Welcome to all of you and thanks again to Mark and everybody for setting this up. I'm Jeff Dugas. We're very happy to have tonight our good friend Dr. Dean Taylor at Duke. Dean is going to present to us on a shoulder topic but also on leadership in general. Dean heads up the Fagan Leadership Academy at Duke University and is also a professor of orthopedics and sports medicine there, team doc, and just a great guy. He's a leader. I describe Dean as being a leader among leaders and that should tell you something. He is a tremendous person, a great friend, and we're really honored to have you and appreciate you doing this and taking the time to do this, Dean. Well, thanks, Jeff. It's great to be here and for those who were listening before, I'm just impressed at what you've done, Mark's done, everybody that's come together to pull this multi-institutional, I think Mark calls it the misfits. It's no misfits. It's great to see this all come together and everybody being so collaborative, which is I think what we need is more people coming together, especially at a time like this. My understanding is that for this, Jeff, I'm going to give a little presentation and then we'll have some Q&A afterwards. Is that right? You got it. You can go ahead and I'll handle moderating the questions. Okay, so I put together a little PowerPoint. I don't want to dwell on a lot of slides, but I do want to talk about leadership, the importance of emotional intelligence and leadership, and we'll talk about how that applies to treating shoulder instability in addition to the technical side of it. Disclosures, I don't think any of these will be pertinent here. Probably bigger disclosures are you got three dookies on the call, Jeff and Mark Safran and I all went to Duke Med School and I stayed on for residency and then I've come back on to the faculty. The other disclosure is I'm a West Point grad and this is West Point. That's where a lot of the leadership stuff, I think, came from. I thought I knew a lot about leadership. I was on the faculty and orthopedic surgeon at West Point for 10 years. It wasn't until I came back to Duke in 2006 and really started to create some programs that were intended for leadership development that I learned that I really didn't know a whole lot. In fact, when I think about being an orthopedic surgeon in an operating room at West Point, I had no clue what I was doing in terms of emotional intelligence. In fact, I think about some of the embarrassing things I did, throwing young scrub techs out of my operating room because they were contaminating the field because I thought that was the right thing to do. I was doing what was right for the patient. In doing so, I actually had behavior that was detrimental to our team and to their growth. I now look back on that with embarrassment. I'll tell you a little bit about how I got to that. This is what the Duke Med School looked like when Jeff and Mark and I went there. When I came back in 2006, that was our medical school. I had this idea that we could do something special with our fellowship by emphasizing leadership education as part of it. We started with leadership education with my partners, Bill Garrett, who we mentioned before, my partner, mentor, and friend who died a year and a day ago. We still think about him every day. Team Orm and Allison Toth, and that's our group of fellows from the class of 2009. That grew out into something really special that Jeff talked about, the Fagan Leadership Program, which was to honor John Fagan. The Fagan Program is a program that really emphasizes leadership development for medical students, residents, and fellows. Out of that has grown a whole leadership curriculum for the entire School of Medicine. This is our new School of Medicine. It's now been open for about six years. That's something that I've taken on as well. This idea of leadership education started small with our fellowship and it's expanded to the entire School of Medicine. Hey Jeff, or somebody may need to mute. There you go. Along the way, we also figured out we needed a framework so people could learn leadership skills. We did the research that defined patient-centeredness as the core principle for effective ethical leadership in medicine. That's why it's at the center of the model. The competencies are interdependent and also intentionally placed where they are in the model. Integrity and selfless service are foundational. I'm not sure you can teach them, but you can certainly emphasize them as a foundation for effective leadership. Critical thinking and teamwork provide the framework. Emotional intelligence, I'd argue, is the most important piece for effective leadership in healthcare. It's the keystone. That's why it's at the top. We defined emotional intelligence. What does an orthopedic surgeon know about emotional intelligence? I guess I should start there. I certainly, 20 years ago when I was at West Point, didn't have any. I didn't even know what it was. It's taken me a long time to learn. It's about understanding your own thinking and emotions and those in others. It's about awareness, and then it's using that awareness to effectively manage your behavior in relationships. For all of you orthopedic surgeons and for me, the way that I've been able to understand it is it's a two-by-two matrix. It's about yourself, it's about others, and it's about awareness and your actions. Self-awareness and self-management. Self-awareness, you have to have that before you can have self-management. You have to have those before you can have social awareness. Social awareness includes empathy. You have to have all three before you can really effectively have good relationship management. Some people, it comes to naturally. Others have to work at it. I'd have to say that I'm in the latter group and have learned to develop my emotional quotient over the years. I'll have a story for you later on that. For right now, I'll give you a case. We're talking about shoulder instability. How does this leadership stuff apply to shoulder instability? I'll give you an example. This is a 16-year-old patient of mine from about three and a half years ago. He had a traumatic anterior shoulder dislocation, boxing. He was reduced in the ED. His main sport is lacrosse, but he also plays football. He was a high school junior. We didn't have any pre-reduction films. This was his post-reduction films. On exam, and he got to me two days later, he was neurovascularly intact. He had some apprehension. These were some additional radiographs that we got. The striker notch view, I think, shows well that small hill-sax deformity. This is a typical traumatic anterior shoulder dislocation. This is what led us at West Point to do a lot of our work and research on this that showed that operating on these and doing arthroscopic Bankart repair could reverse the natural history in that high-risk population. I used to feel like an evangelist, saying these people should be operated on. I think I've changed to come to understand that an operation is one option. Trying to figure out what's best for each of these patients is the most important thing. One of the nice things, when you get these patients in early, within a couple days, you can do some things that really can help that patient understand what's going on and also help you in understanding the problem. I'll get to that in a second. What are we going to do with this guy? First-time athlete, dominant arm, first-time dislocation. The first thing his mom and he say is, we just don't want to have anything to do with surgery. The next thing, when you ask him, is what's his number one priority? His number one priority is to play lacrosse in the spring. This is August. What I do next is say, let's get some imaging. I want you to fill out this online instrument that we have that we use in our shared decision-making process. He goes off and gets his MRI. What this online tool does for me is it helps my emotional intelligence. It helps me understand what he's thinking, what his parents are thinking, and then I can use that in my relationship with him to come to a shared decision that makes sense for him while doing the right thing for him, putting him at the center. Not putting my financial gain of doing an operation, which I love to do at the center, but it's about him and it's about having the integrity and the critical thinking to understand what's going to be best for him and do it selflessly and with my team. One of the nice things, seeing him two days after the dislocation, is I can get the MRI. This is not an MR arthrogram. This is his hemarthrosis. If you get that MRI within the first week, you have your hemarthrosis already there, and it really shows this displaced anterior inferior labral tear. It also showed the Hill Sachs deformity on some other cuts. The online tool that he fills out is based on some decision analysis modeling that we and others have written about, and we get his input on his demographics. We also have a series of questions to determine what the biggest priority for him. Is it chance of another dislocation? Is it cost? Is it avoiding activities that increase the risk of a repeat injury, or is it the time of immobilization? When he comes back, he and his mom still say, well, we've got the MRI. We still don't want to have surgery, and I share with them, okay, well, this is based on your decision analysis modeling on the right. These are chances of a stable shoulder at 10 years, 89% with surgery, 61% without surgery. What's the most important thing for you? Well, for him, it was not to have another dislocation, and the second thing was he wanted to be able to get the contact sports and overhead activities. Not surprisingly, out-of-pocket costs for a teenager wasn't very important. It was probably more important for his parents. So with that information, I said, obviously, you don't want to have another dislocation. You don't want to have surgery, and with surgery, your chances of having another dislocation are the lowest. So why don't you and your mom talk about it, and I'll be back in about five minutes, and when I came back, they said, you know, you're right. We think you should have an operation. So this really helped me in understanding them, and then together, we came to a decision to operate on him, which we did the next week, and what did we find? Well, here's that Hillstock's deformity. This is pathologic anatomy that if it wasn't repaired, I think his chance of having another dislocation was close to 100%. This labrum was inverted and had to be flipped back out in order to be reduced onto the anterior glenoid rim, and if it heals in that inverted position, I think it's going to be set up for recurrent instability. We want to make sure that that labrum is reducible. We're down at the axilla with a grasper from our posterior portal, making sure that we can get everything pulled up, and then we're putting in anchors, in this case, posteriorly, and putting them down at 6 o'clock position to repair the axilla of the tear, and then in this case, these are knotted anchors. I'm probably leaning towards doing more knotless anchors for my instability, especially for tears in the posterior labrum because I think these knots can cause some mechanical irritation, but in this case, these were knotted anchors and resulted in a stable repair all along the anterior inferior labrum. We can talk about the technical aspects of the surgery later, but I just wanted to get to the decision-making and how do you determine what's best for a first-time dislocator. I didn't go in there and say, I'm recommending surgery. I said, let's figure out what's best for you, and if you are doing it with the patient in mind, you build that relationship and then you can really get to the right decision. It's not always surgery. There may be other considerations like the in-season athlete or somebody that is really surgical-averse, and if they have to have another dislocation or have some more dysfunction in their shoulder before they're convinced that they want to have surgery, then that's the right course for them. It's not the same for everybody, and as a result, I think sometimes when we look at algorithms, we can pigeonhole ourselves instead of individualizing the treatment, so I would use those algorithms with caution. For this guy, two-year follow-up, about a year and a half ago, we saw him at two years out. He played lacrosse for his junior and senior seasons, no instability, symmetric exam. His single-assessment numeric evaluation was 98 out of 100, which is a pretty good result. Not all of those contact collision athletes are going to have this result, but in this case, I'm just going to show you the good one, and we got to that by using the competencies in the leadership model. That's in the day-to-day why this model is important. You can use that. When we talk about leadership, we're talking about the ability to lead for the benefit of patients and patient populations. At its most simplest form, we're talking about leading the patient and their family members and helping them come to the right decisions. That's influencing for the benefit of patients and patient populations. It's not about positions of authority, it's about the ability to influence others for the benefit of patients. Well, how about in times of crisis? I would argue that in times of crisis sometimes we forget about these things and we're focused on on self-interest. You see people hoarding supplies of toilet papers or things like that and sometimes this goes out the window. So you have to intentionally think about this especially when when things are are tough and it's a time of crisis so that we can can have effective leadership that that is going to get everybody to the right place. Which leads me to a time, a relative time of crisis. You know, I said I wasn't very emotionally intelligent 20 years ago. Well, about five years ago it kind of came to a head and I share this story just as an example because there's so many lessons that could be learned from it. And some of you probably have heard this and I apologize if you have. But the reason I tell it is because by being intentional about learning to be a more effective leader for my fellows and for the Fagan program, for the School of Medicine, when I had my own crisis situation all those things kicked in. So about five years ago we were doing an ACL reconstruction, medial meniscus repair. I had my normal team there. I didn't have a fellow. I had a second year resident and that was the one little thing that was a bit different. We were going to work with him and have him learn some arthroscopic skills. He started the case and he, without anybody seeing, he put the scalpel on the Mayo stand and I was observing what he was doing and at the time he put that that scalpel on the Mayo stand I did not see him do it. He started doing the arthroscopy and I was watching and teaching and figured I was going to be there for a little while watching this new resident do some arthroscopy so I rested my elbow on the Mayo stand and I thought I was electrocuting. I jumped up, I had a few choice words and when the scalpel fell out of my elbow and hit the floor I knew exactly what had happened and it was at that moment that all those leadership lessons that I'd been emphasizing amazingly kicked in. I don't know, I certainly know that 15 years before when I was throwing a scrub tech out of my OR at West Point for something much less, I was surprised that in looking back at it that I wasn't blaming somebody. I wasn't focused on all the bad things that could happen in the future it wasn't filled with a lot of the negative things. I looked around the room and saw everybody on our team that was more afraid of what was going on I think than I was and we had a patient on the table. We'd already started the case. That 11 bladed had penetrated through my elbow and I knew that my ulnar nerve had been injured so I said let's just get this cleaned up. I'm going to be fine and let's get this case done and we tried to see if there was anybody else available to help finish it up and there was not. So with the help of that resident we did the case. Case went fine and then afterwards I had my own ulnar nerve repaired later that day and it was a complete tear with just some of the epineurium intact and with a group fascicular repair. I was then on the road to recovery and then followed my TINELs for 13 months as it tracked down my forearm into my hand and my strength at that point went from about 30% to about 80% and then I was able to gradually get back to doing surgery and do the operation that you saw on that lacrosse player from before. The main reason I show you this is I believe firmly that leadership can be learned more effectively and part of that is learning to be more emotionally intelligent and it's a great example at least in my mind of seeing what happens when you are focused on learning to be a more effective leader, learning to be more emotionally intelligent so that when crisis situations happen like the global pandemic or your own personal crisis you're going to respond in a way that's much more effective and you're going to be a much more effective leader. And so it all comes back to leadership and the leadership model with that focus on the patient just like in the first case, the second case we were focused on the patient to get that patient taken care of, focused on the team, having the integrity and the selflessness to do what's right, thinking critically about your biases and how to get to the best result but the emotional intelligence is the most important thing I think for all leaders because without it I think you're going to fall short. So with that I'll open it up for questions. I do want everybody on the call, I want to make you aware of the Fagan program, the capstone event, this will be our 11th leadership forum. With the pandemic we're concerned we're going to have to cancel it. All our speakers volunteered to do it virtually so we've got quite a panel of speakers from the military, from athletics, from medicine and they're going to share some of their thoughts on emotional intelligence as the keystone to leadership and also the essential element to leadership in a crisis. We're also going to have our Fagan scholars present their team work from the year and we're also going to hear from some of Dr. Fagan's patients on why he was such a great leader through his exceptional emotional intelligence. So if you want to register for it go to the website at that link below faganleadership.org and you'll be able to register. There's no cost, we're just looking for whatever you think is appropriate to donate to the Fagan scholars program for which we don't get any money from the university, we just get it from philanthropy and our corporate partners. So thanks. With that I'll take some questions and I'll share my, I'll stop sharing my screen. Wow Dean, that's awesome. Thanks for doing that. I'll read the questions to you as they come up and I've got a couple as well. Here's one from J.U. Dr. Taylor, thank you for a great talk. What are your indications for an open bank cart repair? So that's a great question. I grew up with an open bank cart before I was doing arthroscopic so I'm a little older than I look. I just turned 61. So for me, I love an open bank cart repair because I still think it's a great operation. I think you can do more with the capsule than you can arthroscopically and I think you can be very anatomic about what you're doing with the labrum and the capsule. The multi-center randomized clinical trial by Nick Mattotti in Canada showed better results. That was for recurrent instability, 11% recurrent instability with open bank cart versus 23 for arthroscopic. So I think there's a role for it. For me, the indications are a failed well-done arthroscopic bank cart repair. And so maybe an arthroscopic bank cart with one anchor wouldn't qualify for that but if I've done it and they failed or somebody that's done it well and they failed due to recurrent trauma, I think that's an indication. I think bone loss up to about 20% of the glenoid is an indication. Frequently there's bone within the capsule and you can bring that bone back into your repair with the labrum and capsule. And I've had very good results with with that. And for me, latter-gay or distal tibia, augmentation of the glenoid or combined with allograft into the humeral head, with or without for a large hillsex lesion, that for me is more of a salvage operation. I think with an open bank cart, you can restore the anatomy reliably and with good result. And on those rare occasions where it doesn't work, you still have a salvage where you haven't disrupted the corcoid and created an even more challenging situation. I think doing it through a subscap split has been a great thing for my practice because now I don't have to worry about the detachment of the subscap. Dean, let's say you have the same patient and they don't, they come in to see you, but and they say they dislocated and self-reduced and you get the MRI and it's, you know, you can tell there's a labral tear, but it's not, you know, way down the neck like the one you showed. But it's clearly an instability pattern. Again, in the contact athlete, same mentality for that. I can tell you here, we had the same mentality. It would be the same thought process and we would go through the same thing with the patients. But, you know, you trained, you were in the military and I know the first time dislocators, they get fixed and rightfully so. Do you still take that same approach with contact athletes, even if it's a little bit lesser on the severity scale of instability? Yeah, we do and actually Brett Owens wrote a great article that I helped a little bit with in JB Jess. Those dislocations with spontaneous reductions, you know, some people may call them subluxations. I think we were more appropriately, we would call them a full luxation because we know that the shoulder's dislocated. There's a Hill Sachs lesion, there's an impaction there, so it's fully deluxated and that's what's caused the labral tear. The fact that it's not locked out, I don't think changes the pathologic anatomy that much. And for us anyway, in a contact collision athlete, I think that's an indication to have that discussion about early operative intervention, especially if you're in that window of opportunity. Like for this kid, have his dislocation in August and his main thing is he wants to play lacrosse in the spring. You don't want to have that surgeon's remorse of him coming in in March with the recurrent instability when you could have done something about it in August. So that plays into the next question. Dr. Taylor, have you seen a change in rate of operative management using the shared decision-making tool for shoulder instability patients? You know, I would say yes and it probably leans a little bit more towards surgical treatment. If you're trying to convince somebody to do something without the data, I think it's harder to do. When they see the data and they see what's important to them and it's laid out in front of them, my impression is like in this case, the patients are going to opt for a more, an approach that's going to lead to a better outcome. And I think when I first came back to Duke when we didn't have this sort of stuff and I was treating patients like they were cadets and say, hey you got a shoulder dislocation, you're going to do great if we fix this. I think a lot of them just didn't come back. They were like, this guy's overly aggressive. So I learned from that I think and now having that shared decision-making, even though it takes more time, I think it pays off in the long run. You build those great relationships with the patients too. Absolutely. On the leadership front, and any of the faculty that have questions, just send a chat and I'll unmute you. On the leadership front, I teach our guys as the surgeon, you have to be the last person to freak out. That's a very short way of describing leadership. Talk to me about managing your emotions. Talk to us about managing your emotions when things aren't going well, when things don't go to plan, when you have a complication. We're all going to have complications and how do you teach people about managing their emotions to get to a successful outcome? Yeah, that's a great question. A couple things on that. First, that whole piece of self-awareness and mindfulness, understanding your triggers and understanding what you're thinking and what you're feeling at that moment is going to help you in terms of being able to manage that. Because without that, I don't think you can control those emotions appropriately. Once you understand that and you understand what's triggering those emotions, then you can focus on the appropriate management for that and how you're interacting with everybody else. With the shutdown of the medical school or at least the virtual delivery of education in the medical school, we've started a course called Physician Leadership from Daily Challenges to Global Pandemics. Part of that was looking at some things that when things aren't going well, what are your responsibilities as a leader? First, you need to know who you are. The be part, what are you going to be? You're going to be confident. You're going to be calm. You're going to be somebody that is not panicking. Then there's the do part. What do you do? You communicate. You communicate clearly and calmly. In fact, in crisis situations, it's important to over communicate. You're present and you're transparent. Those are the important things. You show your vulnerability. It was really hard for me early on to talk about having my own ulnar nerve injury because I was such an idiot to put my elbow on a scalpel in my own operating room. But I've come to learn that so many good things have come out from that by telling people about it. I mean, I think operator, people, you, Jeff, and people come up to me all the time and say, I was just talking about you yesterday and how we have to be careful about passing sharps. I think operating rooms, because we're talking about it, are safer in the United States. The leadership piece and all of that is an important part. I never knew this thing about the second victim, but the other people in that room were as traumatized as I was. And I've come to learn that that second victim piece is an important part of what I, as a leader, need to be aware of and take care of. So I think there's a lot that goes into it. But it's that, if you think about it as, who am I in this situation? What am I going to be? And then what am I going to do? And understand your self-awareness so that you can self-manage. I think those are the important things. So I assume that that resident, second-year resident at Duke in the traditional Duke model for the last five years, he's been a second-year resident, especially after stabbing Dean Taylor in the elbow. No, I'm just kidding. Tell me about how you managed your relationship, because that would obviously be, like you said, the second victim. What an awful position for that kid to be in as a new resident. Probably one of the first cases he ever did with you in one of the early sports cases. How'd you manage it? What's he doing? Did he become a sports doc? Yeah, that's a great question, Jeff. If it was up to my wife, he would have been banned to Siberia. He was so mad at him. And I said, hold on, just hold on. We got to take care of this kid, because he's a great orthopedic surgeon. And he was really interested, and he was devastated. And to his credit, he said, I want, when we present this, because we presented it at our quality conference as a complication so people could learn from it, he said, I want to present the case. He didn't hide. He stepped up, and we all learned from it. We brought the whole team together to share it from each of our perspectives, and we all learned from it, because we all saw it from a different perspective, and that was a great thing. And to his credit, he really stepped up to that. And I understood that he must have felt horrible. Everybody in the room felt horrible. Everybody was blaming themselves. But that was part of my job, was to take care of them if I was going to live up to those things that we've been talking about in all our leadership initiatives. And I'd like to say that we did. He didn't go into sports medicine. He went into hand surgery. He's a great hand surgeon now and is doing very well. I don't take credit for that, but I also am happy that he didn't let it ruin him, and I'd like to take a little bit of credit for that. It's like in a crisis, when we have cases like that or any kind of crisis, you have to realize that there's going to be a circle up at the end of that or sometime post-crisis where your behavior and your effectiveness as a leader is going to be assessed by other people. And you have to know that when you're in the operating room and you have a complication, and this is for the fellows watching, your behavior and how you handle those things is going to be evaluated by administration, by leadership, by partners, by patients, by lawyers. And you're going to have to circle back on those things and know whether you behaved in a good and leaderly way or did you not behave that way. And you have to really know that you have to manage yourself as we're talking about manager emotions when things aren't necessarily going swimmingly. Yeah, I agree. Questions or comments from the faculty, other faculty on the call? Any other questions or comments from fellows on the call? Dean, you got up to 100 people there at a minute, which I thought was a needy range. Your topic was some good love from the fellows tonight. Anybody else got any questions or comments for Dean? Yeah, Dean, this is Latul. Great talk. And the older I get, the more and more I start to look at some of this leadership stuff as something I can do. And I think I met you for the first time. This was over a decade ago, Emerging Leaders with the AOA. And at the time, I was sort of in this program and didn't quite know what was going to come out of it. And my whole thought was that, well, I'm not sure I wanted to be a chairman. And I think the whole leadership thing has allowed me to somewhat reinvent myself. It's provided more challenges for me because I think we kind of get stuck in our same old same old. We do ACLs. We do rotator cuffs. We do instability surgery. And that becomes fairly routine. There's some nuances and some advances. But I think leadership has really offered some challenges for me. And you don't necessarily have to be the chair of your department. But I think, as you sort of mentioned, it's about leading even on the small scale in your clinics, for your practice. And I think I would definitely advise the fellows to kind of don't shy away from that. Because certainly, it's the best way that you can afford change and affect change in populations. Yeah, and Latul, I think you're exactly right. And your institution is great about promoting the physicians to take on leadership roles. Think about Donnelly is now the orthopedic surgeon who's the president of Cleveland Clinic in London. And that started just because he said, well, I'm interested in trying to help out in a certain role. He was successful at it. And then it just kept building. And I think you're right. Leadership isn't about those positions of authority. It's about taking what you have and where your interests are, being passionate about it, and trying to influence things for the better in that area. And you never know where it's going to lead. When we started this leadership education for our fellows, I had no idea where it was going to lead. And now I'm the director of a leadership curriculum for the whole School of Medicine. The Fagan Leadership Program is in its 11th year. We're doing some amazing things. And we have over 200 alumni from the Fagan program all over the world. And they're sending back all the things that they're doing in the pandemic that have blown my mind. And they're attributing a lot of what they're doing and how they're doing it to the foundation that they received in our program. So the more, and for me, that's the reward that I get out of it. And the more you give, the more you get in this sort of thing. Dean, we've got a question from Jake Kelsey. Dr. Taylor, thank you for a great. Do you have any words of advice for a first year attending, joining an academic practice? How do you balance being on your own in clinical practice with teaching and involving trainees and still being a leader? It's hard, isn't it? I tell you what, that's the one thing that I think anybody, any of the faculty here will tell you. The leadership thing is, we talk about it. And you talk about it that, oh, yeah, you can do that. It's hard every day. And we fail at it every day. And you learn from it. And you get better. And then you figure out how to do it better the next time. When you're a first year faculty member, you're going to be failing all the time. And you're going to be working hard to build your practice and focused on all the things that you need to do there. And you need to find where you can contribute in a way. And if you see something where you think the team might be able to do it better, those are the times where you can speak up. And when I say speak up, as a first year faculty member, you're not going to go to your division chief or your department chair and say, I think you're doing this wrong. It's more about asking subtle questions about, why did we do this this way? Why are we having our clinic set up in this format? Is there another way that has been looked at? I think if you're asking questions and are truly curious about it with those questions, number one, you're going to learn a lot. Number two, if those questions are good, they're going to influence what's happening at your institution. So you actually are leading. You're influencing up to get a better situation for wherever you are. Hey, Dean, I'm going to unmute Bradley here for a second. You still there? Yeah, yeah. I want to know your take was on leading the AOSSM through a pandemic. I mean, you're in a leadership role. I mean, it has to be something you could never have imagined. But take us through what the experience has been like. It's been a lot more time consuming. And you have to temper your judgment. And you have to accept all kind of different people's opinions. And I've learned two things about that. Number one, leadership to me is not about me. It's about everybody else, the first thing. Number two is, leadership is about me. If I don't change my character or change to be calm or to be whatever it is, then I'm not going to have those people accept me as a leader. That's the two things I learned. But the other thing I learned is this, from playing sports. Look, leaders are not appointed by people. They are chosen by their peers. So any team you look at, somebody may appoint that guy the leader, but he's not the leader. Your peers will choose their leader. And you can see it in almost any organization, especially in athletics. I'm used to it. But I just think, for me, it was just a lot more work, which I'm not afraid of. But we had to make some very, very tough decisions. But I had a really great team. I have my presidential line. I got my board. So I have all these people around me that help. So actually, it was hard in some ways. And in other ways, it was actually pretty enlightening. So that's kind of my take on it. But I really want to get that one point across. In any institution I've seen it, people can appoint leaders, but they're not the leaders. And they may be, but they're usually chosen by their team or their peers. That's my quote. Yeah, and Jim, Jeff, I'm glad you brought that up. Because Jim, you have been phenomenal in the most unbelievably challenging circumstances to lead the organization through. And you've been engaged and reached out to the board, to your team, and made everybody feel like they are part of the decision making process. And we have a tremendous responsibility that you're at the forefront of. Because I think our society is especially this society that all the others look to. And that's an even greater responsibility. And they're looking to us now. And I think the path that you and the team have us on is great. And so I think everyone on this call should know that Jim Bradley has really done a fabulous job. And he's done it selflessly. And he's been that leader that he talks about. Yes, he has the position of authority. But yes, he also has everybody by his side because he's a great leader. Yeah, I was very surprised that they do look to the AOSSM. I'm telling you. I mean, they look at us as the leader. And I can't tell you the number of calls we get. Well, what are you doing? What's your letter going to say? What's that happening? And the more I got those, the more I realized the stakes are raised a little bit when you're there. So I got a really quick education on that. But I had a great team. So it worked out. All right. I don't see any other questions on here. So Steve, Ivan Cohen, if you're still there, I unmuted you. You got any comments or thoughts? No, I mean, fortunately, I've had the pleasure of being around a lot of good leaders. And I think that leadership is, there's two different ways to go about it. I think there's the rah-rah leader. And then there's the leader by example. And I think that you can be both. But you can't be, you have to pick and choose those times. And there's not always times when you need to be the vocal leader. And there's not always times when you need to be the, where you're going to lead by example. So I think we've all worked around our colleagues. We've all been in the role being at the bottom, coming up, and then being in the middle, or whether it's coaching your kids. Or there are so many different ways to lead. And I think by example, most times, probably works the best. And I think that's what Jim's kind of referring to, is that people will select the person that is leading by example and doing the right things. But then there's times when you've got to get on people. And again, Bradley is as good as you get on all those fronts. And I think Dean's pointed that out. So to the person who sent that email about being a first-year attending, soak it all in. Be a part of the team. That's probably the biggest thing you can do. And then you kind of take it from there. And people will guide you through. That's where your mentors are so important. All right. Thank you, Steve. So with that, I think we're going to call it. We really appreciate everybody's attendance. Dean, Jim, Steve, Latul, all you guys, thank you so much. Dean, great talk, as always. I encourage all the fellows on this to look for the Fagan Leadership Academy. If you've not taken the chance to sign up for that, it's coming up in about 10 days. And it is a fantastic program full of great stuff, not just for orthopedics, but for life. And especially for you guys at this stages of your lives, it would be very beneficial to you. So I applaud what Dean is doing there. So again, thanks, Dean. And everybody, we'll be back tomorrow night. I don't know who has the con tomorrow night, but we'll be back tomorrow night at the same time. So thank you, everybody, and have a great night. Thanks, everybody. Really enjoyed it. See you guys. Thanks, Dean. We'll see you. Thanks, Dean.

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