So, we're going to move on to our fourth symposium. Our moderator is Dr. Sandra Klein. And she's going to be speaking to us on what I think is going to be a fantastic group of lectures, Surgeon Satisfaction. Dr. Klein. Good afternoon, everyone. And thank you so much for coming back from lunch. The next session is going to be about Surgeon Satisfaction. So, we have some great talks lined up. To talk to us a little bit about what may give us joy in our practice, what kind of things we can add that help keep us motivated and passionate about what we're doing. But then also a few talks about what happens when we lose that joy, what types of things in the healthcare system can bring us down or make things more difficult. So, we're going to start with Errol Baerle talking to us about identifying and avoiding burnout in orthopedic practice. I want to thank AOFS for having me and Becky for including me in this symposium. My topic is about burnout today. I have no real disclosures that are important for this talk. We all want to be this guy, don't we? The good doctor. But, you know, this guy's a TV character. And what you realize is in our lives, it's just not like that. We're this guy trying to balance everything, stay in shape, return all of our calls, be supportive at home. And it can sometimes get to be overbearing. And unfortunately, sometimes we fail and we'll become this guy where we're doing a great job at work, but we've turned our backs on our family and loved ones because we're so busy and we've lost a little bit of ourselves. And of course, pandemics don't help, do they? Not only did the country get sick, but our patients got sick and so did we and we became incredibly stressed out over treating these very sick people. And fortunately, most of us didn't turn in to Frank here who just flat out exploded because he got so burnt out from all that he was doing. So the question is, how do we avoid this? What are the things that we can do to not be in this situation? Because we don't want to look worse than our patients. And I know we've all been in situations where our friends or our family or our loved ones have come up to us and say, hey, you okay? You doing fine? And you think you are because you can't see yourself, but those close to you can. And they can see that there's something going on with you that you're not self-aware of. But you don't want to get here where it's too late because once it's here, you're done, right? So we want to avoid this type of situation. So I'm going to tell you a little story because I've probably burned out and fried myself at least two or three times in my life from overworking because of personal experiences. Because life gets in the way of being an orthopedic surgeon and sometimes there's a tipping point, something that tips you over. And you can't control life, but you can control what you do. And that's a big important part of avoiding burnout. Case number one, me, I was a Massachusetts orthopedic resident at the MGH. That guy on your screen is my brother. He was an NBA ball player. One day I got a call to go see Dr. Henry Mankin, who was my chairman at the time. I thought I was in trouble and he said, call your mama. So whenever a chairman tells you to call your mama, you know something's not right. And I called home and my brother had been stabbed. So I flew home. I was there for four days. We buried him. They were calling me to come back to work because residents were taking my call. That was my head when I got back. I looked like that. I was stressed out. Everything was dark. I was stuck, had the weight of the world, was worried about my mother and my family. I wasn't right. Somehow I finished. There was no EAP back then. There was no employee assistance program. You didn't tell your chairman you needed to go talk to someone because that was like a sign of weakness back then. Unfortunately today, that doesn't exist. I survived. I got through it. I don't know how. And then I went and got this great job in Atlanta. I was assistant professor of orthopedic surgery at Emory Orthopedics. But I was one of three surgeons of color in the entire university. It was a great deal of stress. But I can handle that. It's not a big deal. I had great mentors. A past president of AOFAS, Dr. Lamar Fleming, who had had two brothers who had committed suicide. So we were like buddies. And we communicated and connected with each other. And the other guy to the right was a mentor. That's Hamilton Holmes. You may not have heard of him, but his name's on buildings and signs in the city of Atlanta. He was my orthopedic mentor in town. And he was like a father figure to me. And shortly after I got there, this same guy, who's known for integrating the University of Georgia, he's the first African-American at Emory School of Medicine. He was dead at 54. He used to always tell me, man, I'm just doing too much. I'm just doing too much. Man, I'm fried. I need to slow down. I'm just doing too much. Massive heart attack, and he was dead. Soon after, I left Emory because I didn't want to do academics anymore. So I went and jumped into another skillet, another hot skillet. I joined private practice. So I had this individual Atlanta Orthopedic Foot and Ankle Center practice. Welcome to my world. As we've learned from private practice this morning, it's difficult, right? I found myself picking up the scraps. Because in private practice, you have to pay everybody else before you pay yourself. And you pay yourself what's left. And as insurance companies changed and things got tougher, it became increasingly more difficult to do that. And I had to jump ship. Now I'm at Resurgence Orthopedics. We're a fantastic group of people I work with. Life is good, and I've survived. So some of you may be saying, well, that's not my story. That didn't happen to me like that. But I want to ask you to heal yourself. Because you have your own story, and you have your own stresses that you have to deal with. Mine were personal, and so are yours. So what does this look like? OK, symptoms of burnout. We all know what it looks like. The medical terms are emotional exhaustion. But that's irritability. How many of us know how irritable some of our partners are at work? Depersonalization. That's like loss of interest. Just not having a good time with what I'm doing anymore. And diminished personal achievement. Not setting goals for yourself anymore. Not expanding your knowledge base. Not learning new techniques. Just staying stuck with where you are. The signs. You make errors at work. You become unsafe. And you're just not engaged in what you're doing anymore. You become this, a wounded healer. You're out there trying to help others, but you're broken yourself. So you can't be giving them everything they need because you are not 100%. What are the causes for that? If you look these up in the literature, family responsibilities, being a mother, father, sister, brother, EMR, time, chaotic environments. It's 4.30, and you still have 10 patients in the lobby, and you're two hours behind. And you can't control your pace. In addition, increased work hours, lack of appropriate leadership at work, and increasingly more and more bureaucratic and administrative headaches that we all have to undergo, which creates this toxic environment at work where it's just not a great place to be. What's the epidemiology of burnout? Well, the statistics say that one out of every two of you out there have burned out, are burning out, or are going to burn out. Interestingly, orthopedics is an area where we burn out less than other subspecialties, but it's still very prevalent. Outpatient doctors burn out more than inpatient doctors. And interestingly, residents burn out way more than attendings do. 68% say burnout has negatively impacted their lives and it's affected relationships that they're in. And one in two say that burnout has impacted not only their lives, but their family and friendships and their ability to enjoy living. So what happens? It's a slow erosion. You think you're fine. you start to lose a little bit of yourself until you're not quite yourself anymore. We think most doctors will say that it's clinical documentation that's killing us, that's eating us up. 60% of doctors say that administrative tasks have led to them burning out. 50% say that it's EMR. We only spend, on average, 27% of our day at work with patients. The rest of the time, we're doing all this other stuff. And 33% or more of us take the work home to our safe environment with our families. Here's an interesting study. 800-plus medical students took a survey. They had an increased burnout rate, 17% at matriculation. At the time of the residency match, it was up to about 38% burnout. So what does this say? All this says is the data implies that burnout starts way earlier than when you think, right? It was probably your last two years of college, medical school, and residency. So our butts have been on fire for a very long time. And that's why it's so easy for there to be a new tipping point. So if you ever want to take a look at this, there's a lost burnout inventory where you can actually take this yourself. There's three parts. There's a burnout part that asks questions like, do you feel frustrated at work? Do you feel that your job is hard at times? Do you feel emotionally drained by your work? I would go, like, check, check, check. Part two, depersonalization. Do you still care about your patients? Are you afraid that this job is making you uncaring? Very good, interesting questions. And then part three is personal satisfaction. Do you still feel good about yourself? Do you still have good energy? Do you feel that you have a positive influence on people? There's a score. And then there's a decision that is made based off your moral inventory. So it'd be an interesting thing to look up and do. So where do we rank as a group? In terms of orthopedics, we're good in terms of burnout, relatively speaking. Emergency room doctors and OBGYNs burn out more than we do, so do internal medicine doctors. If you looked at what specialties are happiest outside of work, we're right up there at the top at about 58%. So we like what we do. And if you look at how many physicians would choose especially again, we're right at the top. We love being orthopods. So what's the problem? In the words of a famous UCLA basketball coach, it isn't what you do, it's how you do it. That's the problem. So what's the solution? Pamela's going to talk some more about this after me. You have to change your schedules. You have to take surveys and see how people perceive you at work. Balance, that's always a big one. Figuring out how to have more time and more productive time. And figuring out AMR, you just got to just learn it and just do it. So what are the solutions? Well, there's two ways to approach this. Burn out the solution first or personal. What can you do? You can reduce your workload. You can go see a doctor and take better care of yourself. And you can do things to remind yourself of who you used to be, self-awareness. From an organizational point of view, you have to have effective leadership. If the leadership at the top of your group is bad, it's going to trickle down. And then you have to be aligned with the leadership in terms of values. If you're not, that's probably not the place for you. And you should probably consider being someplace else. Because if you don't, depression seeps in. Now, that's different from burnout. There's addiction, anxiety, suicide. Those are the ones that you'll see in the articles that you read about. But what I think is one that I added on here is the ridiculous accident. You're thinking about work. You're thinking about your bank account. You're thinking about your sick kid. And you miss a step walking down the stairs. Or you run a red light. You do something because you're not in the moment, because your mind is someplace else. So in closing, these are my personal 10 commandments to try to avoid burnout. And I've been pretty happy for about the last 15 to 16 years. Number one, if you're overwhelmed, you just got to reduce your workload and not feel bad about it. Two, if you're married or have a partner, you ought to have a date night once a week. Because you have changed, whether you realize it or not. And you have to spend time with your partner. You have to take the vacations. Just block them off and do it. Finally, creative outlet. I've written a book. I've even written a screenplay and produced a movie that I lost my shirt on. But I had fun doing it. And I think every five years, you have to reinvent yourself. Minimally invasive surgery has re-energized me over the past five years. And I find something in orthopedics that I still love. And I think you have to do that constantly. You have to grow and challenge yourself. Don't worry about your numbers at work. Show up, do a great job, the numbers will be OK. Go to the gym, see your doctor, and be nice and be a human being to your staff. Because you can't do it without them. And then number nine is my favorite. Just go buy yourself something really expensive that's really nice. And don't feel guilty about it. I just went and bought me a Porsche electric take-in. And every time I get in that thing, I just feel better. I deserve it. And last, remember that you are replaceable, regardless of how fantastic you are. Soon as you're gone, they're going to fill your slot with someone else. So in closing, right now, who you are being matters more than what you are doing or saying. And you are more than what you do. Your title does not define you, nor does your job. Be a better human being. If you're better, work is better, the workplace is better. It all starts with you. That leads to a happy family. Thank you. Next, Pam Luke is going to talk to us a little more about burnout, but sort of digging into the tools to help manage it, and how we deal with it if it happens to us. Thanks, Sandy. Thanks to Becky and AOPS for inviting me to be on the podium to talk about this topic and including this as part of our discussion. I think it's a very personal thing to talk about burnout. I am a board member for the society, but have no financial disclosures related to this talk. So I just want to put up the definition that Errol showed, again, just so we can see for burnout. Just want to take a poll of the audience. How many of you have, and it's a safe space, so how many of you have you had felt burnout, have been through burnout? Okay, so I'm going to start with Errol. I'm going to start with Errol. You guys can look around the room. And then how many people who can admit that they do not know burnout, they are doing well, and don't know this discussion? I see your hand there, Sheldon. Did you raise your hand? Sheldon, yay. So I'm happy for the people who are able to admit that, but hopefully we can still take away something from this talk because as Errol talked about, this is a large problem, and we have to recognize the problem in order to be able to identify it and then manage it, and I think it's really well written about how this talk is titled. It's management because, as you can see, the majority of us have been through it, so it's not really about avoiding it. It's about how to deal with the problem when we are faced with it, and so Medscape comes up with a report every year looking at the depression and burnout rates, and for 2023, this is one of the graphs looking at are you asking over 9,100 physicians and over 29 specialties all these really basic questions, and so the respondents give their answers back, and so to the question, are you burned out or depressed, more than half of the respondents admit they are burned out, and almost a quarter of them admit that they're depressed. So the additional problem, who are burned out? And Errol had talked about this, too. Orthopedics is not at the top, but it's definitely on the list. This one says that there are 45% of the respondents surveyed admit they're depressed, but if you look at this, the bigger issue is that our colleagues, our emergency room physician colleagues, our internal medicine colleagues, people that we rely on to help us have good diagnoses, help us do pre-op clearance, just take care of the patient, they're burning out really fast as well, and they're making maybe more medical errors that then put their onus on us, to pick up when we see them in the office. It's harder to manage comorbid complications, and they're also leaving the field, so even though they're not in our direct subspecialty, it does affect us. So you might ask, well, okay, depression and burnout, are they related? Could you be getting depression from other signs, other issues? But these physicians that were surveyed rate that job burnout is their number one contributing factor to their depression. So burnout and depression are serious issues in and of themselves, but then we get into a bad spiral, and unfortunately there are people who then have these issues that lead them to suicide. So the data on this slide is from a study reviewing deaths by suicide from 2003 to 2017, and included 28 medical cases, surgical and dental subspecialties. 905 reported suicides were reviewed, and the prevalence of suicide was the highest among orthopedic surgeons, with 20 suicides in a 14-year period. And so these are our friends, these are our colleagues, and they are suffering in silence. The reasons that burnout takes such a heavy toll is that it persists, and it can be severe. This slide shows you that over 60% of the people that were surveyed on this Medscape survey stated that they have had burnout for over a year. This slide shows that the burnout was so severe for the majority of the respondents that they were at some point even considering leaving their field. So when we talk about how to manage, we have to see what's causing and what are the contributing factors to burnout. As you guys have probably felt, all these things are familiar to us. It's the reasons why administration's on us for higher volume to see patients in the clinic. It's having to do every single thing in the OR when you're supposed to just do the surgery, but you are then your own scrub tech, circulator, trying to get the implants. It's trying to do peer-to-peer calls, returning patient phone calls, not having the support and adequate staff People are leaving medicine as well because of pay and the stress as well. Too many hours taking work home. And so this list goes on and on, but when it lasts for a long time, then it leads to burnout. So this is from a discussion paper in the National Academy of Medicine. It's looking at work-related factors and how they increase the rate of burnout. And just kind of looking at these, it's really interesting. If you have a homework conflict, it increases your burnout odds by 200% to 250% based on this study. And so simple changes would be if you have to choose between a work event or a family event. Most of us, by just our training, we would choose the work event. But if you are trying to protect yourself from burnout, you should always select your personal event first. Other things that are pertinent on this, having a career that doesn't fit what you find personally meaningful can increase your burnout risk by 275%. Other things, taking work home or performing work-related tasks at home increases your burnout risk by 2% for each hour that you work at home. So when talking about how to manage burnout, we look at what Errol talked about, individual and organizational coping changes. It's much easier on an individual's basis because you have 100% control of what you choose to do. But it has been shown in multiple studies that there's a more dramatic reduction in burnout when changes are made at the organizational level. I do want to point this out, that while we're talking about changes that are possible on the individual scale, the individual should never be blamed. There is no shame in having burnout. And just because there are individual solutions, it does not mean that burnout or having it or depression is a weakness of failure of any person. It is a failure of the system in which we work. And that is what we have to change. So there's a big stigma of burnout and depression still. This was one of the other questions from the Medscape survey. And you can see there's a lot of people that answered that they haven't sought treatment. Maybe they didn't recognize it in themselves as Errol was talking about. But also, they might recognize it, but they're for fear of retaliation from their employer, from what their partners and friends and family may think of them, that they are unable to ask for help when they're struggling. So this pie graph is to kind of show kind of the categories in which an individual can try to cope with burnout. In relationships, it's talking about spending quality time with your friends, family, and significant others, being present, choosing them over work when able, and develop connections with colleagues to reflect the other aspects of being a physician besides the cases. I think that's why so many of us come to conferences like this. Of course, we want to learn about the medical issues. But it's being able to see friends and colleagues who you haven't seen. It's a touch base on a more personal level for people who can understand and just kind of have a venting session, if you will. A lot of people have stated for religious belief or spiritual practices that can be something in an organizational fashion or something as even simple as meditation, taking time to take deep breaths several times throughout the day, kind of balance out your heart and your breathing. It's also change in work attitude, trying to find meaning and fulfillment in your medical practice, even maybe smaller little details. And then also trying to actively limit things that you do not find fulfilling in your workplace. I think a lot of us are guilty of saying yes to doing everything, don't know how to say no. But there's a lot of things that we'd rather not be doing. So it's trying to take an active role in stopping that and finding and replacing it with things that you find meaningful, whether it be education, research, volunteerism, other aspects of the practice. For self-care practices, what this is is promoting yourself well-being. And this is easier said than done. It's exercising, eating well, making sure that you eat regularly, not skipping it as we did in residency, fellowship, and then practice. Getting regular sleep, I know that's difficult. And then actively seeking regular medical care. And if you are suffering from mental illness or any other physical illness, that you put yourself as a priority and seek medical attention. And then the last thing, adapting a positive life philosophy. There's some people who do this very well, and maybe they have a better way of preventing burnout. You have to believe that there's an equal balance between your professional and your personal life. And again, this might seem really easy to say, but I think this goes against a lot of the core beliefs that have made us all successful in this room. We got to this place by putting work first in medical school, residency, fellowship, your job. And it's hard to change that, and hard to switch a different mode of thinking. So they're all easy to do, but it requires a big paradigm shift. I'll just go through that. So the other part is organizational strategies to manage burnout. And big things are to reduce administrative and regulatory burdens, finding ways to use EMRs most effectively, and hiring competent and adequate numbers of staff to support you. Build a good team approach to hold everybody accountable. It's not just the physician, not just the surgeon that's responsible. Also enhancing physician autonomy and speaking with other colleagues who might be dealing with the same problem, but figuring out by gathering a bigger massive number to fight these obstacles. And also reducing the stigma in seeking care. The AMA has done a lot to try to help promote physician care in supporting acts and laws that would protect physicians who are suffering from burnout and depression. And then also encouraging changes in the application so that there's not questions asked about mental illness in relation to how your performance is. So I think there's a lot of people in this room and in this society who have a lot of power and connections with their own institutions. And then for the people who are younger, reach out to your more senior partners in your practice. But it really takes leadership of the individuals to make an organization and institution recognize the systemic problems that need to change. So one last slide. When burnout is no longer manageable, the option is not suicide or to just think that everything is doomed. Talk to people, talk to your friends, talk to family. And if medicine is practicing surgeons, it's not the way for you anymore, it's OK. There's other avenues that you can look for. And you can even do something completely outside of medicine. Medicine does not have to define you. Your career does not have to define you. You just find another way to go on. So thank you very much for your attention. Thanks, Pam. So now we're going to flip maybe to the other side of things in terms of practice and things that we can do that help make it more meaningful for us and hopefully, in doing so, reduce the likelihood that we'll burn out. So Kent Ellington is going to talk to us first about innovation. Thanks, Sandra. Thanks, Becky. So this is the exact opposite of avoiding burnout. This is like going after burnout. Because this is a full-time job on top of a full-time job. So these are my disclosures. So many things we'll talk about, not in detail. But you'll see some x-rays with some of these things. So I appreciate the commentary and the talk this morning. It's a good reminder to think about. And as I was watching some of the slides go by, I can see some of those things happening in me. And it's good to hear it and see it and get ahead of it and quit being irritable with my fellows when they screw up a case or something. So some of them are here. It's a joke. So these opinions are based on my experience. They may or may not relate to you. Everything you do has got to comply with the DOJ and the Sunshine Act. And honestly, your ethics should be higher than that. So the most important thing is that you are who you are because of other people in your life. And I'll talk about that through the talk. And so when you get into the innovation process, the real question is, why do you start doing this? How do you start it? Where do you start? What to expect and what to ask for? And you have an idea of what's next. And so you've got to come up with that process. How are you compensated? How are you going to close the deal? How are you going to grow the idea? And how are you going to navigate the world? Because it's not as simple as just you have an idea and you give it away. It becomes a lifelong thing. I'm going to talk about what to do, what not to do, when to say yes, when to say no. And you don't want to go to jail. And that's happened. So you want to avoid that. So I've been in practice 14 years. I have a lot of ideas, but most of them are meaningless. So every time I have an idea, I realize that somebody else has already had the idea. So you do have to do your diligence and realize a lot of things has already been invented and been out there. I do have over 20 patents now. And that's a cool feather in your cap. But most of them are pointless. I've helped start over 10 companies. And it's a lot of work and a lot of weekends and a lot of nights. And that's the burnout part. And so what's your role as a physician? He's got to give clinical perspective and insight to the clinical problem. So you have companies that care about profits. And you've got engineers who understand metal. But you understand the patient and how to put it all together, right? And as you propose solutions to current problems, you see this, and you're arping, and you're working on a case. You may think, hey, I could do something to make this better. In fact, 10 minutes before I got here, one of my former fellows called me with, hey, I have an idea. I want to take it to a company. How do I do it? And I'm like, well, you should be here at the society meeting instead of home. And you've got to keep the team focused, right? Because it can go off in all kinds of directions. And you want to keep the patient at the center. And it sounds kind of cliche-ish, but it's very important. You have to be a leader of the team, but also a listener. You have to innovate. But you also have to be ready to modify your idea and eliminate ideas and to get things going forward. So the why for me is you want to improve care. It's fun. It's challenging. Bailey talked about having a passion outside thing. And so to me, although this is orthopedics, it's also kind of PE world, venture capital world, innovation. And it's fun and challenging and stimulating. And it breaks up into monotony of daily practice. It's formed amazing relationships in my life. And that's the most important thing. It's opened a lot of doors. These relationships went from business to friends to now it's considered a lot of these people as close as family. And obviously, some of these things can make money. But that should not be the focus. And importantly, going back to relationships, I joined North Carolina and Charlotte almost 14 years ago. And I was very privileged to be able to be mentored by very smart people that have been instrumental in the innovative process. So Bob and Hodges and Bruce and Carol were there when I joined. And obviously, they have made a tremendous impact in foot and ankle with Right Medical, now Stryker. And so they were great role models for me on how to get things done. And so it goes back to the point I said earlier. You are who you are because of other people. So how do you do it? You could talk to a local rep or a manager. You can talk to corporate head and different roles of people you target when you talk to them. It's often a company you use, maybe a lot of. And like I said, you may have an idea that might improve their idea. And then what do you expect when you start talking to these companies? A lot of loves and hugs. They will shower you with a lot of attention, especially the young docs that are in the room when you get into practice. Companies love to kind of latch onto you. And then there's silence and there's frustration. There's empty promises. You go in circles. Is anyone listening? And there's more silence. You feel like you're in high school dating sometimes. And it's your role as a physician to keep the ethics high and keep the focus on the patient. And so what I've learned in this process, the developmental process, is fast and cheap is not good. Fast and good is not cheap. And good and cheap is not fast. And so these are the steps. So one of the most common questions I get asked by people who have an idea is like the guy who just called me. How do you do it? So you get an idea on the napkin. Then you have to, these are the higher type level questions. You get access, markability, concept visibility, design development, verification, validation, reviews, design freeze, regulatory clearance. That's either at the FDA or outside. Design transfer and manufacturing, commercialization, monitoring safety and handle problems. So everybody wants to design a new whatever, right? But it's a lot of work that goes into it. It's not just to have an idea and have some company make it. And not every idea should be pursued, right? So this is a patient I saw last week in clinic. And these are her fingernails. So I'm like, just because you have an idea, maybe just don't do it. And so the design process is broken up into phases. So you have production definition, design inputs, output, design transfer, and then alpha release to limit the docs and surveillance. And then you move on to beta and full relaunch. And companies like to do that for just risk mitigation. So you have an idea, what do you do? It's very important to get an NDA that protects you and the other side. Speak to an R&D team. I like to talk to people more at the top of the food chain versus at the bottom. And keep the sales people out. That's a bad thing to do. It's a compliance issue, legal issue. So your rep, you might be, you see him a lot or her, but just keep them out of this process. You want to get a consulting contract that's typically an hourly rate with some royalties if you have some design ideas. And what I'm really interested in is equity where you get options in a company or you put your money where your mouth is and you invest yourself. And so it's interesting, you talked about 20% of our day is spent in dealing with patients and the other whatever, 73 is not. Where I want to change your opinion and the way you think about innovation is I'm kind of, and I love to, I've made good money in consulting world, but I'm a little done with the 1% royalty thing, right? So why should you people in this room who are the smartest people in orthopedics get 1% of your idea? And so I'm going to challenge you to kind of think about it a different way. So you got to be the champion, you got to be involved in all aspects, everything from start to finish. And don't fall in love with your own idea because I've had a lot of ideas that have been adjusted and tweaked by other colleagues or other engineers. If you have a really unique idea, I do recommend you patent it, it can be pretty cheap to do so. You can do a provisional which lasts a year and then you can convert that to utility. And you have to be able to listen and the whole process is innovation followed by optimization and that takes years. You have to navigate this world, it's all about teamwork and communication, it's like everything in life, don't chase the money, listen more than talk and be humble. Engineers, man, I can tell you how valuable they are, they're amazing, these people are just at the top of their game in the orthopedic world. A lot of these people have even PhDs in biomedical engineering and they can really take your idea and take it to the next level. And you have to understand that it is a business, right? So just because you have an idea, you got to understand the sector, the business, the challenges, the marketing. And you really have to know your idea. I've worked with some people that have some ideas and you start challenging them and they really can't get deep on it. So really be, understand what you're thinking. This is just normal life skills, right? Play nice in a sandbox, don't give up even when you're told no. So my C, I got these things called the Ellington P's. So the people, the product, the process, the plan, the performance, it's patient focus. And the last one is profits are a bonus. So again, you go into it with patient care at the focus and then I think the rest will flush itself out. And then this is not an easy game, so I have the Ellington G's, right? So you got to have guts to be in the game. And so it's long and arduous, it's nights and weekends. But what's cool is, being at Ortho Carolina, we have a great practice, we have great leadership. Bruce Cohen's here now and you were talking about that Earl. I mean, it's amazing to know that you have great people at your leading organization. But outside, I've been able to do this consulting and industry stuff and it's created some outside income that's allowed my life to be pretty dang cool. So these are family photos of me going out and doing things. And so just real quick, a couple of x-rays. This is old school stuff, and this is how we used to do it. And there's hard surgery. But some of the things that I've been able to work on and design over the years is night and all based. And that's made hard surgery a little bit easier. And so this is me in surgery thinking like, man, we could do this better and faster and easier and quicker. So this is how some of the things that I've worked on over the years to come to fruition. And then you start taking that stuff and you expand it outside the box think and you can use it in other fields of the body that are not just for foot and ankle. This has also resulted in really great research. So over the years, through developing of products, we then research them, we test them, and then we get peer review publication looking at some of the things that we've developed. And then you see challenging cases. And then if you have an implant that can perform better than others, then you think you can help the patient. Again, that's the focus, right? So it's been cool to work on all kinds of different things. And this is not me bragging. This is just kind of showing the kind of stuff that you can do and innovate with a company. This is a great story. I developed this idea like eight years ago when I worked on it, they told me it wasn't possible. So remember, I said, don't take no for an answer. So I just kept pushing and seven years later, it finally made it, right? So we were able to make a subtalar compression device that's been a really neat thing that compresses post-op. So what's your role? You gotta push the envelope a little bit, right? But safely. And so I'm a pilot and this is me flying in a storm. So this is a bad idea. And so I've learned as a surgeon, as a pilot, you gotta be safe, but you also gotta take risks. And so working with developing a total ankle or doing custom cases that require a little bit of guts to do these things to patients, but you feel like it might be the best thing for them. And then maybe making other things out there that we've kind of learned in our society don't work so good, but maybe you can make something better, which now you can maybe make a procedure that would work for us. And so the new role is don't just be a consultant. Don't just get 1%. Okay, I've talked about starting these companies. I've raised a lot of money. I've been a part of exits. I've already been a part of one IPO. I got another IPO in a couple of years and I've started my own spine company, all right? So I'm a foot and ankle guy. And this is, I took what I learned in Knight and all and I turned it into spine. So we found this company. We've now done 13 cases. We've got a bunch of patents. And this is the cool stuff is the things that I've done in the last 13 years prepared me to do this. So this is our patent portfolio. And now you can do an ACDF with one sterile implant pack like this. And we're doing multi-level lumbar, et cetera. And these are some x-rays here. And so again, this is just what you can do in the innovative world. And this is my C-suite. I don't know why my picture's upside down, but this is John White, my CEO, Dave Schmidt, my COO, and then I'm the CMO. And this is what I do for PressU and other companies, and never stop innovating. It started with one idea on a napkin to make a staple for a spine. And now we have all these things. We have one patent, now we have 12 patents and you got to keep advancing. So whether it's doing a tater or flying to the Bahamas in my plane, you always want to kind of keep going to the next step. So again, that's all about the patience of me as a patient a few years ago. And then I'm going to finish with, again, it's not all glorious, right? You got, I just quit taking level one trauma call, but you got patients that come in with shoeboxes and this patient cut her leg off and then took her bones to a beetle and they ate the flesh off the bones and she gave this to me as a gift. So weird stuff, right? And so leadership is not what someone accomplishes, but who they bring along with them. And that's really important to me, family. And then so, and this is cool. This is my dock, my lake house, and my dog's looking at two butterflies flying around and one of the butterflies landed on my dog's nose. So it doesn't get better than that, right? And then fellowship, you know, it's been an honor to be able to take people all over the place in my plane and fly around. And so, and then this is me as a fellow. Okay, with Mark Myerson, this is 2010. Becky, she wasn't in this photo, but she was there when I started. And this is old school technology. And then this is what I just bought recently. So this is a cabin class Meridian. And this is me coming to Louisville at 28,000 feet yesterday. So this is me doing high altitude oxygenation failure, me flying right through a rainbow. How amazing is that? Who's ever done that? And so in the aviation world, things that kill pilots are things that can get surgeons into problems as well, which is complacency, preoccupation, neglect, fatigue, and distraction. So I'll end up with that, guys. Thank you much. All right, great. Next up is Sam Adams to talk to us about incorporating research into your career. All right, thank you, everyone. So, you know, for me, we'll get back to the burnout. One of the things I like to do in medicine is do research. And so one of the ways I help with my own burnout over the years is to kind of switch buckets and do a lot of research because I enjoy it. And I'm gonna kind of go through how I develop my research endeavor and maybe give you a few points, especially for the younger people that are in the audience just starting out. So here, my disclosure, I have nothing to disclose related to this. I am a consultant for several companies, but nothing else that matters here. So what do you need to start this research career, like the Big Bang Theory? Sorry, my slides are off. So first, we'll go characteristics of successful research. This was a study that was done. It was widely based on all researchers. And they found that the best researchers had a high energy level, high motivation. They were passionate about the research. They were resilient, creative thinkers, team players, effective communicators, and they were detail-oriented. What I think is the most important about this is that none of it has anything to do with whether you took statistics in high school or college, whether you have a PhD, you know, all those things that we typically think about successful researchers, it's really about how interested you are in research and what you want to make out of it. It's not rocket science. And so if you're going to start this research endeavor, expand your research universe, what do you need to do? And I group things into things that are up to you, things that are in your control and that are 100% in your control, and things that are somewhat up to you. Because as with anything in life, not everything is all about what you can do. But if we look at each of these individually, you'll see that you can really build a very successful research career. And so we'll first talk about what is definitely up to you, and that's your energy and perseverance. If you're not going to be happy doing research, I wouldn't try it. You have to have a lot of energy. The research isn't going to do itself. You have to dedicate time to it, and hopefully you'll enjoy that time that you dedicated to it. And you have to have some perseverance. You have to have thick skin. Research is constantly a kick in the pants. You'll write a grant. You'll spend months writing a grant. You might not even be scored. You might get terrible criticism. And that really hurts, but you've got to be able to pick things back up and start over again. And when you start shopping around your ideas, everyone always says they had that same idea or their idea is better than yours. And so you really have to be able to take some criticism, handle it, and then regroup. Research has many failures. You can't control patients, animals, cells, things that you're going to try to manipulate in the lab. They don't behave like you want them to, and there's going to be a lot of failures along the way. And you should expect these setbacks, delays, and doors that will close. But then as with anything in life, there will be other doors that will open. Idea generation. And I think that's the biggest thing, especially for the young folks in the audience, is you want to build kind of a research platform, and you say, I want to solve problem X. And so at least you know that's the goal, and you're going to figure out how do you get there. And you're going to figure out what do you want to tackle in research. And it needs to be something that's interesting to you, and hopefully it's clinically interesting, but also interesting in other ways, such as biomechanics or a cellular level. And something that you can say, well, I can dedicate my career to this. The idea that you want to do or what you want to solve has to be interesting to others, otherwise it won't go anywhere. Are my colleagues really going to want to read what I want to put out? Are people going to be interested in my grants? Is this going to help patients? Things like that. And it also has to be something unique. You know, every university in the world has somebody that's working on cartilage repair. So do we need another cartilage repair scientist? We probably don't, but maybe there's a different way to look at things, and that's really what you want to focus on. And is this going to be something that then will allow you to be an expert in your field, in a field that's not already crowded? And so when you combine all those three things, that's really, to me, the best idea that you can have as a young researcher. And then you have to say, well, I've got this idea. What do I want to do with it? As I just mentioned, well, maybe it can make you an expert in the field. Maybe it can garner you a lot of prestige. One thing that I have found is that with the ever-expanding ability for patients to see the things that we do, it really has helped. I have a lot of patients that come and say, well, I've read your articles about this. And it can be a way to bring in additional patients. Some people's goals are to get government funding. It is one of mine. There are very few orthopedic surgeons that are NIH-funded, and so that can be a research goal of yours. And then, as Kent did mention, sometimes this can lead to industry collaborations. I certainly do a lot of things in my lab for companies that they may not be able to do on their own. One of the biggest things that I've learned over the years for developing a research career is mentorship. And you need to find a good primary mentor, and that may be somebody at your university. Maybe your chairman. My chairman happens to be one of my primary mentors. But it has to be somebody that's really going to be interactive, somebody that's not going to be dogmatic, saying that their way of doing things is the only way to do it and not listen to what you have to say. So finding somebody that really that you can honestly be a friend with, bounce ideas off of, and also your role in this is to respect their criticism of you and really learn from what they've done or what they have to say. Another big point is to find a secondary mentor. Actually somebody outside of foot and ankle, hopefully even outside of orthopedic surgery. What we do overlaps with a lot of other medical sub-specialties, even other non-medical specialties such as engineering, and finding people that you can bounce ideas off of is really going to be beneficial. And I found this. I think this is totally true. This is getting out of your comfort zone, and when you can really find people in other fields and you can excite them about your ideas, your ideas potentially related to foot and ankle surgery, that's really where success happens. But the problem with really anything in life is it needs money. So this was an empty lab, it wasn't my empty lab, but my lab started like this, and when you have no money to start this research endeavor, and this is a wet lab, but this could apply to a biomechanics lab, it could apply to really even if you just want to do clinical research and you need an office space with research assistants, how are you going to start this? How are you going to fund it? If you're a mid-career person wanting to do this, it is actually a little bit harder because you don't have something called a startup package, and I'll get to that in a second, but if you're a mid-career person, you can potentially ask your institution for money, but that can be difficult. One of the best ways would be to apply for society grants such as the grants offered from the AOFAS. It is easier to do this if it's your first job, and there is a lot more money from your institution available to give to assistant professors that are starting out. You can certainly apply for these society grants, which we'll talk about in a second, but one of the biggest things is negotiating a startup package, and that's one of the things that I did, and that is money because a lot of times when you're going into an academic center, maybe every starting assistant professor has to make a certain salary, but we're not talking about salary, so you can negotiate other things into your contract such as a startup package, and mine was a reasonable amount to hire a research assistant to buy a minus-80 freezer to start outfitting this empty lab with equipment because everything in research costs money. The society grants, you know, the AOFAS has a great portfolio of grants, especially for young researchers. I've had a few of these, and they've definitely helped boost my career, but it doesn't have to be just the AOFAS. As I said earlier, we do a lot of things that overlap, we treat pathologies that overlap with many other fields such as the trauma surgeons, arthritis foundation, diabetes, orthobiologics, et cetera, and so really there are a lot of grants out there that you can apply for that don't have to be just foot-and-ankle related. One of the problems and one of the ways that I'm facing burnout now is that I'm starting to run out of money, and you need, unfortunately, to feed this research machine, you need money, and as I talked about, some ways to get are the societies. Sometimes you can go to your home institution, or my institution has bridge funding for people that are running out of money. You can apply for more government grants, and then one thing that has helped me stay afloat is going to industry and doing some studies for them, but that means you're also potentially funding a research assistant or buying more equipment, and so these are certain ways to get funding and to keep funding going because that is one of the most important things for you to be able to keep going as a researcher. Even though I said mentorship earlier was probably one of the, it is the most valuable thing that I can tell you about, this other support category is also very valuable, and this is where I found that my research career kind of exponentially kind of took off, and the idea being is that initially I didn't have any protected time or I wasn't salaried, and we were trained to be surgeons. We spent so many years being clinicians and surgeons, and our obligations to our patients are very real, and so you can sit down, and I sat down many days saying that I'm going to write a paper. I'm going to start writing a grant, and inevitably, before I had support, I ended up answering patient phone calls and completing notes during that time, and I really didn't get anything done, and it really wasn't until I got a PA to help, you know, answer some of these calls, and it really wasn't until I was salaried or got protected time that was actually salaried that I really was able to sit down and start doing meaningful research, and so this is definitely something to consider and ask your chairman, ask for these things if they're possible because they really did help accelerate my career. Other support also includes supportive colleagues, right? You're not going to, if you're doing a study, you're not going to enroll, usually not enroll every patient in that study, and so you have to have colleagues that buy into your ideas and want to help you. You don't want to be on an island. You also need to collaborate, and as I mentioned about getting mentors, you can find collaborators outside of foot and ankle surgery, outside of orthopedic surgery, and you're developing a team. You can't do this by yourself. Eventually, you'll fizzle out, and you won't get anywhere. You really need to develop a team, and in that team, you want to know what role you play. You don't always have to be the lead. You can find some good collaborators that are well ahead of you that can also act as mentors, but you want to have everyone that says to be able to play in the sandbox and keep adding people as needed because really collaboration is the key to success, and then the most important thing is have fun. I try to stimulate a fun environment. This is one of my lab assistants. They made a little basketball hoop and put my picture over it, so they dunk on me every day, but it is something that I stimulate. I have fun. I go to the lab, and everyone has an enjoyable time, and that's really what keeps me going. Thank you. All right, so we're really tight on time, but Steve Steinleff is going to talk to us about teaching and how that fits into an orthopedic career, and we may not have time for questions, but I encourage you all to approach the panel here at some point if you do have questions about the talks. Well, thank you for having me up here. By a show of hands, who's in academic medicine? Who's in private practice? Who teaches? Good. A lot of hands went up on both sides, and that's going to be the point of my talk, and it's interesting. I'm the final talk, right? So there are two talks about burnout and two talks about totally different things, but I don't think they're totally different. I think a lot of us are very driven, and we're very hard workers, and sometimes we prevent burnout by finding interest, whether it's innovation, whether it's research, whether it's teaching, whether it's being with family, but we have to have a passion that drives us. So no pertinent disclosures. I'm going to talk about my journey, sort of what Errol talked about, and understand that it's not simply what we were taught. See one, do one, teach one. You're a great professor, and understand you can teach in any setting. I started in private practice. I was there for 22 years, only recently going to academics, and one thing you find out when you get to academics is you're not as good as you thought at the whole teaching thing, and there's a whole science behind teaching that I never really understood. And so general tenets. Being a professor at a university doesn't mean you're a great teacher. A lot of people I know that work in academics, and they don't really love to teach, and then being in private practice doesn't mean you can't teach. Being in some hybrid, hospital-employed model doesn't mean you can't teach. There's always someone who wants to learn. So I started at the University of Miami, that's where I did my residency, and I did a Florida orthopedic fellowship in foot and ankle and trauma, and I was supposed to go immediately back to the University of Miami, and well, something happened, and 22 years later I was still in private practice. But during that 22 years, I had not a small private practice. I was very busy. I was out of a level one trauma center. I had my own surgery center. We made a good living, and I saw every bit of complexity. And the question was, was that enough? And the answer was no. It still didn't give me this fulfillment that I was looking for. So what was missing? It was the camaraderie of the residency program. It was the challenges of the residency program. It was my deep desire to take everything I learned from my mentors and instill that in the next generation, and if you do that, you have a multiplier effect. And so early in my career, I came out in 2000, about 2002 and 2003. I'm a little bit bored, so I decided, you know, maybe I'll go and do some mission work. Maybe I'll go into another country and do some surgeries. People were doing that through the OFAS or whatever it might be. Then I said, wait a second, I have an inner city in Miami where no one's doing high-complexity trauma. No one's doing crazy reconstruction. We just didn't have anyone at the university doing that, and I said, let me go volunteer. Take a day a month, two days a month, and volunteer. And so I started doing that. Was it enough? No, it still wasn't enough for me. It wasn't giving me what I really wanted. So then some opportunities came about. Opportunities are what you make of them, right? So there were two people teaching for the university. One of them left, and so they had two foot and ankle residents, and they said, can we send the PGY-3 to you? No problem. Send them on up my private practice. Year later, their other foot and ankle surgeon sent them out. Now they had no one, and they said, can we send the four to you? I said, sure, send me the four. And I figured out a way through my surgery center in my hospital. I had them get on board, and I said, sure, they can scrub with you. They could do cases with you, and you alter how you do things. We were very efficient, very fast-moving, but when you bring residents in, everything's going to slow down a little bit. My days got longer, and you know what? I enjoyed every bit of it, and so it was a lot of fun, and I started doing more of it. Well, how do you do more? Another hospital down the road had a DO, orthopedic residency, and they didn't have anyone doing complex foot trauma. So they would say, hey, Steve, come on. We have a pylon. Can you come up? Sure, come up. Three residents there ready to help you in a heartbeat, because they have no one teaching them that. And so I did that. Then the other university called and said, we have non-op sports medicine fellows. Would you mind taking them in your office maybe once a week? Yep, send them down. I don't mind. You know, patients have to understand that there's an entourage coming to evaluate them, just like in any university, and maybe they don't expect that in private practice. But we made them, you know, basically aware that they were going to be in a teaching setting, and my patients, 99%, really enjoyed it. Then there's private demics, and people sometimes look down on this, but if you consult with industry and you design with industry, you can start teaching with industry. The AO, which was always Synthes Arm, maybe not anymore, the AO would put on conferences around the world. If you speak Spanish, go down to Latin America and start giving talks. It's very nice to meet surgeons from other countries. I did it through China for five years. It was a great way to make friends in China who would then come back and spend time with me for a few months. It's all teaching. And then there are your societies, Florida Orthopedic Society, every year has a foot and ankle breakout session. We have the LFS Minimally Invasive Society, so et cetera, et cetera, et cetera. There are many opportunities for you to teach. Take advantage of them. Was that enough for me? No, it wasn't. At the end of 22 years, I said, huh, where am I at? The pandemic has made it so my hospital doesn't want my residents scrubbing anymore. They're not getting the education they want. And I said, you know what? I have a new chairman down at the University of Miami, one of my old residency buddies, and this guy wants to develop something bigger and better than anything we've ever had. He got me to drink the Kool-Aid, and I said, after 22 years, I'm leaving a lucrative private practice behind. I'm leaving my surgery center and all those ancillary dollars behind. I'm going to go down to the university. So instead of slowing down in my mid-50s, I said, let me hit the gas. And I think you've heard that in research. You've heard that find another outlet, reinvent yourself every five years. This was my reinvention. And you know what? I gave up a lot, and I gained a lot more. So now I'm at the university full time, and I use every opportunity to teach. I don't just go into a room and say, all right, what's wrong with you? OK, flat foot deformity. This is your treatment. Goodbye. I incorporate the patient. I incorporate my resident. My athletic trainers want to know what's going on. They enjoy learning. I incorporate the nurses. I incorporate the PTs, the OTs, anyone who wants to learn. I have conferences, and we teach in the OR, of course. So what do we do? We teach how to deal with more than simply flat foot or cave ovaries. We teach how to deal with medicine, right? And the residents are looking at you. The fellows are looking at you. How do you interact with nursing? How do you interact with the scrub tech? How do you interact with the person in SPD when they've lost all of your stuff? Have I walked down to SPD to find it? Yes. Be kind to them. Be nice to them. The residents learn not to be a prick, and maybe things will get better for them. Teach how to deal with conflict. Teach how to deal with complications. You heard that this morning. Do not walk away from the patients. Get closer. And then teach them how to build. Teach them how to code. Teach them how to run a business. And so where does that come in? Lunchtime talks. My residents don't have to eat with me. I say, look, you don't have to eat with me, but if you want to spend an hour with me and learn what private practice was like, learn about different models, learn about, you know, what else do you do outside of medicine? Well, I invest in real estate. Well, how do you do that? How do you learn about that? How many kids do you have? I have four kids. Well, how do you balance being with your kids and your wife and your practice and your research and your design? And they want to know these things. They want to understand what they're entering. You can teach every day, every aspect of everything. And so now that I'm at the university, I realized I have to learn. I have to do more. And we have mentorship. Ideas are going to be on the table. We're going to start a mentorship committee. You've heard that from Sam. These are very important things. And basically, we're all students. We're all going to continue to learn. And then you realize there's journals like how to be a better medical teacher. I never knew these journals existed, but they do. So now you get to start reading articles on how to be a better educator. In the past, we would just fill people's heads with everything we could. I would read. I read books from front to back. I read about every case before the case after the case. Now it's not only about that. Your resident is in the room with you finding out information on some rare disease. By the time you're done talking to the patient, I look at my resident and say, all right, what did you read? He goes, I know nothing about this. Patient knows nothing about this. They're one in a million. The resident has informatics at their hand. They can go online. They can extract data immediately. This is a new paradigm. So what's important? Number one, you've heard a lot today about innovation, design, research. Universities have a lot of priorities. My main priority, my patients. You've heard that from everyone today. Take good care of your patients. My next main priority, my residents. Teaching to me is the most important thing. And that's not always what's brought down from the chairman level or the CMO of the university. You need to do this. You need to do this. And somewhere at number 10 is teach. No. I came to the university for a reason. I've been teaching a lot longer than I worked for the university. I came there to teach more. I came there to start up a fellowship. And so student-centered, be up-to-date. You better be knowledgeable because when your residents ask you something, either you know it or you know how to find out information very quick. Be the expert. Encourage them to be exceptional. I'm not into this, well, you know, we're all going to strive for mediocrity. No. You're going to strive for excellence in everything you do with me. And I want to instill that in everyone. And then I thought this was a very good article I read about peer review, meaning I should now go and hang out with a hand surgeon for a day and see how he does things so I can learn. He should come and hang out with me. I should hang out with someone else from tumor oncology, see how they solve the problems. This is this peer integration. And then we all get to grade each other and understand what we're doing right or wrong. Again, incorporate everyone into teaching. If I walk into a room and I see someone with an Achilles rupture, I say, all right, you want to learn about Achilles ruptures? You want to learn about your treatment options? Yeah, doc, I want to learn. Okay, here are your options. I go through with them. But by the time I leave the room, they've understood it better. My resident understands it. My athletic trainer understands it. Be empathetic. Be compassionate towards people. Your residents pick up on that as well. Balance autonomy and supervision. Your residents need some autonomy. Confucius had a very good saying, what I hear, I forget. What I see, I remember. What I do, I understand. You're going to have to be able at some point to give up the knife and let the residents operate and with fellows, even more so. So be that teacher that's better than everyone else. Strive for that excellence. And then what else can I do? I've taken it on my own goal. We don't have a virtual lab. I want to have a lab where my residents could work with sawbones, they could work with the VR headset, they could work with cadavers. That's going to be my goal. Hopefully in a few years, I could come up here on the podium and say, this is what we instituted. This is what makes them better before they ever even get into an operating room. So what about research? I need to learn about research. In private practice, I had a paper here, I had a paper there. Now I'm trying to put together studies that mean something. So Sam, I'm going to be calling you. You can give me some insight. Okay. What's the payoff when it's all done? Twice, I've been the professor of the year, the teacher of the year. This is voted on by the residents. You know, when 35 residents say you're the best one they've had for that year, it means a lot. To me, it's the most important thing and hopefully I'll get this more in the future. So in summary, you can teach in any setting. Working in an academic institution doesn't mean you're a great teacher. Working in private practice doesn't mean you can't teach. You have to do it. But it means you're going to be spending more time, you're going to be putting in more effort, more weekends, putting together talks and making sure that your academics run smoothly. But the payoff is immense. And I think the more you give, the more you're going to receive. That's why I went back. That's why I hit the accelerator. And, you know, the first six months were rough. It was a new setting for me. And I was wondering, what the hell did I give up and why am I here? Year and a half into it, I'm very happy I did this. It's giving me more opportunity, more autonomy to develop my practice the way I really want it to be. And hopefully next year we add the fellowship. Thank you. Thanks everybody. I don't think we have time for questions, so sorry about that. But we'll go into the next session now.

surgeon satisfaction

burnout

healthcare system

strategies to avoid burnout

careers in orthopedics

innovation

research career

mentorship

teaching in orthopedics

continued learning

orthopedic practice

self-care

organizational strategies

innovation in healthcare

patient care

teamwork

communication