Everyone, I'm Matt Tao from University of Nebraska. We appreciate you guys being here for ICL 205. Since it's not a huge group, as long as you guys can all see it well from that side, we have kind of the smaller room. So if you wanna shift over, certainly feel free if you wanna be closer to the screen. But whatever you wanna do, feel comfortable doing that. But definitely appreciate you all being here. This is a different kind of ICL, obviously. I mean, we'll go through some technical trips, tips and tricks of things as we go on to some of the site-specific things. But the hope here is that this is something where we can kind of talk openly about something that affects everybody. It's not something that's often talked about from the podium. This was kind of the brainchild of Beth and Chris, actually, Beth Schubenstein. So there is a change in the schedule from that. Unfortunately, they did have a family emergency, so they, just on Wednesday, were not able to come out. So very graciously, Jackie Brady has stepped in to help with Beth's talk. And Chris actually recorded his. So apologize for the late change on that front. But hopefully, this'll be kind of a fun talk. We want it to be interactive. I think that's generally the case with these ICLs, but certainly with this one, certainly stop us along the way. This, hopefully, will serve more as fodder for discussion than anything else. So in terms of disclosures, really, I guess the only main disclosure is that we all have complications. Hopefully, we're not too much experts in them yet, but nothing really relevant as far as this goes. So just to introduce the panel a little bit more, Chris's talk, like I said, will be recorded, so we'll have that up. Chris is from Columbia, takes care of the Yankees and NYCFC soccer. So he's gonna be talking about throwing elbows, some kind of hardy and soft complications. Jackie Brady's out at Oregon in Portland and is an expert in patellofemoral, so really aligns well with Beth's side of things there. I'm at University of Nebraska, like I said, and then Allison is a tremendous shoulder surgeon at Duke. She actually did my surgery on my shoulder when I was in residency, and so I didn't bring my sling with me. I still use it sometimes when I'm not operating, so we can talk about myself as a complication along the way. For those of you that don't know, Nebraska is part of the country here. I put this in when Beth and Chris were gonna be here, just because most of the time, they assume that it's not actually part of the country and people get confused with where it is, but it's kind of smack dab in the middle, and it's actually been a really fun place. Here's kind of our rough outline. I'll talk for a little bit at the beginning just about some kind of strategies around how to manage complications in general, and then we'll get into some of these specific things with shoulder, with Allison, Chris is gonna do elbow, Jackie will do patellofemoral, and we'll do Q&A and ACL and things at the end. What I would say is, I think the premise of this talk, just in one phrase, can be somewhat summed up by former Secretary of Defense Jim Mattis, this is a really interesting book that's not that old, that he said, we learn the most about ourselves when things go wrong. I don't know how many of you can resonate with that, but I remember being a resident at one of our VA services where we had a ton of autonomy, which is somewhat true of, I think, most VA services, and I just found myself yelling, slamming instruments down, I don't think I've ever told Allison this, and I thought, gosh, is this really who I am? I always thought I would be just cool under pressure, totally composed, no big deal, and it was really not me, and I thought, I can't go through my whole career like this, but I think this phrase is totally true for many of us, and I think many people have seen that through training, and if we're honest, sometimes see that in ourselves, that when things are tough, especially in kind of a high-pressure acute situation like in the OR, it sometimes reveals things that are challenging for all of us. So just to start out, just to kind of frame the perspective, one of the things that I have really, really come to appreciate over time, and I still very much consider myself young in all of this, but is that there's a difference between knowledge and wisdom, right? Meetings like this, studying anatomy, looking over surgical techniques, those things can definitely help improve our knowledge, we should do those things, those things are great, but there's a difference between wisdom, which is really gained over time, and so there's something about that kind of gray hair perspective, if you will, that really should be honored and respected, because it's just not something that comes easily, and so hopefully some of that will come through here, I mean, and my part's just trying to draw on pearls that people have taught me, and you'll hear from these guys as well on that, but just a couple quotes from people that I respect to start out, Bill Richardson is a spine surgeon, and he said at one point, if you don't have complications, you're either not being honest with yourself, or you're not operating, and I think that's actually very true, sometimes we like to pretend we don't have any complications, but obviously all of us do, and then Kevin Garvin is an arthroplasty surgeon, past president of the Hip Society, and said just remember that surgeons don't have complications, but patients do, and hopefully these things are hard for us, you know, I remember calling Allison my first year, and just saying, I can't even remember which one it was, but this is awful, and she said, it should be awful, these are awful, you're taking care of somebody where you've electively indicated for surgery, and they've had a bad outcome, like that should be terrible for us, but you have to remember that they're actually the ones going through it, so I think those just kind of help to frame some of what we're talking about here. I don't know how you'll view this, this is, probably you'll look at this and just say, wow, I'm really glad these aren't my patients, but these are pictures of some of my patients, my kind of not top 10 if you will, and I was telling one of my buddies yesterday as I was just reviewing this, saying it's very humbling looking back through all of my cases, because I make a note anytime anybody has a complication, and looking through every one of your complications over the last few years, going, man, there have been more than I like to admit, I think there's not that many, but if you really look at it, there's a lot, and they're not insignificant, you can see that top picture is one of my colleagues that did a quad tendon repair on, and he fell and completely re-ruptured the whole thing and pulled the little anchors out of the bone, cuff that failed very quickly, went on to CTA, another one of my colleagues in the bottom right there did a meniscal root on her, and she went on to rapid onset medial compartment arthritis, and under a year, septic knee after a knee scope, DVT in a young kid, I mean, some of these things are really, really not fun to go through, they're much more fun to talk about here, especially when they're not your own, but you guys know that, like when they're your own, it's really, really not that enjoyable to go through these things. So I kind of broke it up in different sections here, and Jackie, Allison, please jump in along the way here, but probably the thing that I was most nervous about coming out of training was intraoperatively. You're out on your own, for those that are young or in training right now, what do you do when something goes wrong in the OR? And I think that's part of the whole reason for being here is because it's not a matter of if, but it's a matter of when, right? We know that's gonna happen, and so, to a degree, you wanna mitigate those things ahead of time, which we'll talk about, but they're gonna happen, and so I think you have to know how you're gonna respond, and some of you may know Jocko Willink. He has a really popular podcast. I think this was actually the first book that he and Leif Babin wrote, but they were former Navy SEALs that now do business consulting, and I think this is actually a great book because all of us, to some degree, are leaders, whether it's just in clinic or the OR, but they talk about here that it's easy to just get overwhelmed, and that even the most competent of leaders, when a lot of things are going on, you can get pulled in a lot of different directions, but they say that leaders must determine the highest priority task and execute. When you're overwhelmed, fall back on the principle of prioritize and execute, and I think that's definitely true in the OR when something goes wrong. So, for me, this has been really helpful. When something goes wrong, even if it's not a big thing, but we hit a, I was doing something in the back of the knee the other day, and a wire hit one of the little veins, and it started to bleed a ton, and I was like, oh, man. It's like you're deep in this hole. I'm kind of having the light down like this. The resident's like, wow, that's a lot of blood, and I was like, stop talking. I know it's a lot of blood. You don't need to tell me it's a lot of blood, but I try to hit the pause button as soon as something like that happens. I'm not saying run out of the room, but just for a split second, just stop, and I'll literally just stop for a second, close my eyes, kind of relax my shoulders, take a deep breath, and then go on. It doesn't have to be long. It sounds kind of silly, but for me, it's just a nice way of just saying, we're gonna be okay. Just reset for just a split second and say, we're off the game plan. We gotta focus and get on, and then I think that second step is to focus, so whatever else is going on in the room. I like Rihanna, so Rihanna radio's usually blasting. The scrub techs are usually talking. Anesthesia may be eating breakfast. Whatever's going on, just focus on it and remove some of those distractions, so if there's other things going on, you just have to put those out of the way. Focus really acutely on what the issue at hand is, and then I think this is something that I know these two and Chris all have talked about before, but be willing to ask for help. This is something that is not easy to do. When you're new in practice, it's not easy. I'm sure as you get further and further into practice, it's not easy, but it's okay not to know, and I think the crime in some of this is not being willing to ask for help, and so personally, I take it wherever I can get it, so I have no problem asking the scrub tech, the resident, and the nurse, like, anybody have an idea of what would be best to do here? I mean, just the other day, it wasn't something bad. I can't remember exactly what it was, but the rep said, what do you think about using this? And I was like, oh, yeah, I hadn't thought about that. Okay, yeah, let's do what Chris said. That sounds really good. Let's do that, and so be willing to ask for help, because sometimes people just see things a different way. Same thing, ask one of your partners to come in if there's somebody next door. It doesn't have to be sports, but sometimes my trauma partners will be next door. Actually, when we hit that bleeder that I was talking about, one of my hand partners was next door, and I was like, call Joe in, please. Somebody have Joe come into the room, and Joe's like, what do we got going on here? And I was like, you're used to working with vessels. Can you help me sew this up? He said, you can do it, and I was like, I think you'd be better at this. I'd really feel better if you were in here, and honestly, sometimes just having a second presence in there just helps you relax, like even if it's just talking through, somebody walking in the room, and you kind of saying, hey, this is what we got going on. I'm not quite sure what I'm seeing here, or the fracture's not reducing, or can't get the meniscus fixed, whatever it is, just having somebody to talk through it with can be really helpful. It doesn't have to be long, but just don't be afraid to call somebody in, or phone a friend, you know? I mean, I remember in my first year, I called Bob Marks in the middle of, or at the start of a case. It was the first needless location that I'd taken care of, and a college basketball player, unfortunately, and she, when I examined her ahead of time, I think I undersold how much dynamic firing she had, and she didn't seem that unstable laterally, and then we got in there, and she just gapped into a ton of errors, and had a really high-grade spinoff, and I was like, well, I'm not quite prepared for this. I said, hang on just a second, I'll be right back, and so I went and called Marks, and I was like, Marks, tell me what to do, and that's okay, right? Like, if you need to scrub out for a second, and Marks would actually do this during big cases, you know, with some regularity. Like, if it was a long case, like, just scrub out for two minutes. Go get a drink of water, splash water on your face. If you need to call somebody, like, that's totally fine, but don't be afraid to ask for help if something's going south. I think what you can't do is these two things. You can't let one error or one bad thing start to snowball into a string of mistakes, and we've probably all seen this happen. Hopefully not to ourselves, but probably in actuality, it's happened to all of us, but where it just starts to snowball, and things, you know, just start to go south, and south, and south, and that's why I say, I think if you can focus and just correct what's going on, and then just move on. I think the other thing that's hard just emotionally, and this is on the softer side of it, is don't let it just totally derail your day, because if it happens at the end of the day, that's one thing, but most of the time, it happens when you have either a clinic in the afternoon, or you have other cases, and you still have to get through that case, and so I think emotionally, sometimes that's really hard. You're just kicking yourself, especially if it's something that you did. Deal with it at the end of the day, right? Take some time to reflect, come back. Don't beat yourself up too much, even though we all do, but deal with that at the end of the day, but you gotta get through the day first, right? You have to be able to manage everything, and the patients need you there, especially if it's in the OR. You can't short the patients that come after this one, so just don't let it completely derail your day. This is an example of mine. This was a 16-year-old girl who is second or third opinion, and I think probably was misdiagnosed, honestly, from the beginning. She had what was probably just an OCD lesion, but had had a couple surgeries. It was this lateral trochlear defect. You can tell here, the cartilage really is not that bad. Most OCDs, it ends up being pathology underneath the bone. So she had fairly significant cystic changes underneath the bone. So planned to do an osteochondral allograft, and nothing really special about that. You can see this is obviously a much, I'm measuring it out based on MRI, so bigger area than you would see just based on the surface, but things are going smoothly. Mark out the grafts. I'm taking all these pictures, which the staff finds annoying. Ream out the defect. Go to put the plug in. Everything's going well. Rihanna's blasting. Everybody's in a good mood. We go to put the plug in, and it ended up that they gave me a 25-millimeter reamer instead of a 20-millimeter reamer, and I didn't look at it, and so it was, or maybe it was 22, but it was the wrong size, and the plug is grossly undersized. Not like, oh, maybe it's a little bit loose, but this is definitely the wrong size. So Mike Barron, as Allison knows, is a high-volume arthroplasty surgeon in Indianapolis, and this is what he calls the not-so-fresh feeling. You've probably all been there, and obviously, this isn't a huge thing, but you only have one of these grafts, and so whose fault is this, right? Like, you're in the middle of the case. This sucks. There's no way around that, but you can't use that. It's too small even to consider maybe using a compression screw or something like that. So is this the tech's fault? I mean, they handed me the wrong instrument. Obviously, they should have checked that, but no, right? This is my issue. This is, they did hand me the wrong instrument, but I actually neglected to look at it. I should have looked at the reamer. Since this case, I always look at the reamer, but I should have looked at that, and either way, you're the surgeon, right? You're the captain of the ship, and so everything for the care of this patient ultimately falls on your shoulders. That's one of the principles actually in that book, Extreme Ownership, that they talk about is that in the end, if you're the leader, you're the one who's responsible for everything for better or worse, and so I'm glad my staff's not here because I don't always handle this perfectly, and they'd be happy to tell you that, but in this case, hopefully we did. There's not really a point in yelling or screaming. If it makes you feel better, you certainly can. One of my partners likes to stomp his foot when things aren't going well, so sometimes we do that just out of spite for him, but you just have to change course, right? I mean, regardless of how upset or frustrated you are, you still have to fix it, and sometimes there's not necessarily an easy solution, but in this case, just go to a different part of the graft. It's not a huge deal. You can tell if you look at the sides here. The fit is not exactly what I wanted. I mean, I'm not super happy about that. If you look at it kind of in profile, it really does look pretty good, and it ended up not being a big deal. She's two years out now, she's done very well, but in the moment it's not fun and that tech, you know, I mean it was over two years ago, she still brings it up and every now and then like, remember that time I handed you the wrong reamer and I'm like, I do. In fact, I use it as an example sometimes for cases, but maybe let's pause there for a second. Any, for you guys, any tips on intraoperative things, like when something's going south and how you like to handle it more just emotionally as opposed to like specific case examples? Yeah, Matt, I think your point about taking a moment or taking a breath, I think that's, that's really important and you can do that in several ways. I know people that sort of actually scrub out for just a minute and go out in the hall. I think that's particularly if you're upset with your staff, sometimes that may be better than, than, than losing your cool, but I do think it's that ability, like when something's going wrong, you have to focus a lot harder than when, you know, things are going correct and going well for you, but I think your points are well taken. Something like this that happened to you with the osteochondral allograft, if this was like a medial form of condyle and you had a hemicondyle and that had happened, you might not have been able to recover from that so well, so I'm really glad that that worked out. Of course, that was a great thing to do here, but some of these things can be, you know, less salvageable and I think that that's even the more of the challenge of how to handle, you know, things when you can't fix it like this in the OR and that's some of what we'll talk about is, you know, when things really go poorly and you have to leave the OR with it unfixed, that's certainly even more of a challenge, but I like your thought, it's about stepping away and don't let it derail. Most of us have multiple cases in a day and you have to stay, you know, focused, but then taking your time to decompress and I would really encourage, as I know Matt, I know you really do this, when you say you ask for help, I think what that means to me is that when you've had a complication or a problem, particularly if it's really troublesome to you, calling a mentor, calling even a colleague, like somebody that's your same age, like when you're first out of fellowship, fellows call each other a lot to say, you know, you know what happened to me, I can't believe this and it really helps to touch base with same age peers to normalize that, that this happens to everyone, but something, you know, like this, I think calling for help with mentors, you know, I hope that people that do fellowships feel like they can call back their mentors in fellowship or residency, you know, or others that they know. I feel like it's a sign of strength to be able to call and discuss the case and ask what would you have done and, you know, and probably even better, Matt, calling before cases when you know there's going to be a challenge and not being afraid to say, I'm not even really sure about the order, can we just talk through this case. I think that people sometimes feel like it might be viewed as they don't know and so when they're asking about that, I think that that is, it's kind of a shame when people don't want to ask. I think most of us that have been doing this a long time, you know, feel like that's just great to talk through. So many of the tips are not things you can read in a journal article and when somebody's showing their very best video, you know how that goes, you know, that's why I was kind of glad yesterday in the general session to see somebody have a little bit of a struggle like exposing something like that's the real life right there, seeing Preventure do an absolutely perfect exposure, everything was already done, but, you know, that's the real life was the first case, that's how it goes for all of us. We have a little trouble exposing something or doing something, so I really, you know, I think it's just great to reach out for help and then take a breath when you're struggling in a case and stuff. I'm sure, Matt, you struggle more than most of us so I'm sure you can comment a lot. I'm really glad I asked you to be a part of that. Jackie, any thoughts there? Hey everybody, I'm pinch-hitting for Beth Schubenstein and so I did my fellowship at HSS with Beth as my main mentor, but there were many people there and so I'm gonna share with you my very best tip because about six months into practice I had one of those moments where it was like, I'm gonna be here all night, that terrible lack of the person sitting over your shoulder just saying, that looks good, or I would do this, or hey why don't you try that, and I remembered that Andy Pearl, one of the cartilage restoration surgeons at HSS, who I'm sure has lots of talks here as well, he turns on Neil Diamond on the music, so Rihanna works for Matt. Neil Diamond is a real, like, sort of special power or something, I don't know, and so I ran into Andy Pearl at a meeting a couple, you know, months down the road and I was like, thank you for sharing Neil Diamond with me and it's been working and he's like, you know, I think he's losing his luster for me so if he doesn't work for you, try Kenny Chesney. So if Neil doesn't do it, then put on Kenny Chesney and that, I say with some jest, but actually it's become kind of a signal, so it's this recurring theme, right, like I struggle in the arm more than I would like to admit sometimes, and if I say to the staff, hey could we put Neil Diamond on the music, that's sort of a signal in jest, but like a real signal, like, hey everybody, this is a struggle, let's focus, let's like bring it home, and so if you have, if you have your team with you, I think that matters a lot. If people alienate those in the room around them as they're struggling, as they're starting to get frustrated, I don't think they realize what they're losing, because everybody in the room has good ideas sometimes and you don't want to lose that objective third party, fifth party, sixth party, anybody, I'll listen to anybody if they have a good idea. So I think if you can keep it humorous, take a deep breath, just keep it internal if you're really, really mad, and try to keep it as a team in a foxhole together, then I think that the benefits of that are hard to quantify. Yeah Matt, I just want to say one other quick thing, and you just spoke of this a little bit Jackie, but the, you know, kind of something like a second victim thing with your staff, you know, I'm in a role of patient safety for Duke Orthopedics where every complication is something that I hear about and see and have to keep track of, and actually a lot of the problems that follow are the staff, you know, felt belittled or got, the staff gets really upset when they make a mistake and sometimes we forget to get back with them and tell them it's actually, it's okay, like everybody makes mistakes and our staff, you know, we're all, when you get to like an orthopedic surgeon, you think about the level of training you've had to have along the way, sometimes surgical techs or scrub nurses, you know, even if they've been working for years, they don't have like the same level of confidence in themselves sometimes and all, and that can really, you know, sometimes easy, like I have quite a temper as certainly Matt knows in the OR too, and I can get really short with the staff and they take that home and it really hurts them and when they make a mistake and they know they made a mistake, sometimes you forget that these folks are, you know, really human and they really lived this for months and even years and when they make a mistake, so, you know, take some time, right after the case actually, I try to take some time and tell them it's okay and they made a mistake, you know, of course none of us wants it to happen again, but check in with them and then a couple days later, check in with them, make sure that they're okay. Yeah, I mean, you don't have feelings, so you probably don't get upset when people yell at you, but for, I think it's a really good point and actually in this case, Candace, who's my, you know, one of my main scrub techs, she's great and she just started like, oh, I can't believe, and I said, Deuce, we call her Deuce, but I said, Deuce, it's okay, like, let's talk about it at the end, but focus on the rest of this case, like, I have to focus, but you have to focus too, like, we still have to get through the rest of the case and we did exactly that, I just sat down at the end and I said, look, just spend two minutes to just say, you've seen me screw up plenty of times, I haven't seen you screw up that many times, this is fine, we're okay, you know, but some of it kind of falls back on what you said too, Jackie, is just having a relationship with these people, so let's go on to the post-op stuff, so less of the acute setting intra-op, but how about when somebody comes to clinic or you get a call from the ER or whatever, this is not just because Chris was a part of this talk, but if those of you that haven't read this book, it's actually a very short read, it's really good, one of the titles of one of the early chapters is called, It's Not the Environment, It's You, and so I think this concept of taking ownership of our complications is hard for many of us, like, it's just counterintuitive, it doesn't feel right, but it is something that I think is really important, it doesn't mean that we need to assume fault, like, from a legal standpoint, and it doesn't mean you need to beat yourself up, but it does mean to say, again, we're the captain of the ship, you're the one that's responsible for this patient, you have to take responsibility for what's happening and fix it and let them know that you're going to be with them and show empathy along the way, and so similar to intraoperatively, I really hate running behind in clinic, but this is something like when something really goes wrong, I think you have to stop the clock and just say, all right, I may be behind in clinic or I have to get to you or whatever it is, but give that patient and that complication the time that it deserves, and I think, again, this is on the softer side of all this, but I think your posture in these times really matters a ton, so meaning both physically and emotionally, so sit down, like, I really like to sit down and just get on my level with people and just not feel like they have the sense that you're rushing and I got to go, we only have a minute to talk about this, but even though internally you're, like, angry with yourself and thinking about all the other things, just give them the time that they deserve and just sit down comfortably and just get on eye level with them and let them know, ultimately, that last picture there, that you're in this together, you're part of the same team, and you're gonna get this fixed, and that fixing part is not always easy, and sometimes it's not us that do it, and that's okay if you have to ask for help for that, too. This is one of mine from my board collection in my first year that I still take general call, unfortunately I haven't figured out a way to get out of it yet, but this is a nine-year-old lady that came in with a hip fracture, and so we're doing a HEMI for, and I decided to press fit it, which you can say 90, that's a stupid idea, I don't necessarily disagree retrospectively, but at the time I thought, she's actually got pretty good cortices there, she had kind of a dwarfy femur, she should fit this, you know, geometry of the stem pretty well, really went slowly with the broaching, got an intraoperative film, looks good, got a post-operative film in PACU, looks good, she comes in for her first three-week appointment, and I see this before I walk in the room, and I'm just like, oh, and it was already in my first year of practice where I'm super inefficient, I'm behind in clinic, and I was like, this is just awful, so I walk into the room, and literally before I said anything, this is not an exaggeration, they spent probably two minutes just effusively praising me, this the patient and the daughter, just, Dr. Tao, you are just so good, we are so thankful that we came here, we're so glad that the ambulance brought us here, you have taken such good care of us, and I'm like, this is just crazy, so, and I said, well, I am really appreciative that you guys are so grateful, but I have some bad news for you, so, and you know, this is in my board collection, and I thought, well, we did a lot of arthroplasty in residency, but I haven't done any really in two years now, so I called one of my partners, Bill Konigsberg, that's one of our joint surgeons, and he said, you know, yeah, you can do this if you want, but this is why we're here, like, I'm happy to take over for you, so put the ball in motion, getting her admitted and all that, and I walked back into the room and said, hey, you know, we're gonna get this fixed, okay, this is really not great, but it is a fixable problem, we're gonna admit you to the hospital, I already talked to Dr. Konigsberg, he's one of my partners, all he does is total knees and total hips, you're gonna be in great hands, and no joke, at the end, they said, well, you know, Dr. Tao will do whatever you think, but we just have to ask, is he as good as you are? Literally all I've done for this lady is, she came in with a broken hip, and I broke her hip in another place, so, like, I can guarantee you that he is better than I am, and he will get this fixed in the right way, and sometimes we need that, right, sometimes you need another win, or somebody to co-scrub a case with you, or whatever, and so that can be quite helpful too. I may have kind of mentioned at the beginning, I don't pretend to have all the answers in this, I don't know that any of us would say that, but I do think this is something that's really important, we've kind of alluded to that, this is something that we hear about in training, and once we're out, that even just purely from a medical legal standpoint, your relationship with the patient matters a ton, and I can say for me, and I think this is true for many of us, that you see these people on the schedule when they're coming to clinic, whether it's, even if it's not a complication, but just a difficult patient, and you kind of go, oh man, I do not want to see them today, maybe the PA can just see them, and I can just walk by and say hi, maybe we'll just have the resident go in, and that's the tendency, right, is to pull back, and just, or if they're not doing well, maybe like, yeah, I don't need to see him as often, I'm just gonna see him in a month, hopefully it'll be fine, but I really have to fight that urge, press into these people, see them often, make sure that they know you care, show them empathy, and give them the sense that we really are on the same team, you know, this is something that I feel like I got a lot from Allison, is just, build a relationship with these folks, it doesn't mean you need to be best friends, but they should have the distinct impression that you guys are in this together, and that you're gonna help get them through this. Jackie already kind of alluded to this, which was perfect, but much of what we're talking about is kind of on an individual level, but I completely agree with what Jackie said, that I think if we're gonna succeed as surgeons, we're gonna succeed as a team, and we don't necessarily always have control over that, depends a lot on your practice setting, and a number of factors, but I think building a team around yourself that has kind of the same perspective, and the same goals, is really, really ideal if you can do that, and for those of you that haven't read this article, I don't know how popular this article is, it's quite old now, from the 80s, but it is a short read, it's very quick, and it's really, really good, and they contrast the ideas of the theory of bad apples, versus the theory of continuous improvement, and it's roughly speaking about how you motivate people, are you somebody that's kind of this foreman in a factory, where you're constantly yelling at people, telling them, you've got to go faster, you've got to do better, you know, you're never gonna be good enough, or are you somebody that says, look, our goal here is to be great, if you see something that I'm doing, or that the system's doing, that's impeding that, let us know, we want to fix that, I feel strongly that that's the way to do it, but anyway, I encourage you to read this, it is a very quick read, to me, I think this progression is how to build a team, and this is certainly a work in progress for me, but trying to have people around you that share a unified vision of excellence, that you want people that really believe strongly that you're there to be great, and have great outcomes for patients, and then build relationships with these people, this is something I really took from Allison, and we talked about a couple months ago, actually, that it, again, it doesn't mean you have to be best friends with everybody in the OR, but a lot of times, I think, when, you know, you get out, they just don't, they're not expecting surgeons to care about who they are, and just get to know their name, even, or ask how their kids are doing, or one of our care techs really likes basketball, so we're constantly talking about basketball, if I see him in the locker room, and that kind of thing, and just get to know them, and have them understand that you value them as people, outside of just being a worker in your OR, one, two, three days a week, whatever it is, communication, this is something I talk to our residents about a lot, like, especially when you first start out, communicate a ton, ahead of time, and in the OR, like, if you have a special case coming up, one of our nurse managers said, when I started, you know, I'm glad you're talking to us ahead of time, most of the time, we just have surgeons show up for their first case, not having any communication ahead of time, and then they get upset that you don't have the right instruments, and all that stuff, and I'm like, well, that doesn't even make sense, like, how could you expect, as a new surgeon, that they'd have what you want, if you don't communicate, so I think that is really important, we have to prepare a ton, one of the things that, you know, we love seeing, especially if you go through training, and kind of a high-volume place, is, you see these super efficient surgeons, and then you get out, and you're really inefficient, you want to be fast but I think it's important not to focus on speed but focus on efficiency like the speed will come with time but work on being efficient and fixing little things along the way and then ultimately the fun part is to go out and perform right to go out and and have these cases where everything goes really well which doesn't always happen but how do we be better as surgeons Allison kind of alluded to this a little bit already and for those of you that have read any of Atul Gawande's books he talks about this in one of his book that in a lot of other professions like pro sports and business and in many other professions you have coaching to some degree along the way coaching consulting whatever that helps you try to improve over time and we really don't have that right I mean we have meetings like this where you get to learn from people on the podium or you get to hear about new research that's coming out but it's a more of a knowledge thing it's not really like a skill improvement type thing and so this is something that I think we have to seek on our own and that seems somewhat intuitive that you're not going to get better unless you want to get better but I don't think that's always the case I think this is really something that internally you have to have this drive to want to improve and for those of you that haven't read this book this is a great book it has nothing to do with medicine but it's a very popular book and it's on the idea of grit so the combination of passion and perseverance and something I think for us that we really need that you have to have that combination if you want to succeed I think that's true for kids growing up it's true really for any field but I think this quote is very apt that there are no shortcuts to excellence that doesn't just happen I think we also have to be willing to kind of take a good hard look at things and and both the good and the bad you know this is not meant to just be a talk about when things go poorly but you know kind of acknowledge when when there are wins especially when it's with the staff just say gosh that case went great today you guys like this that was really fun love how that went everybody was really well prepared it's good to kind of reinforce the positive side of it too but also take a look critically at ourselves when things don't go well ask for advice afterwards about how we can you know how can I handle this better next time or I ran into this problem with the tunnel what should I do with the instrument you know Chris talks about taking notes in there I have found that to be super helpful it may not be for a case that you're doing often but if there's cases that you don't do multi legs or a complex shoulder instability or whatever it is take notes on that because maybe you only see it once a month or once every other month or whatever and then you can come back and change those notes over time this also is a non-medical book it's called mindset by Carol Dweck and it's out of the psychology literature it is a great book just on basically having an open mindset to improvement and she has this quote in there and this is one of the themes of the book that we like to think that our champions and our idols are superheroes who were born different from us like this idea of naturals that other people have written about we don't like to think of them as relatively ordinary people who made themselves extraordinary and I think that's totally true we love watching LeBron James or Sidney Crosby or some of these great athletes and think well you know I'm not six eight and 260 pounds and I can't do that you know but we don't like to think all of the hours and years that have gone into that over time and she actually has a some very as a parent of two little girls some very cogent advice I think for parents as well and she says something to the effect of if you want to give your kids a gift give them the gift of hard work teach them to love adversity to embrace challenges and so we're trying to do that with our five-year-old Madeline and as I was putting this together there was something that she was doing I said you know Mads it's good to work hard isn't it and she goes well it's supposed to be I was like well that's a pretty appropriate response like this is a work in progress for all of us but this is this is a great book and I think there's just no substitute for that right there's no substitute for hard work and that's true in any field really so as far as patient selection goes this is a picture of David Tieran who's the CMO at Duke and just a really thoughtful joint surgeon and he gives this talk about starting practice and he kind of introduces this idea that the first five years of practice are about learning how to operate the next five years are learning who to operate on and then the five years after that you learn who not to operate on and I approach this topic definitely humbly because I have found if anything I am not good at predicting who's gonna do well and not do well and I think we have to balance the the ethical obligation of helping patients but also especially on an elective side that who do you think you can help I mean are there red flags there that you're getting into trouble just by even signing them up for surgery and as far as preoperative planning Allison kind of mentioned this already but if you're going into a tough case or really at the start every case is tough for me as she said every case is still tough but planning I think helps a ton there's this idea in the psychology sociology literature of deliberate practice where you're intentionally investing time and effort to get better and that's not really a challenging concept to embrace but the the point there is that that's an active process not a passive process right that that doesn't just happen that if you're intentional about it you're gonna get better over time and so it results in more of flow which is a psychological term or for those of you that row we're just I was talking actually to Bonnie Gregory one of the former Duke fellows the other day who was a rower and this book boys in the boat has nothing to do with it really anything that we're talking about but it's about the 1936 gold medal rowing team and they talk a lot of this idea of swing and I wasn't a rower so I don't know that I totally understand it but basically just that when everybody in that boat is in total unity that the boat almost lifts off the water that Bonnie said it was kind of like levitating off the water that you can definitely tell distinct difference when people are just off a little bit whereas when you hit that moment where everything's in in unison and and those are the cases that are so fun where you walk out just thinking man this is great like I'm great the team's great everybody's great and then the next three cases go really slow you know but but that happens more the more that you plan and the more that you practice right that doesn't just happen on its own intraoperative strategies we've kind of talked about know how you're gonna respond again not to scare you you all know this but it's not a matter of if it's just a matter of when it's gonna happen and then this idea of walkthroughs the Giants haven't been good for too long unfortunately but when I was in fellowship or worked with them and all high-level teams do this right at any different sport but they do this walkthrough of their game plan and so one of the things that I've found to be really helpful before tough cases or just a case that you don't do very often is go to a quiet place close your eyes and force yourself to literally walk through everything single step of the case like what instrument am I gonna grab what am I gonna do with that where am I gonna put my tunnel all that it sounds very Zen and kind of ridiculous but gosh for me it helps a ton and I've continued to be amazed how many times especially if you're doing it ahead of time not just like the morning up but if you do it ahead of time that you'll realize oh actually I do want that one instrument that's in a different pan for us those pins don't live at the ASC so then you have to ask for it ahead of time or you know shoot maybe I need a different implant or I'm not actually totally sure I know what to do at this step I should call somebody or read about that for me it just gives me the confidence that when I walk into the OR I know I'm well prepared I know I have my main plan I know I have a backup plan I've thought through all the steps and I feel like I have the progression ready to go here and then the last thing is when things go wrong you got to get back in the game right this is and this is hard some of these complications are completely gut-wrenching hopefully we can talk about some of those either from you guys or from from these guys as we go here one of my good friends in in his board collection the first year scope to young girls need totally healthy no medical problems meniscal repairs I recall sorry two or three weeks she was doing great and then didn't show up for a next follow-up appointment and she died and it was like I mean that and that happens but you know poor guy it's his first year he's in board collection and it was just devastating and I think back often to what an eel ran a lot told us and I saw him yesterday and said I'm still thinking about this which made him smile that he said after you have a complication the best thing you can do is get back into the OR soon which feels kind of wrong on a gut level but I think he's right you know that we can't let these failures just trouble us forever that we have to address them work on getting better and then get back in the saddle and move on so I couldn't help with any of it and with a couple different cheesy sports quotes I I love Kobe Bryant and if you look at these ten rules for success much of it is what we're talking about right like it's just how do you want to try to be great and I'm sure many of you have seen this quote this is one of my favorite quotes of all time from from the goat but I think it's true for us too as you know people that want to be elite performers that we can't let our failures define us that we have to use them to help us sprawn to do greater things going forward so that's kind of the end of the intro do you guys have thoughts on that we can launch into the case specific stuff or anybody from the audience questions things that you want to talk about based on any of that yeah please because oftentimes they go from one step to the next step I think it's better to just say we're in here with a patient and the patient is 100% without attention and the radio is going to talk about what you're going to do after after the surgery is over it should be reserved for the lion. yeah totally I know that's a tough statement some people don't like it but I mean I've seen people start talking to their stockbrokers everything else on your cell phones and everything like that and they can get out of hand so fast if you just make it reserved hey this patient is in a situation where they have a very serious complication and they do sometimes too to be put in the wrong orifice sometimes you know they have complications I just think it's wrong to let those steps go beyond the pain of taking the surgery and the patient's decision oftentimes I think that's a great point I think everybody's got their threshold that is their distraction level right and I think a lot of people I don't really seem to hear the music that's playing when I'm operating and so I defer to whoever's in the room if they have an opinion about what they want to have playing but I know a lot of people who are distracted by music and I think that's a really good point and I think the thing that always kills me is the Christmas shopping season I'm like online on the side looking up what they're going to get for their aunt or whatever I sought out a mentor after one particularly frustrating day it wasn't so much the music as just the level of distraction I had a resident who was post call and asking when we were going to be done and the circulating nurse was Christmas shopping online everybody was just sort of going off in every direction and I grabbed a mentor and was like what do you do in this situation and she said call another time out just stop everybody, re-center, start over just sort of draw everybody's attention back in which I thought was really good advice not ideal sure yeah this is a great talk I don't know what happens when you're like ACL graph won't fix it or something like that but this is actually super relevant I'm a department chief at my hospital and I have not uncommonly really high performing, very skilled surgeons that can't create that environment of collaboration in the operating room and so they won't work with that guy and that guy won't work with them so it creates incredible friction for people that are stuck being healthcare administrators for the department trying to help solve that and I really struggle with ways to help guide surgeons toward understanding that they're a team and operating really as a team and they're not just the king of their environment so any tips you've ever had with helping to get improvement out of your otherwise extremely high performing colleagues would be really helpful I feel like Allison knows this one that's a fun one so it's a great question I'm in charge as an executive vice chair of the department and I'm in charge of discipline slash anytime people are having conflicts so we have a system where people can report bad behavior slash lack of professionalism is the nice term but it's usually nurses reporting doctors is all it is but the issues I see with friction are certainly it's frequently nurse to doctor but it's also anesthesia we're making fun but these things are really real we work in different worlds, we have different motivations and so we have a program at Duke it's called One Duke Periop and it's an expectation set by the chief of surgery of all surgical services and there's at least twice a year a meeting where they kind of stop the OR even if it's several hours and have kind of a the first time it was a rally which I thought was really immature but it was kind of a thing to say the surgeon's not the king of the OR and we all have to work together and like really stop in the day and saying we gotta get this culture better and I think that that's helpful but more, you know, when I'm dealing with an individual surgeon I ask like what, let's talk about the exact, like what are the issues that you're having with this team or why are you having difficulty working with people and see if we can nail it down to just a couple individuals can't work together or if it's a broader issue of that surgeon can't work with anybody because that's a little bit bigger problem of course and then sitting people down and figuring out trying to understand what their issues are with the team and seeing if we can like change who's on the team or just change how that surgeon's thinking about it I do think it's something that takes a while and probably the most severe penalty I get into is requiring coaching for a surgeon and I like, you know, I say coaching rather than, you know, you're not going to the principal's office but you gotta get some help with your interactions with other people, like your interactions with others are poor and it's noticed by many and it's just, and it's really bringing down morale at our center so I need you to kind of work on that with somebody who might be able to help you with interpersonal relationships and so we usually will be nice as a department and pay for it unless someone's really like difficult, resistant, keeps having problems and we make them pay for it and we'll cut their privileges if they don't come around some people will leave I guess it depends on the severity, right? Like I'm not, most people have little conflicts but sometimes people are pretty rough on the staff and it's out of hand and so I think you kind of escalate from a personal conversation through maybe some coaching or changing the team and then all the way up to if you don't want to do this or can't change your ways maybe this isn't the best place, which is unfortunate but that's kind of how I handle the spectrum and just creating a culture with your group if you can so if it's okay guys I wanted to move on because I do think part of your saying I want to hear about ACLs and real complications, I think we really want to do that here too because I think that's what most people kind of expect. I think the general discussion of complications is great though

complications in surgery

open discussion

organizer

panel

communication

team building

patient selection

continuous learning