we get out and we don't have any more coaching. You have all these elite level performers, musicians, athletes, et cetera, that continue to get coaching going forward, and we're kind of just done. So you have to seek that, and that seems to be kind of intuitive, but I don't know that necessarily always is. This book I really like a lot, but the concept of grit is passion plus perseverance, and that you need both of those. I love this quote from it, that there really are no shortcuts to success, that you have to do that and seek that improvement on your own. So sometimes that means asking other people. I think we have to look at things critically on our own, but for instance, one of my spine partners is just an amazing surgeon. He technically is so good, and he just does a really nice job of distilling things down in clinic. He has this ability to kind of talk to patients well about complex issues, so I love bouncing things off of him. Not necessarily just when things go wrong, but it doesn't have to be another sports surgeon where you say, oh, what would you do with this ACL? Some of it's just how do you think through some of these and try to improve going forward? I'll mention taking notes a little bit later, but I think that's also a really helpful way to try to improve both when things go well and when things don't go well. Hard work. This, I know you guys like this book a lot, but this book has been around for a while. Carol Dweck is a psychologist. It's actually an awesome book as a parent for those of you that have kids, but it's centered around this idea of a growth mindset, of how do we get better going forward, and I resonated with this for sure when she talks about how we look at these athletes like Michael Jordan or Tiger Woods or whoever it may be and just say, they're just built differently. That's just how they are. I'm not like that. We don't see them as people that have made themselves that way, that have worked tremendously hard over hours and hours and years and years to get to that way, and I think there's just no substitute for that. I think that's the same in our field, that if we want to be technically good and efficient in all of those things, it just takes time and hard work. There's really not a great substitute for that. Patient selection. This is Dave Atarian, who's one of the joint surgeons at Duke, and he used to give us a talk when we were in training about how the first five years of practice, you learn how to operate. The next five years, you learn who to operate on, and then the five years after that, you learn who not to operate on, and I think about that a lot actually because there's no perfect answer in terms of patient selection, but I think if you can try to find that and be thoughtful about who you do and don't offer surgery to, that mitigates some of this up front, and so that can help a lot. Preoperative planning. Just in terms of mitigating it, I think one of the things that I really have tried to do over the past few years is try to minimize the chance of some of these complications happening from the beginning, and some of that's just a plan. There's this idea in the psychological literature about deliberate practice, which the key to that is just that it's an active process. It's not a passive process. To some degree for us, we'll improve over time with more cases, but if you really want to improve well, just like with any skill, it takes deliberate practice, so those of you who have read the book Boys in the Boat, they talk about this idea of swing, where the whole boat's moving as one, or in psychology, they talk about flow, but really the point is just that none of those things happen unless there's been practice, and as I mentioned before, doing it as a team, developing strategies where you think about it ahead of time and just think, well, what if I break the tubercle here? What am I going to do? Or if this happens, am I going to yell and stomp, or am I just going to take a deep breath and go back? Or maybe scrub out for a minute, go grab water, and then come back in the room. One of the other things that I have found really helpful, and a lot of teams do this, I did fellowship in New York and worked with the Giants, and so they would always do a walk-through the day before, and I have found that to be super helpful mentally before a tough case. So if you do a lot of shoulder instability, it may not be before a labral repair, but if it's, say, a multi-leg and you're not doing a lot of multi-legs, spend some time ahead of time, not right before the case, but ahead of time where you mentally walk through everything. So hopefully this isn't TMI, but for me, the quietest place is in the shower where nobody else is around, there's no kids, there's no other yelling, nobody's knocking on my office door to ask me a question, but just stand there and walk through every single step from the moment the patient walks in the room, to how you're going to position, to each of the steps that you do. And it's amazing, especially for cases that you don't do as often, that you'll come up with things like, oh man, I totally forgot that I need that instrument, which is in a different tray that we have to ask for specifically because it's not in the OR. So that mental walk-through, I think, can be really, really helpful. And this is the last one here, but when things go wrong, I think you have to get back in the game. Aneel Ranawat has talked to me about that before, about it feels counterintuitive because you just want to say, man, something bad really happened. Like one of our fellowship classmates, he had a lady, this I think was in his board collections, a 27-year-old girl that he did a meniscal repair on, came in at three weeks doing fine, next time missed her appointment and she had died. Don't know what happened, she had no history of anything, probably a PE, but Aneel said, you've got to get back in the OR. You can't shy away from it, and I think he's absolutely right. It does feel counterintuitive, but you have to be willing to get back in and engage. I couldn't help but end with a few shameless quotes, but I love Kobe Bryant. These 10 things that he lists as his 10 rules for success very closely mirror what we're talking about here, and I'm sure most, if not all, of you have seen this quote before, but I love this quote from Jordan because I think this is totally true for us as trying to be elite performers in the OR in that we can't let failure define us. We can't just be guilt-ridden and unwilling to engage, but that we have to let that help us improve and try to be better going forward. So hopefully I'm staying on time here. So that's kind of my intro. Do you guys have thoughts on that? I know you guys are all thoughtful about how you approach this. We don't really have a ton of microphones, but it's a small enough room. Beth, anything on your standpoint for an intro? I echo what was hard for me, and still is hard for me, is to see the patients that are not doing well more frequently, to let them know that you're not going to desert them because I think that's the biggest fear for everybody, when something's not going well for whatever reason. It's not on me or not on us. It's still their perception, and their biggest fear is that they're going to get abandoned. So seeing them more frequently has been something, and letting them know that we're all going to be here for them through this process and make sure they get to the end of it in the best way we can has been probably the most helpful information that I received when I was going through this stuff and learning and training. How about you guys? Question? I mean, we've intentionally kind of built time for discussion in here. Thoughts on things that have gone well or poorly? Strategies that you've seen that other people would benefit from, either intraoperatively or postoperatively? Anybody have thoughts on that? Okay. All right. Good.

medical professionals

complications in surgical procedures

panel discussion

patient outcomes

strategies for handling complications