Do you guys want to pick the brains of these three and any questions you want to talk about? Anybody have anything to go through? Yeah, as far as I'm concerned. So what do you do when the patients contribute to their own complications? Do they basically push you over the edge into the precipice and you have to deal with it? I mean, how do you tell patients, this is sadly largely your fault? We're going to be here with you, but we're going to help you fix it. But you've got to recognize that this is contributed by the fact that you didn't do what we told you to do. I'll tell a story that I tell to all my patients before I do an osteoporosis. We had a 15-year-old kid, I didn't show his fracture, but I had a 15-year-old kid who was a great kid. He didn't need to be non-compliant, but about two weeks after his surgery, he was icing his knee. When the game ready, I took the game ready off, didn't feel like putting his brace on, put it in the bathroom, so I used his crutches. He said, okay, I'm going to comply a little bit. I'm going to use my crutches and not put weight on it. And his crutch caught the edge of the carpet, you know, one of the carpets. And he went flying, and he fractured his tubercle. So to your point, he caused the complications. He knew it. I didn't have to say anything to him. But I use that story as a cautionary tale to all my other patients. And some parents are like, well, you're scaring us. I said, I'm trying to scare you a little bit. I want you to know that complications happen. And most of the time it doesn't, but when it does, sometimes they're avoidable. And by being compliant, you can avoid a lot of this stuff. So I think that's, you know, something to explain. We didn't treat the patient any differently. We fixed the problem and made sure he did well. Sometimes they know they're responsible, and if they don't, I think it's okay to tell them. And I'm very honest with the patients when something's going on. I think it's hard to do. It gets easier as you get to practice longer. I think the more wins you get under your belt, the easier it is to acknowledge your own failures. I'm pretty forthright about that. Actually, one thing I want to say, I think one of the things that Chris and Matt and Allison all talked about is knowing how to get better once somebody stops telling you how to get better. We don't have any mentors in ROR anymore. And so after every case, it gets easier with a fellow. After every case, I try to grade it. If I didn't do something right, if my portal wasn't in the right place to do the surgery, if I didn't like the position of where I put my graph, I try to grade it at the end because it's the only way that I can get better. But I also think it's really helpful for them. It would have been helpful for me as a fellow. The most valuable cases I did as a fellow were the ones where the attendants had complications. I learned more from the complications that I operated on than 20 straight RODCLs. And so I think acknowledging that in the OR when you're not in front of the room and saying, you know, I can do better. We're all human. And I think figuring it out, saying it out loud is actually really helpful in figuring out how it will change what we do next time. This is maybe somewhat off topic, but sometimes I'll use my nurse in that way. Caitlin, my nurse, is just really, really personable and develops a really good relationship with these patients. So sometimes if they're just not doing something well or whatever, we'll talk about it. If I know I'm ahead of time and she goes, I'm just going to go in there and use my mom's voice. And sometimes it's nice, honestly, to have somebody that's not the surgeon to emphasize and be able to go in and say, especially to the high school kids, and just say, something that maybe is not as comfortable for us to say, but it's coming from somebody else that they've kind of honestly interacted with more through pre-op and post-op. And I don't know. So I've found that actually helpful because they tend to interact with their surgeon differently than they interact with me. So then they get a kind of experience. Patrick, I was going to say, you know, telling your patient when they're not being responsible, like confronting the patient about it in a way that's respectful, but tell them you're disappointed that they're not doing their part. And I think the other thing is then setting goals. So, you know, if you're not attending PT, we talked about the importance of pre-op, and you're not showing up. So I'm going to be checking on you, and I'm going to have your therapist tell me if you're not showing up. I want to see you attend, you know, four visits by your next return with me in four weeks, kind of like or else, and contracting with them to do the right things. I mean, if they call and break something, you know, that's a pretty big penalty. I think I'm fortunate they do things like that. There's not much to say except, boy, that's unfortunate. Now we have to take you back to surgery. But for me, it's really the they're not going to PT. They're not doing their exercise at home. And I think you just got to push them and tell them that you're going to set goals and expect them to hit that. Here's exactly what you need to do the next time you come in. And that seems to help. And then also, I'm going to tell your mom to call me if you're not doing it. And you should have a little bit of a threatening personality, and it helps. So probably it helps. There's another question in the back. Yeah? I'll just add to that. We have an obligation to find out why. Try to maintain a good relationship. It's okay to say why when you're not following the protocol. Because sometimes you don't want to get angry and say, you're messing this up. You're doing it in a place with a signed claim. Maybe there's something going on with your patient's life or something. Your husband's dying. Something's happening. You're not disclosing it to me. So, you know, just ask me why. I'll go back to you. Yeah. We talk a lot about the aging athlete. You have to modify their gait so that they can play the same piece with age and want to continue. Probably not true for the aging chess player. I don't know. But for the aging orthopedic surgeon, what needs to be modified to avoid complications? Okay. Fair enough. I see you've dealt with that. What's your role? And do you go out and do this? Yeah. I think if you're asking, like, you know, how do we deal with, like, the aging surgeon, and if they, you know, maybe are at the top of their game, is that your question? Yeah. And we're all going low. But you lose some stamina. You lose. You can't practice the eight cases a day you normally do. You do lose a little bit of cognitive ability. That may not be an issue if it's automated. But there are other issues. Should we address that as a society for the aging orthopedic surgeon? Yeah. And I'll say, so I hate that Matt's asking me because it makes me think. Your question is not addressed to me. I'm not sure why he's asking me. But I will say, so I have a role as, like, vice chair of our department, and I get to handle all that stuff. And we've had some issues recently. And, boy, it's one of the most difficult things to have to talk to another surgeon who's aging and is very respective and all that but is slipping, clearly, you know, based on complications, patient complaints, fellows, and residents are talking, and all those things are going on, and you know that the person is not capable in the same ways. And I think, like, you know, I hope everybody, every surgeon has someone in their lives I can tell them when they're slipping, you know. And sometimes even telling people around you, as you know, you're getting a little bit older, hey, like, can you tell me, you know, or at least be honest with me. But lots of people don't have that insight. And so I just think you have to have a strong, whether it's your practice or a department, like having someone that's in a role that's usually going to be, like, a vice chair or something to have a discussion. It doesn't go well all the time. There is cognitive testing available. There's other ways. And so for us, it's getting a person to realize it's happening a bit, asking them to slow down, and occasionally it's monitoring their practice. Having a colleague in their area, you know, it's foot and ankle or something else, somebody else kind of watching a little bit and helping. But just being honest with somebody, it is a challenge. We should monitor it better. And I don't think you do a great job in, you know, any of our societies or something about really having a plan for that. It's uncomfortable. You know, our senior surgeons, we often have a lot of respect, and they're some of our best people, but there's some age in which that changes. I think it is challenging. I think you may be asking more than just policing the declining surgeon, but I think you may be asking what can we learn from Tom Brady, somebody who's getting older but who still wanted to perform at your best. This book, D.U. 12, I've read it a couple of times. Our bodies aren't made to do what we do. The things that we get physically, neck problems, nerve problems, are self-occupational. That's just being a surgeon. But we can learn from athletes, not just, you know, take the chess players aside. As I get older, you do less cases. You stretch the night before. You keep your body in good shape. Physical fitness is a big deal for surgeons. So you've got to keep up with your health aspects of it. Nutrition, I used to think that I didn't have to eat all day. I would get cramps because I'm unhydrated and didn't eat anything by 4 o'clock in the afternoon where I'd have tetany in my arm. I hydrate throughout the day. Now I have whole game plans on how to approach it like an athlete would approach an endurance sport. And sleep is such a big deal. We take for granted that we're residents. Sleep is like a priority, at least for me at this point in my career. So I have a whole athlete's approach to being a surgeon. Thanks very much for this non-traditional ICL topic. None of us do enough cases that we'll experience all of these complications or all possible complications. So we've got to learn from each other. And our MNM peer review conferences are joints and spine and trauma, very rarely sports, which is a great thing. Another good way besides this is reviewing legal cases because very often, as Chris pointed out, one mistake leads to the next mistake. One small mistake leads to some huge, catastrophic problem. So thank you very much for doing this. It's been a great ICL. My question is, what do you do when you're assessing the results, six months, a year, five years, whatever it is, and your subjective outcome is different than your objective outcome? Say your patients are, this happens all the time, they're very happy. Patient outcomes, their scores, whatever they're reporting, they're really happy. But you're not as happy. You hear something on the X-rays, or your tone's in the wrong spot, or they've got a pitch shift, and yet they're totally satisfied with that person's work. I used to think that we needed to tell the patient that their surgery wasn't successful, which I now know is wrong. But how do you handle that situation? Great question. We've all felt our ACLs, and there's a couple that I'm unhappy with. I felt my own ACL, and it really didn't allow me. I did not feel like I wanted to feel. And I'm usually pretty honest that I feel a little looser. But I don't do it in the way that destroys the patient's confidence. Because as you said, the patient thinking they're okay is probably the most important thing. They think and feel they're okay, but they're okay. But it certainly is my office staff and the people who are seeing the patient with me, and I'm pretty honest, and I try to look at why it might have happened. But it's a great question, because I don't think the role is to say you need to revise your surgery just because it's not technical, or to be so honest that you say your surgery is a failure. It was a success for them. But I think you can hopefully be in there for them. I think, too, this is one of the slides that I had in mind, is using whatever information that you're supposed to use, you're kind of critically looking back at whatever time point it is. One of the things that I've learned with ACLs is that one of our ongoing studies is imaging their involved side and uninvolved side at multiple time points. And I really realized my tibial tunnels were too posterior. And we talked so much about the femoral tunnel, it's all about the femoral tunnel. And I had an example in there of, you know, my tibial tunnel was pretty posterior, and the kid re-ruptured, and, you know, I kind of thought, well, he didn't rehab well. He went back to the sport before I told him to. But, you know, looking at, as you said, X-rays or whatever it is, maybe it's objective things in the office, and being willing to change, I think sometimes can actually be very hard. And we think, well, you know, it's fine. It all depends on the subject. But being willing to improve based on other things that we're seeing post-operative is important. And I'll say, yeah, so we do, like, if we say ACL is the example since we're talking about that, so we do a KT-2000, like the old, like, so every patient gets, like, a functional test. They do Biodex, they do the KT test, they're doing hopping before anyone goes back, because most of us do that. So they do the KT, and it's, like, in your face, like, if your ACL is loose. And the patient, you know, they all see their notes, and I'm sure all of you see that in your practice. The patient had their, any note that's generated, essentially, they get it. So there's, first of all, there's no, you know, ability to, like I say, eye that, that's looser than the other side. They're seeing, actually, that data, and when they're doing the testing, they hear the numbers, they know it's different. So it's probably a little bit harder to hide from that. And I think, so in our practice, talking about what those tests mean, and, you know, whether or not it's the concern, I think it's important to disclose if, you know, if there is some laxity in talking to the patient about what that means, that they don't feel instability. If they do well on every other test, you know, then I'm, you know, less likely to say, I would not say we have to do something about this if they're not doing well. But I also say, if you start noticing instability, what does that mean? You know, what would it mean for this to be, like, a clinical failure for you? So that they're clear about what to look for. You know, but if there are, again, other aspects that feel a little loose, but they're doing well clinically and the other tests are good, you know, I certainly, but I feel like it's important to tell them that we just need to be watchful. And that's a great question, because looking around the other side, everything objectively was, you know, the patient's upset, frustrated, or something. There is a recent populism, and I think that that populism, in trying to just advocate for the patient, and not just disclose everything, because you deal with a high-level aftereffect, and it lies in their internal, and they're thinking it's, you know, especially in the first step of going out. He's got a label tape on his shoulder. Every time he walks around, the next thing he does, he gets on the phone, and he's like, this guy told me I got a label tape. And it's like, it becomes a whole thing. So you choose words, depending on how psychologically affected this person is. You know, you have some adaptive changes in the shoulders, like he keeps, or he's just lying around, having label tapes. So I'm worried about the patient who's going to respond to intrusive thoughts about the pain in these groups. And sometimes, as a coach, or as a judge of the patient, how much information do you want to give? I don't know if that's right, or more comfortable with this. Because we all like to be honest and say, this is what you got. So sometimes I tell patients, I tell patients, I'm going to tell you something, and then I want you to forget everything else. You know, the typical one is, if you have an arthroscopy, and the patient has some underlying arthritis, that wasn't fully appreciated, or maybe it is, got a little arthritis, now that I said that, forget all about it. Rehab, get back to it. Pretty much out of time, so feel free to leave. If you guys have questions, I'm happy to take the chance and certainly appreciate you being here, and enjoy the rest of the meeting. Thank you.

patient responsibility

surgeon accountability

complications

aging surgeons

patient satisfaction