I'm going to introduce our first symposium. And our first moderator is Dr. Cesar de Cesar Neto. He's going to moderate our first session. And I'm going to have the speakers come out as well. Our first symposium is Starting Practice at a Fellowship, Our First Five Years. Morning, morning. So this is going to be awesome. This is going to be a great session. Welcome. Wanted to thank Dr. Hunt and Becky for the invitation. We're going to be talking about starting a practice out of fellowship the first five years. I think they invited me because I can't stop moving. So too many moves. And so I think I'm supposed to be an expert on starting practices out of fellowships. So with that said, let's go straight to the first talk. I'm very excited for the talks. We're going to have the first talk by Lara Atwater from OHSU. She's going to be talking about choosing the right foot and ankle practice. Lara, please. I'm Lara Atwater. I'm from Oregon Health and Science University. Delighted to be here. I don't have any disclosures. This is my hospital. All right. So disclaimer, this is a tough process. You're never going to have all the information. Some of it depends on timing. Some of it depends on luck. And you just need to roll with it. Essentially, about 50% of people do not stay at the practice that they went to straight out of fellowship. They end up switching within the first five years. And that's OK. So the general advice is to make sure you pass your boards. Maybe don't buy a house if you're not so sure about the practice. But you just need to roll with it and give everything your best shot. So what are the variables? There's location, practice type, income, lifestyle, and then autonomy. And these are going to have different weights for different people. So what about location? What do you want to do? Where is your dream to be? What about family? Do you have kids? Do you want to be near grandma and grandpa so they can take care of your kids? Do you need to take care of grandma and grandpa? What other proximity things are important? And then what about your spouse? Where is their dream place that they would like to be? Can they work remotely? Can they work from anywhere? Then there's urban versus rural. So there are some downsides to rural. High cost of living, commute, competition. But that population density also does make it easier to subspecialize and do mostly foot and ankle where, as in a rural setting, you might be doing a little bit more general orthopedics. And then there are city amenities that you can take advantage of versus the rural setting. And then there are basically four main practice types. There's small private practice, large private practice, traditional academic, and then hospital employed. There are other smaller subsets, like locums, which means you're sort of a traveler or you might work for the military. But these are the four biggest ones that are about 90%. So with small group practice, you're going to have the most autonomy. You are the boss. You're the king of your kingdom. You have lots of financial gain if you do well. But you also have to take all of the risk. You have to figure out how to start a business, basically. And so you're trying to figure out how to be a clinician, to be an attending for the first time. But you're also trying to figure out how to run a business. And you may or may not have had training for that. And then finally, who takes care of your patients when you want to have some time off if you're in a practice with one or two people? That can be more complicated. There are larger group practices. These are multi-specialty groups or just a big group of orthopedic surgeons with different subspecialties. In terms of income, it's based on production. So they say you eat what you kill, meaning you can do a lot of cases, make a lot of money. But if for some reason those patients don't come through the door, you're kind of on the hook financially for that. And so you need to understand that going in. You can have potentially more control over what you're doing. There are passive income, ancillary revenue streams that are often a big portion of income in private practice, especially with declining reimbursements. But you have to understand, how do you get a piece of that pie? And then with call and rounding, how is that shared? Who makes those decisions? And what kind of say do you have? There's traditional academic, which is separate from privademics, meaning you work for either a teaching hospital and you do research. And so residents and fellows are great. They help take care of your patients. But you may take a little extra time in the OR or in clinic because you're doing teaching. And then with research, there's productivity expectations. Your institution might say, OK, you need to publish at least one paper a year. Or they might be expecting that you have an R01. It can range varying on the institution. And then often you will have a quote unquote academic day or admin day. And based on your salary structure, if you're salaried versus reimbursed by your clinical productivity, there might be a financial upside or downside to using that one day a week to do research. Because if you're leaving cases on the table, if you could be doing half a day of research and half a day of cases because it'll make more money for you in your productivity-based salary scheme, you need to understand that and consciously make those decisions. And then there is the hospital or health system employed model where you just kind of set it and forget it. You show up to work. You don't have to deal with the nitty gritty business things. One thing to be aware of is that the contracts are highly structured. So you can't really tailor them that much. And sometimes they will bring you in on a certain salary. And you really need to understand what the productivity expectations are when that guarantee runs out. Because in a health system employed model, you don't have a lot of autonomy. And so if they want you to produce something and you can't change OR, clinic structure, whatever it is, you may take a dive in terms of that income. So we've touched on this salary versus production. When we say production, it can be in RVUs, meaning relative value units assigned by Medicare to your procedures and your clinic visits. Or it can be in the form of collections. How much are insurance companies and patients sending back to the hospital or sending back to the practice in terms of payments? And again, what happens after that guarantee? You really need to understand that. With ancillaries in private practice, often there's a buy-in. And so it'll be tens of thousands of dollars often to have a piece of that, of ownership of whatever that asset is, whether it's physical therapy, MRI, et cetera. And in some practices, you need to be a partner in the practice. And so what does it mean to be partner? Do you need to be there for five years? Do you need to reach a certain level of productivity? And what's the likelihood that you're going to get that if you're counting on that passive income to make decisions on where to take that job? And then there's benefits, incentives. Many, many fellows will use assigning bonus and fellowship to support their families. And then the lifestyle, group culture, like this is so important. This helps with burnout. This keeps you coming back to work every day. And so ask yourself, do I want to be with other foot-and-ankle people? Or do I want to be the foot-and-ankle guy and have everyone come to me for those questions? What kind of totem pole is there? If I join this practice, am I going to get the worst insurance in all of the cases that they don't want? Or is this person going to give me all of these better cases for me to learn on since I'm coming out of fellowship and I'm trying to get my sea legs under me? In terms of call and rounding, who decides it? How much control do you have over that? If you need to switch, is there a big call pool where you can switch with somebody? And then ask how long people have been in practice. Have they been there for 10 or 20 years? Or has everyone been there for three to five? And why is there instability in the turnover? And then when you're meeting with these people, try to pick up on whether they like being with each other. Do they like coming to work and being around each other? Do they hang out outside of work? All of that stuff's really important. And then autonomy, which we've touched on. How is overhead shared? Within the practice, if you want to do more things in the OR, if you want more OR time, how hard is that to get? Like who decides that? Do you get to choose your own staff? If the practice says, hey, we have three PAs for the practice and they're going to help you, be very specific because they may get assigned to clinic instead of helping you in the OR when that was your expectation. And then, again, ability to shape your day-to-day and call schedule with a bigger practice. Often there's more flexibility because there's just more people that you can trade with versus an individual practice. So this is a lot of stuff, but you already have a lot of resources. You have been in this field for at least five years. So you've been learning all of these things whether you realize it or not. Understand that your fellowship director and mentors really want you to succeed because it looks good back on them. And so use them. There are job boards, which are sort of postings on various websites, which I'll show you in a second, which have available jobs. You can, what they call cold call practices, meaning you call private practice and say, hey, are you looking for a foot and ankle person? I'm so-and-so and I'm awesome. Or you can send emails to the chairs of departments. Keep in mind that if you're trying to, you know, sell yourself, they may need a year or two to sort of get that position developed and approved. So if you're cold calling, that's a process you want to start early because it just takes a while to make a new position. And then there are recruiters, which can be helpful, but keep in mind that the practices they recruit for needed to hire a recruiter for a reason. Like there are usually some thorns within those practices which made them less popular. So there are many job boards online with various societies or with journals that can be helpful. And then questions to ask yourself throughout. Like what is your gut feeling? Does this feel right? Like that stuff is just as important as the objective data. If they're telling you, you know, we think you're going to be really busy, like what data do they have to back it up? Do they have market research? Do they have RVUs of the existing surgeon? Is there a six month backlog to see their existing foot and ankle surgeon? Make them really prove it to you. And then with all of these variables, like the sacrifices that you and your family are going to give up, you know, that may change from the beginning to the end of this decision and that's okay. And then finally, if you're filling in a prior role that somebody had left the practice for, you need to talk to that person, figure out why they left, what happened, get an honest answer. And you can always find that phone number just through your fellowship contacts. It's important to talk to them. Cesar asked me to talk about my story a little bit, which briefly is I wasn't sure what I wanted to do. And somebody told me that it's much easier to go from academics to private practice than from private practice to academics. And so I looked for academic jobs in addition to private practice jobs. I got forwarded a job by my program director, which was the OHSU job and it just fit. Like the culture fit, the job fit, like it just worked. And for me, I realized that teaching was gonna be the thing keeping me coming back to work every day once the clinical stuff sort of had its own rhythm going. And that was gonna make my day fulfilling every day. There's the private debits part, which is similar where you either do research or teaching, but it's actually a private practice reimbursement model. And that's all I got. Well, this was awesome. It's a lot of information. I wish I had all this information. I think I'm much simpler than that. I just like hunch gas and make decisions, but maybe I shouldn't. We're gonna keep the questions to the end just because we have a busy, we have total five talks. So we're gonna keep the questions to the end, but please start thinking about questions so we can have a little bit of interaction in the end. Next one is gonna be Dr. John DiPretta. He's gonna be talking about contract considerations, understanding medical employment contracts. Good morning. Thank you, Cesar and Becky for the opportunity to speak. Some of what I'll talk about has already been covered by Lara in much better detail than I went through. So we'll go through some of those highlights. I'm in one of those private-demic groups, 22nd year of practice. So as Cesar said, I wish I had some of this knowledge ahead of time, not that I think I made a bad decision, but it definitely is extremely useful information. I have no disclosures. So this is sort of like the light at the end of the tunnel, right? You've worked hard for five years. You've done a fellowship. You're looking to make yourself a very viable candidate, but ask yourself what your worth is. Don't sell yourself short. Don't settle. I think these are considerations that Lara went over that ask important questions about what you want, what your family wants, where you're gonna live, where you're gonna be happy, and nobody wants to leave practice. We saw the statistics. So looking at these things very honestly and openly with the people in your life is very helpful. Things to deal breakers, and some of it has to do with location, the practice, the population, what you think you wanna do, the culture at the practice, which as many people will probably express to you during this meeting, where they've been in different practices, what the practice is like, and who the players are in the practice. These are the models that we talk about. Solo practice is largely something that's not typically considered these days just because of the challenge of being a solo practitioner, but there's definite advantages and disadvantages. Call coverage and not really having a mentor. When you're at a fellowship, I think it's important to have somebody who you can bounce ideas off of. I was one of two foot and ankle people that came to Albany 20 years ago, and we have four in our group, and then the other group has three. So it definitely helps having somebody around. Single specialty group, obviously you have guys that are in your office and women in your office who are other specialists. So if you're seeing patients as a new practitioner and you're seeing somebody with a shoulder problem, you can walk down the hall and get somebody to take care of a shoulder problem until you build your foot and ankle practice. Coverage usually is a little bit more equitable. We share a call pretty much person to person, even if the oldest guys and the youngest guys take the same amount of call. There's a little bit less autonomy, but there are definite advantages if you have a group that's very democratic. There's usually a buy-in of some type, but that's really not something I would really get scared away from because if it's a buy-in into a surgery center or some sort of ancillary, you'll see that that's a good revenue stream. If you're in a multi-specialty group or an academic group, you're with other providers of different specialties, there's advantages to that. You do lose a little bit of autonomy, but you have access to other providers and specialists who may help you take care of your patients, which in a system where if you're taking care of diabetic patients and complicated conditions like that, having people around certainly makes your life a lot easier. If you're interested in research and an academic program, I think that's certainly an option, but it carries, obviously, the pros and cons that Lara touched upon. And all of these offer you the option of either being an owner or an employee, depending on how engaged you wanna be in the staffing, scheduling, or marketing process of your group. We have guys that are very savvy at marketing and the business parts of our practice that have really been able to put us into different situations that really help our group flourish. And depending upon your contract, if you're an employee physician, you may not have that opportunity. But there is some financial risk if you're going on your own. You're on, you're it. You're the entrepreneur, you have to develop a practice. If you're a group, it's more collaborative, risk is shared, there's less risk there. If you're employed, and again, depending upon your opportunities, you have some responsibilities for management, but there's still some risk. As a locum's physician, depending upon if you're between jobs or if you're maybe an older physician that you're just looking to work kind of periodically, it might be a good option for you. Pathways to payment, how are you gonna get paid? So understanding how this works. This is placement based on productivity, which is largely the model that we all face. You do have control over how hard you work. Again, depending upon who you're working with, there may be benchmarks that are induced by your employers or your senior partners, and you have to be efficient at seeing patients. So that's definitely a bit of a learning curve when you come out of fellowship, depending upon how much you were seeing patients. If you're in a capitated system or a system where there's a set ceiling as to what you can pay, you're working under a different set of rules in terms of how the system has spent their dollars, which may affect your bottom line. There are hybrid ways of getting paid, from fee-for-service to productivity-based to RVU-based programs. And again, it does provide a little bit of a durer stream of income, but again, some of these things may have some downsides. Concierge practice is not very common, obviously, in orthopedics, but more commonly in primary care. But again, you can establish a set fee that you get paid for certain services. So obviously, you gotta start looking fairly ahead of time. Some of our residents, I'm sure for many of you, have known before you left residency where you're gonna work. I would say that you wanna give yourself plenty of time, because when you're being credentialed at hospitals or surgery centers, sometimes that's a six-month or more process. It's longer than you always think it's gonna be. So definitely, when you think you know where you wanna be and who you wanna be with, try to work on getting that out. And as Lara talked about, meet your prospective employer. Try to get a feel for the culture. Talk to the partners. If there's any sort of pushback or reticence, that's a red flag. Look elsewhere, and if it doesn't feel right, it probably isn't right. Look at the people who are gonna help you. Somebody who's been in practice for 22 years, I've had three or four secretaries, it's hard. You wanna have somebody who's reliable, your gatekeeper who can take care of you, and keep your trains on time. EHR, it's here to stay. We've had two or three in the last 20 years. It's a bit of a grind at times, so knowing what system you use. Some may have had systems that you've worked in residency or fellowship, so it may be easy to you. We've had to learn two different systems simultaneously. Know the mission of your group. What's the culture? What is their camaraderie? What are the, who runs the group? Is there a hierarchy, or is it a democratic situation? Does everybody have a say in the managing of the practice? And, you know, are these guys or women working, you know, seven days a week? Do they have life outside the office? That's important to know, because you're gonna be working for, hopefully, 30 years or more, and you wanna make sure that you have good balance. So, look at the compensation plans. Know that certain compensation plans, you may be at a fixed salary. Understand what that means. Is there room to grow? Is there incentive-based bonuses? Some of it's goodwill. Some of it's based on productivity. And you can get a sense, if you ask around, what other groups are doing in your geographic area. Production-based, again, most common model. Fee-for-services, and it can be a contract where it's anywhere from one to two years where you're then set for a certain benchmark after that, and it depends upon how the model is, whether it's RVUs or collections-based. We have two ASCs, so our income is based also on part of our use of those ASCs. So, again, this is where you'd get salary plus some bonus from the use of the ASC. What are their options? What are the benefits? 401K, if there's built-in funding for CME. Again, do you buy into an ASC, which I think certainly is an important revenue stream. Understand your risk. Depending upon the program you're going to or the practice you're going to be joining, what's the financial risk in terms of the group itself? What's its financial health? And if you're in a capitated system, what is your opportunity to make, to earn a living based on your productivity? So look at your contracts, negotiate, advocate for yourself. Understand there's a restrictive covenant. We'll go into that in a little better detail now. Basically, that prevents you from operating or working after you leave a group, okay? In medicine, there's three basic types of restrictive covenants, confidential agreements, non-solicitation, and non-compete clauses. These basically prohibit you from either using patients or a proprietary's information for your practice for your own gains. For non-solicitation, similarly, you can't solicit either coworkers or employees if you leave the practice. The non-compete clause is really the most prohibitive because it links a geographic landmark as well as a time-based thing where you can't practice if you leave a group for whatever reason. It could be 18 months. It could be 20 miles from your closest office. And so for a group like mine that has nine satellites, it could be, you know, 70, 80 miles from our main office. And enforcement of these things is largely based on the state you live in. Some states have no-compete clauses. Some do. I think they're not all that enforceable, and part of it has to do with the framework in which the state you work in and also the reason for why you left or why you were terminated. And some of it has to do with the fact that, you know, depending upon the individual in the group, if it's an older physician, has, you know, years of history and patients that follow him, that might be a little bit easier to enforce because it would have more of an impact on the employer. But again, reasonable would have to do with the geographic scope, the hardship on the employee, the hardship on the practice. So this is what the courts will consider if it comes to that. And again, look at these sort of with... Don't focus on this too much, but just understand what these things mean. And again, it may be a nonissue, depending on what state you're in. But again, depending upon your role in that practice and, again, reasons for termination, which nobody wants to think about, those are things that can be enforced. We're seeing it in New York. Not going to be much in the way of, I think, affecting medicine. Even across the states and with federal legislation, there's not going to be, I think, a big impact on medicine, at least from what we understand now from Washington. So know where you're going to be practicing. Understand the terms of the contract. Talk to friends, families. Get a lawyer. OK, I think it's important that you find somebody who has medical contract experience. Talk to fellowship directors. I think they're probably your greatest resource. But the use of an attorney, I think, is helpful because they understand the language. We don't. They can tell you what the landmines are, and, again, I think it would be helpful just to have them advocate for you where they can speak the language of the practices and, hopefully, even in a practice where you're going to be there for 30 years and flourish. Thank you. APPLAUSE Awesome. We had some very good, positive overlap there for the residents and the fellows that are here today. So we have a lot of residents that will be negotiating contracts and thinking about the job. So thank you so much for this valuable information. We're going to have now Andrew Tom talking about building your reputation. Maybe Andrew can help me get rid of my reputation of going over my talks. Hopefully tomorrow I'm going to be able to make on time. So, Andrew. Good morning. Thank you for the opportunity to be here. I don't have any relevant disclosures. So when I think about building your reputation, I think about a patient I had early on with an ankle fracture who had this kind message for me. And, you know, working through their post-operative care, building a relationship with the patient and, you know, turning this into a positive outcome and a positive review. Some of you may be Taylor Swift fans and the rest of you are probably just in denial. But her Reputation album, you know, has some song titles that demonstrate some of the challenges that we face as orthopedic surgeons and how we cope with these challenges can really determine your reputation. And then once you have your reputation, similar to Taylor Swift, it's hard to change your reputation and that takes time. So when you're starting practice, it's very stressful. People are constantly looking at you and they look up to you and see how you respond to the stress and that can be an important determination of your reputation moving forward. Complications, how you handle your complications, really says a lot about you and acknowledging them is the first step in that. And then dealing with the hospital administration, how do you, you know, meet with your administrators and have a positive team aspect. And then, you know, even how you retire can determine your reputation. So the old adage was the three A's. You know, you have to be available. If you're not there, people aren't going to send you patients. You have to be affable. People have to like you. And you have to be capable. And, you know, my mentor has a nice translation of this, but early to bed, early to rise, work like hell and advertise. So you need to have goals. So if you write these goals out, you're able to accomplish them. And, you know, a one-year goal may be just passing boards. Your five-year goal may be to try and become an associate professor. Your 10-year goal may be to be involved in some national committee. And then 15 years, maybe looking at trying to become a division chief. I think it's important also to have some kind of niche, something you particularly enjoy, such as if it's MIS or Bunyan's, something that you can really rely on and become known for. And, you know, this doesn't have to be the only thing you do, but just something to try and build your reputation as being the guy for that in your area. The marketing team's super important. People trust what they read online. Some of the highest traffic sites are plantar fascia stretching protocols, post-op protocols, and these can drive patients to your practice. Something else I've done is, you know, meeting with the therapists in the area. Give them a sheet that has some recommended shoe options for a particular pathology and put your clinic number on there, and then that's an easy way for patients to get access to you. And then you can also give a talk on an interesting topic at their facility, and this is a great way to, you know, build a bond with them. You need to know where your referrals come from. You want to talk to patients about them. You want to thank them for their referrals. People sometimes talk about this hierarchy of referrals where, you know, everybody gets sent patients from primary care doctors or therapists, but when you end up start getting patients who refer other patients to you, that really feels good. And then, you know, being involved in a local journal club's a great way to establish your name in the area, presenting cases, and even getting some advice. The AOFS has plenty of committees. You know, I joined the Young Physicians Committee. You can do a hospital committee as well, and then it's really about building your support network and, you know, having people that you trust and can talk to cases about, but I'd start there with your fellowship mentors and then expand in your particular area. Saying no is super challenging starting out. There's a lot of pressure on you, and don't be pressured just to do cases because someone else said that you needed to or they saw someone else, and they sent them to you. There's probably a reason they didn't want to do it, and you don't need to be a hero, but you should accept challenges that you feel comfortable with, and if someone else asks you for help, you should always say yes. And then, know when something's out of your wheelhouse, and don't be afraid to ask for help. And this should go without saying, but kindness goes a long way. Everyone's there to take care of the patient, your staff, and if you're a kind person, they're going to respect you. They're going to want to work for you to take good care of the patient, and you don't want to be known as the mean guy, and being kind just goes a long way. So, in summary, you never know who's going to walk in the door and who they may know, and I think if you take really good care of your patients, they're going to take care of you, but also that will take care of your reputation. And I'll be happy to take questions afterwards. Thank you. Thank you. Thank you so much, Andrew. That was awesome. We're going to keep the questions to the end. For the social media, we have to bring a popular guy, so here comes Jonathan Kaplan to talk about how to navigate with social media. Thanks, Jonathan. Thank you. And thank you all for having me. This is great because I get to listen to really important talks that manage light practice, and how do you build a practice and be successful, and then I get to come in and just talk about how to be on social media, so I'm appreciative of this talk. These are my disclosures. Nothing, I think, that will sway my opinion here. I've given this talk a few times in different formats, and this is always the one I like to start with because it just shows you that people are using social media. This was back in 2019. 3.5 billion people were on social media, almost half the world's population. Well, now we fast forward a few more years, and it's gone over half the population, so it's obviously not going away, and even myself, I was critical saying, you know, do I really need social media? I'm going to be a physician, but the point is it's out there. It varies by generation, so it's not one of those things that it's only younger people using it. It's everyone's using it. I thought interesting, 48% of baby boomers, so a lot of people have some form of social media. Not surprisingly, it has an impact on customer experience. This is what we know about marketing and branding, that social media is a tool that we can use to drive people in certain directions for a brand or a social media. So specifically, you know, what about medicine, though? We're obviously a unique specialty. We're a unique profession. Does social media affect us the same way? And the answer is kind of. 40% of consumers say that they use social media and it affects the way that they deal with their health. Patients trust physicians more than any other group. These aren't great numbers anywhere across the board, but if you look, there's 60% of patients trust doctors, 55% trust hospitals, 42% health insurance. I was surprised. I felt that should be lower. 30% alternative medicine. So the point being is patients are using it. They do believe what they see, but they also take it with a grain of salt. Also, physicians are using it to network with each other. I actually think this is probably a higher number than what's shown here. This statistic's a few years old, but about a third of physicians are using it to network with other physicians. 60% of doctors say that it improves the quality of care that they deliver to their patients. I think it's because we get exposed to different technologies and techniques and ideas and it allows us to take it back to our practice. It's basically you get a daily AOFAS meeting when you follow a bunch of foot and ankle surgeons. You can see what they're doing in real time. Two-thirds of doctors use it for professional purposes one way or another, whether it's peer-to-peer collaboration, industry, or within their hospital system. These are all statistics that just show you it's out there, so even if you bury your head in the sand, people are using it. I didn't survey the audience, but if I did, I'd bet that about half the people here would raise their hand that they're using it in some way or another. 54% of consumers do feel comfortable that their physicians are using it, so it's not faux pas, it's not a secret. We don't have to be, you know, hidden about it. Our patients are looking for it. I did figure I'd try to find some research on this. There's not really a lot out there, but there are a few studies looking at this, so this is a survey done by Chris Gross, who's, you know, part of the AOFAS, looking at AOA members. They surveyed their members and found that about a third of them were using social media in some capacity, 29% for patient education, 28% for patient marketing. I threw this tab in on the left side, the online reviews, even though it's outside my scope, because I do think it's important to acknowledge as well, 60% of these survey respondents said that they had negative reviews that were unrelated to patient care. So even if you work hard, like Andrew said, and you build a reputation, you're still gonna get negative feedback, and that's okay. Don't take it personally. Although interestingly, 31% had negative reviews for not prescribing pain medications, so just be cognizant of that. Don't bend, don't break. Just accept the fact that there's gonna be negative reviews, but it's not gonna change how patients look at you. Additionally, looking at OTA members, they looked at 1,400 of their members. They basically just did an online review and found that about half, almost half of them, had an online site of some sort, most commonly LinkedIn, which I think makes sense, because that's probably the most peer-to-peer collaboration, and I think it's obviously specialty-dependent, but within trauma, there's so many different ways you can solve the same problem, so a lot of people are looking to their peers to see what they're doing. This one I also thought was interesting because there was no correlation with activity on social media with your online reviews. So I would never sit up here and say that you should have a social media site because patients are gonna look more favorably on you. That's gonna come down to how you interact with them, how you engage with them, how you treat them, how you listen to them. This is just a tool to have in your toolbox for, you know, expanding your experience. Looking at pediatric patients, very similar theme. About a third of them, or pediatric physicians, about a third of them use LinkedIn, about a third use YouTube, and then it was scattered amongst the rest. A little higher percentage in private practice, which I think makes sense. In private practice, you're gonna kind of look for other ways to differentiate yourself, look for outreach, whereas in an academic setting, I think you don't really look for that as much. So the question is, how often do you use it? And I found this infographic that was giving insight into how to use each site, but the truth is, this is really for most businesses. This is not really practical for medicine. I don't think you have to post on Twitter 15 times a day. You don't have to post on Instagram one to two times a day. I think it's more medical-dependent in what you're looking for. So logically, try to have multiple interactions on Twitter. Try to post every so often just to kind of keep yourself in the algorithm, but understand that the algorithm relies more on quality than quantity. And so certainly it's not something that you have to be on your phone all day, every day. Think about what you're posting as opposed to how often you're posting. Going off of that, there's a lot of different ways you can do this. This is a talk in itself. I didn't want to belabor the point. You can use images, different text. Everyone has their own style. Just go unique to you. The biggest thing is interaction. On all these sites, the more you interact with your peers, the more you interact with other posts and users, the more you're gonna see yourself trend up. And you have to understand your goal as well. So specifically for LinkedIn, it's more peer-to-peer networking. I use this for physician-to-physician or even relationships with industry, keeping a tab of what's new and coming out, exposure, things like that. There's a lot of different ways you can do this, but again, you want to engage with other users. Looking at Instagram, this is maybe more for patient outreach if you're looking for that, but it's also a good peer network as well. You're not getting as much high-yield things. I think you're getting more photos and videos, and then you have to read through the text within it, so you can kind of get creative with that. The more I've done these things, the more I've realized you do kind of have to include some images of yourself, which is a little awkward. I try not to overload it. I know there's some people that use only images of themselves. Some people only use clinical images. I think the biggest theme that I've seen is the popular users are the ones that stick to their profiles. Some people, it's only x-rays, and some people, it's only images of themselves. Tag other users, collaborate with people. Some of these people that I tagged here in this room, people that I know and hold very near and dear to my heart, so it's a good way to keep connections with people that you've crossed paths with over the years. There's a lot of different tools for success, so you can have pre-templated hashtags. You can have pre-templated posts. There's so many different ways you can do this. I mean, I think efficiency is key, so you're not spending a lot of your personal time on all these different factors. But again, interaction is most critical. I think it gives good collegiality. You get bidirectional value. When I started using this, I was thinking I would use it as an outreach tool, but I started to realize that I actually go on the social media and read more posts than I ever post, and so I use it really to learn more and teach myself than I do kind of to teach other people. The biggest thing is, if you're going to disagree, and I've made this mistake before, if you're going to disagree, if you're going to kind of say something, be considerate of what you're saying. You want to respectfully disagree. You want to avoid confrontational, because nobody wins there. Even if it's the most asinine thing you've ever seen, and you would never do that surgery, I would never put that out there. I would never say that. Either don't say anything at all, or just respectfully disagree. Moving on, so Twitter formerly known... Twitter now known as X. I think there's a great peer-to-peer network. I use this a lot just to see... Really, I look at trauma a lot, see what people are doing on the trauma side, because there's a lot of great resources there. There's a lot of apps you can use to pre-template your posts. Again, outside the scope of this talk, but I just threw a few in there that I think are pretty valuable. Understand that it's all about networking. You're building a network. You're collaborating with your network. You're interacting with them, but you want to do it in an organic way. You could pay for your followers, but you're not going to get as much out of the experience, and I'll be very honest with you. I think that if you're looking for just a sheer number, then maybe it's not the right form for you. So how do I use it? I use it for physician networking. I use it for networking not only with my peers, but also with our hospital system. This is our foot and ankle fellowship site, and I think it's a really good tool, because we use this for patients. We use this for, hopefully, future fellows. I use it to educate myself. I think there's a lot of great, valuable things on there. I use it to educate others. Try to have good interactive engagement with people. I do have some patient engagement. I put this in here, because a patient messaged me on Instagram. I think it's really important that you be open-minded to it, but you be very cautious in it. So I don't totally ignore them. I don't want them to feel like they're not heard and listened to, but if a patient ever reaches out about any patient care issue, I try to immediately just direct them. I didn't show it here, because it was kind of thrown off, and I thought it was a good example, but I try to direct them to coming into clinic. I try to direct them to my staff, communicating through my staff, because I think it's really important to keep a layer between yourself and patients directly. Not because I don't want to interact with them, but there's a whole other realm of discussion about the med-legal side of things, the patient interaction. I just think it's something really important to keep in mind. I do know some people that interact directly with patients on these sites, but I just think you need to be cognizant of how you're doing it. Keep in mind, we do have a responsibility to ourselves. Try to limit yourself. Being on your phone all the time is not living, so just be considerate of the time you want to spend on it. Think about how you're improving other people's lives. Most importantly, think about what the issues are that you're committing to. So number one, your time. Make sure you're balancing your time. Understand patient privacy. We see stories about this all the time. What are your healthcare organization policies? And most importantly, maintain professionalism. I didn't know this stat until I found it. About a third of hospitals actually have a written social media policy, and you need to go online and look at it. Sometimes they just don't want you using their brand. Sometimes they don't want you on it at all, but you have to understand that. This can come back to bite you in the butt. This is a good example of someone who lost their medical license, and it wasn't because they were on social media. It's because they were on social media while giving patient care. There were known complications. They were able to look back. They saw the complications, tied the two together, and this person lost their license. And it's really important to understand that it can happen very easily if you lose track of why you're doing certain things. So think about how you want to do it. Look at what your goals are. Commit to it. And then evolve over time. Most importantly, make sure you have fun. You're on your phone. You're avoiding your family and people. So just have fun. Shameless plug here, but you don't really have to follow me. It's no big deal. And here's my references. And last but not least, this is why we do this. So I'm not burying my head on my phone and avoiding these people. Jonathan, last but not least, we have Michelle. Michelle's gonna give us the pearls and pitfalls. Very broad, very interesting. Let's go for it. Hi everyone, it's nice to see you today. I'm Michelle Coleman. I'm an assistant professor at Emory University and also an associate residency program director. I learned so much from everyone today. Today we're gonna be adding a couple more pearls and pitfalls to think about when you're starting your practice. I learned that you can pay for users today. I didn't know that. I'll have to take note of that. No, I'm just kidding. I don't have any relevant disclosures for this talk. And so we're gonna kind of organize the pearls and pitfalls for before you start your new practice, when you first, first start, and then kind of what to think about along the way. And I don't think there should be any overlap with what people talked about before. So the first thing I highly recommend that you do before you start a practice is organize your resources from training. You've done a million years of training. You've looked at 1,000 books, 1,000 websites, 1,000 articles. Find the ones that you really found most helpful along the way and organize them so that you can use them as a faculty member. I highly recommend you save them in a place you can easily access them from your laptop or from your phone. So things like Google Drive or Dropbox that have an app that you can download are really helpful so that when you're sitting there and your case is delayed and you wanna kind of review some stuff, it's right there in your hands. The types of resources you might think about putting in these folders and in these categories are your favorite textbooks, good review articles that you have looked at before that you thought kind of summarized things the best, helpful surgical technique guides, and PowerPoint presentations that you thought were helpful from your previous mentors. So I have some examples on the right of some of my mentors in the PowerPoint presentations I've used as a faculty member to go back and remember things that they taught me. Also, if you've taken notes during residency and fellowship, which I hope you have, take those case examples, those x-rays, those pearls and tips for different cases that you've learned along the way and kind of organize them by subspecialty topic. And then don't forget about general trauma. If you're gonna be taking call, have a folder on tibial nails and hip fractures and femoral nails so that when you get that call from the resident and you have to go in, you have that right there on your phone to kind of review and look over again. And the next thing I'm gonna advocate for is taking some time to create some aids in your documentation. So make your life easier once you start. So depending on your electronic medical record, you may be able to make some clinic note templates, and those things may be as simple as pulling in patient information so you're not doing it manually, or providing some sort of template for anyone who's helping you in clinic to quickly get the important information you care about in an HPI or a physical exam. And you also may create some sub-templates for your assessment and plans for common diagnoses you see, like ankle sprains, posterior tib tendonitis, non-op fractures, things like that, that you're gonna say the same thing over and over again, you have a spiel, write it down, and kind of bring it into your note and adjust it just as you need it. You don't want every note to be exactly the same, but you also don't wanna waste time on common things. Next, I highly recommend you make some operative note templates. Now, again, you need to customize these. It can't be the same for every single surgery, but for things that you do all the time, like fix an ankle fracture or perform a lateral ankle ligament repair, have a template so you can quickly plug in the things that you need, either through a drag-and-dictation or through an epic clinic note, I mean op note. And also, take some time to sit down and figure out what are your post-operative protocols gonna be as a faculty member. You've seen multiple attendings do things differently, and you gotta figure out, what is my approach? How do I feel most comfortable taking care of patients? And once you figure that out, write it down so you can easily copy that post-op Achilles protocol into your physical therapy prescription, or you can share it with your team to print for patients when they're asking about what to expect after surgery. And finally, I recommend creating a billing and coding cheat sheet. You shouldn't have to recreate the wheel because your mentors may already have these that they've made for themselves. You can organize them by topic. For example, here I've got an example of flat foot, so here's an MDCO, an Evans, a cotton, FDL transfer with the codes there so I can easily post cases myself and not have to memorize all the CPT codes, or my clinic staff can go through and post cases for me. Next, when you do start, expect to be uncomfortable. It is normal to be uncomfortable when you start practice. You're not just gonna slide on in and be the most confident, attending right out of the gate. In clinic, it will take you longer than you expect to go through imaging. So when you're going through MRIs, you're gonna be looking like a hawk. Oh, I don't wanna miss anything. I'm the boss now, right? And whereas in fellowship, you could've looked at the same MRI in a much shorter period of time because ultimately that patient wasn't yours and you weren't responsible. And also, it will take you longer to make some plans for patients. So whereas your fellowship attendings might have zoomed in the room and kind of been bam, bam, this is what we're gonna do, you will realize that surgery is gray. It's not black and white, and you kind of have to find your way in some of those gray situations, and it's gonna take some time of really thinking about what you wanna do. Recognize your knowledge gaps and address them as you go along. So we all ascribe to this idea of lifelong learning. Maybe you went to a fellowship that was really sports heavy and so you feel very confident in that area, but then you have somebody walk in with Charcot and you realize, oh, I actually haven't done that much Charcot. So I'm gonna go back to the literature. I'm gonna read and really be ready to take care of these problems. And one thing to realize, just like one of the speakers said earlier, you don't have to offer everyone surgery just because other people did or they're a candidate. It's okay to think about it and give them an answer later. Just because you've met the patient for the first time doesn't mean you have to sign them up for surgery. So it's okay to order additional testing to help make your decision. And during that time when you're getting additional testing or getting clearances done, you can search the literature or discuss those cases with your peers or with your mentors to make sure that you feel comfortable. Also expect to be uncomfortable in the operating room in the beginning. It's normal to be stressed before cases. So I went to a fellowship where I had three co-fellows and the four of us will have this group chat. And in the beginning, it was like, why am I so stressed about cases that I've done a million times? This is a Weber beat ankle fracture. I can do this. Why am I staying up late studying for an ankle fracture case or why am I waking up anxious in the morning? It's normal. Do whatever you normally do to handle stress and you will get through that period. Use your favorite resources to prepare. And again, if you have those organized, that's gonna be easier. And you can take time to visualize the steps of your cases, think about what you're gonna do and how you're gonna handle things as they come up. And so if there are any potential complications for that procedure, be aware of them, review them, and have a plan B if things don't go as you think they should. And during surgery, just breathe, keep your cool, be flexible. And remember, you can always phone a friend. It may seem like you're the captain of the ship and you're the only ship in the sea, but you're not. You can always call a senior attending from another OR, even if they're not in your same subspecialty, to come and give an opinion. And sometimes there's just strength in numbers. Even if they haven't done an ankle fusion in 20 years, coming in and talking about orthopedics can really help you feel confident moving forward if you're hitting a crossroads. Or you can always call a fellowship mentor. Like Laura said earlier, these mentors, they want you to be successful. Your success is their success. So call. I've actually, in my, I think, first or second year of being an attending, I called a mentor in the middle of the OR, had my nurse call and say, hey, this is weird. I've actually never seen this finding before in this type of case. These are kind of my thoughts. I think I could go this way or that way. What would you do? And so hearing a trusted mentor say, hey, I think you're thinking exactly right. I would do this personally, but I think either way is okay. That can really inspire confidence and make you feel good about moving forward. So you are not alone. You can reach out for help. Now, along the way, I highly recommend you stay organized, keep records. That's gonna help you as you go through ABOS part two. So keep up with what cases you're doing. Take case notes about what went well or what didn't go well or what was confusing to you. And then track your complications. You wanna know how many surgical site infections you've had, how many non-unions you've had. And you wanna analyze why those complications are having and adjust your practice accordingly. So maybe there's something you need to remediate or maybe there's something in the system that needs to be addressed. I'd say these last two slides are the most important in this talk in terms of pearls and pitfalls for practice. It's very important for you to maintain your peer relationships. So don't forget about your co-residents. Don't forget about your co-fellows. Keep in contact with them. Maintain that camaraderie with them. You never know when it's 8 p.m. and you have a complicated subtroke and you haven't fixed one in a while and you need a little discussion with a co-fellow who went into trauma. So keep those people in your phone, maintain those relationships and seek their advice as you need it. And really commiserate. You're gonna be going through the board's collection process together. You're gonna have a lot of the same fears and anxiety as a new faculty member. So don't do this alone. And similarly, utilize your senior mentors. So don't lose touch with your residency attendings or your fellowship attendings. Your success is their success. And don't be afraid to ask for advice and to discuss cases. A good surgeon is a humble surgeon. It's somebody who's really willing to discuss cases and discuss complications and try to hone their practice. So use these people to the best of your ability. And your new partners may not even, just depending on the type of practice you go into, they may not be the same specialty, but that doesn't mean that they can't offer advice or good principles of orthopedics. With that, here's a summary of our pearls and pitfalls we discussed today. I'd like to say thank you for your attention. And I would definitely invite anyone in the audience, whether you're an early career physician or whether you're a more senior physician, to bring up any pearls or pitfalls that you can think of as well. Thank you. So this was an awesome session. A lot of advices that I think are important. Like I said, we have a lot of residents in the audience today. So we have time for questions. Isn't that awesome? Anyone from the audience? I think these pearls and pitfalls, we could start there. And when we discuss by email, that would be a good way to start. Like, we have a lot of senior people here that are on the final part or like last third of their careers. If you were able to give one advice to all of us, the younger people, I'm still considering myself on the young side, even though I can't read from close anymore. So anyone will come and give us some advices on pearls and pitfalls. I've seen some people walking towards the microphone. Hopefully if... Ray Nickel from Ventura, California. And just one principle that I give to our residents is the type of practice that you choose changes the type of headache, not the amount of headache. So in the solo practice, you don't have to go to committee meetings, but you have nobody to turn to give you advice. In a group practice, you have to get everybody to believe that they're same direction and heading in the same direction. So it's just a different type of headache. So one that I get a lot from residents and fellows, and I wanna get the panel to, and we have people with different pathways here, is like, well, I don't know, I'm thinking about my jobs and I'm not sure if I wanna go private or if I wanna go academic. I like the residents, I like the fellows, but at the same time, there's always the financial issue, there's family, there's so many variables. So we have people here that took different paths. So for example, we have Jonathan that went private and now moved to academics. We have people that went straight to private and some people went straight to academics. So if you guys could comment, like a minute comment on how was that for you? Like how do you guys, because that's a very frequent question from residents and fellows. How to make that decision? I think it's important that we touch on that point. Michelle, do you wanna start? Sure. Can they hear me from down here? I believe so. Oh, okay, great. So when I was, I'll take it back a step. When I was deciding on just what specialty in medicine to go to, the big question they said is, can you live without surgery? If you can live without surgery, then don't do a surgical subspecialty because it's not worth the extra time and headache. But if you can't live without the operating room, then you should be a surgeon. I think of academics versus private question the same way. If you can't live without research and teaching, then do academics. But if you can live without it, then don't do academics because it's not worth the headache. So I chose academics. I like that. That was a simple path. Jonathan, you did like the pathway of, and I know there's advantages and disadvantages. Some people wanna go first to academic because they're gonna have the support. They're not gonna be under pressure for production or less pressure for production, but at the same time, they don't feel very comfortable in starting teaching people right away. They wanna take their time to get their own protocols and things like that. And then there's people that think the opposite, right? That they wanna go straight to private to like build, do cases, get an expert on something and then come back to academics for teaching. So how was that for you? Yeah, and to give people quick background, I broke all the rules. I left my practice and private practice eight years in, in a thriving private practice and went academic. I mean, I've kind of violated every statistic there is, but I think the things that are really important is number one, you have to know yourself. Like if you don't know yourself, if you don't know what your goals are and your priorities are, you're gonna make the wrong decision. It doesn't matter what decision it is, you're gonna make the wrong decision. So my advice is you have to know yourself and you have to really do some deep introspection to understand who you are and what your goals are. The second one is gonna sound bad, but it's realistic. Don't set your expectations too high, no matter what. And that's life, right? If you go into any situation in life thinking everything's gonna be perfect, you're going to be disappointed. So you have to set a reasonable intermediate bar, be excited about the opportunity to go into practice and you're starting, you know, finally starting your career, but you have to understand that nothing is perfect and it's okay and you'll be okay. And no matter where you end up, whether you change practices a year later or 25 years later, you're still gonna be fine. Good. And feel free to stand up and come for comments, guys. This is supposed to be a little bit of an interactive session. So, John. So I kind of went through all these things that we talked about. So when I was in fellowship, and I think even in residency, you get headhunters calling you and they won't go away. And at one point, my wife had called me and said, when are we going to Binghamton? I go, what are you talking about? So my in-laws are from Saratoga. Our reason to go where we are was family. I had two kids and that's where our family was. But upstate New York is huge. And so he set up an interview with a group in Binghamton. I didn't want to be in Binghamton. We didn't know anybody in Binghamton. So I called him and said, look. You know, very nicely said, don't call me, I'll call you. And so about six months later, he calls me, kind of contrite. Oh, there's this group in Albany, you know. And he made this fatal error. The contact is so-and-so. So I went, hmm. So I went to the AOS, found my current practice partner, called him, and did the end-around with the headhunter. So that, and that's really sort of how I ended up where I am. And, you know, I think, as Jonathan said, I didn't quite know what I wanted. I thought maybe a smaller group. The group I joined at the time was 15, 16 people. We're up to 40 now. And Keith Wapner said, look, you know, you're the only foot-and-ankle person. You have a built-in practice. And it's true. So I think those things are definitely important. And we have a hybrid group. There's 30 of us that are private side, 10 of which are university-based physicians. And the thing is, we all operate under one roof. All the billing and coding goes through our business office, which works out probably better for the university people than anything. But, and it's been a great opportunity to teach residents and be involved with residents. It's got its ups and downs, too. And as Michelle said, don't be afraid to call your current practice partners. I've been in, early in practice, I'd had fractures. And I'm like, I don't, you know, we're two hours in. I'm like, this is not going well. And, you know, they would come in at nine o'clock at night and help me out. And even there are times now where I may reach out to Keith or Paul, what do you think about this case? So, you know, it's okay to not know even 20 years in because patients will always throw curves at you. Great, we have some questions, comments from the audience. Hello, Gary Stewart from Atlanta, Georgia. This was really a great session. Michelle, great job, all of you, great job. I think one of the things that you need to do is really like you guys said, know yourself. First, where do you want to live? You know, you're foot and ankle. There's not a lot of us, and you're at a premium. That's number one. What do you want out of life? Again, I mean, I actually am in a private setting, but I have residence as well. And so I do that private-demic model that has really kind of driven my career. And then, what do you want to do with your free time? We talked a lot right now about, you know, being prepared for practice and the stresses of that and tips on that, but I think you need to look at how you're gonna spend your off time because that recharge of, especially when you're starting, I mean, it's like you can't let the patients get out of your head, and you just need to be aware of some of your personal time as well. So I just wanted to add that. Yeah, those are great comments. I think we have time for one more comment. Hi, I'm Dr. Lins from France. I want to thank you for a great session. I have a very practical question. Like, there are some people who are very, very effective with social media. I'm not so much, so I'd like to know if you guys know of an app where you can create a post and then it posts it on all your social media. Because I know of an app. It's called My PA or My Secretary, but I wanted to know if there's a more digital one. Jonathan, you want to take that one? Yeah, I mean, there's actually a lot. There's a lot of good resources because there's companies designed to make a lot of money off of just social media posts, and they're advertised for all sorts of businesses, right? And so, like, Canvas has one. I mean, we can talk offline. There's probably about 20 different ones, and they're pretty intense where you have to pay for them, but you can pre-template a post all the way down to the exact time that it will automatically post it for you and the day and everything else. So you can load 30 different publications or posts that you want in there, and you can set what time, what day you want it to post, and it'll do the rest. It just depends on what kind of resources you want to put into it. So, yeah, I can give you some. Okay, thanks. Yeah. Great. I think we're pretty close to the time, so thank you, speakers, for being on time with the talk so we had time to have some discussion. Let's go to the next session. Thank you.

social media

medical field

foot and ankle surgeons

marketing

branding

research findings

peer-to-peer collaboration

patient education

online reviews

professionalism