And so now I'm going to introduce our moderator for the fifth symposium, Dr. Brian Den Hartog, our current president, and he's going to speak on mid-career triumphs and challenges. Good afternoon, everybody. I'm Brian Den Hartog from Twin Cities Orthopedics in Minnesota. I just want to thank Becky Serrato. She's been the program pre-meeting chair today, and just let's give her a hand for a great program. Just want to remind you as well that these talks will be archived, so if you need some more time to digest kind of what the speaker said, there's a lot of information there. So hopefully in a week or two, we'll have this on the website, AOFA S1, and so you can review these talks again. So again, I'm going to be the moderator. We have for the next session, which is mid-career challenges. We have a very outstanding list of speakers here today, and then we're just thankful that they can be here and share their expertise. So the first speaker, Selim Parekh, just moved to Pennsylvania from Duke University, and he's going to talk to us about changing practices. All right, thanks for the invitation to speak tonight. I guess it was appropriate to ask me to give this talk because January I just shifted my practice from Duke, where I was in a private academic setting, to Rothman Orthopedics in Princeton, New Jersey, and in the Bucks County area. Can we get my slide deck up? There you go. All right. So here are my disclosures. You know, when you think about being in practice, and you've been in practice for a while, I'd been in practice in one institution for two years, then I jumped for 14 years to the private academic group affiliated with Duke, and now I'm in a different location with Rothman. But there are a lot of changes that are constantly occurring around you as an individual in practice, and these can be technological advancements. When I first started practicing, we didn't have EMR, and then EMR came, and then Obamacare came, and all the clicks and double clicks came, and that became problematic. Patient expectations and experiences started becoming more relevant, where they can rate you for their interactions with you on the time that they waited, the people they interacted, the communication style. You had regulatory changes that happened. You've got reimbursement changes that continue to be a pressure on us. Competition is a change that constantly is occurring within your own group, but with the outside the group in other practices that are in the local area, and there are mergers and acquisitions in the healthcare landscape changing at all times. And all of this is always going around you while you are just trying to take care of patients. So these bring difficulties associated with it, where there's financial pressures, staffing challenges, especially after COVID. We had a hard time retaining staff and recruiting people to help us take care of patients. Patient volume fluctuations that go up and down and change your bottom line, malpractice liability, continuing education opportunities, patient satisfaction, healthcare IT, and security problems that became more relevant over the last few years as hackers tried to extort money out of health systems. You had aging patient populations and changes in the pathologies that we're seeing. Achilles tendon ruptures used to happen more in the 40-year-olds. Now we're seeing it get pushed up because of pickleball and paddleball, supply chain disruptions from COVID, and then burnout and work-life balance. We had a whole session on that earlier today. And then the pandemic itself really brought to light a lot of these problems. So you get to a point in your career and you start reflecting on where you are and what you want, kind of the next phase of your life, how you want it to roll out. And you think about are you happy where you are or is it a time to move? Now there may be reasons to move, whether it's your career is at a point where you need to change the trajectory of what's going on, and that could be because the practice setting has changed. Whether it's the type of practice you're in has changed or the partners have changed, the location could change, whether you're in a group that has moved you somewhere else or you're in a university setting and now put you in different locations. You can have evolving professional aspirations. You can have shifting patient demographics in the clinics that you service. There can be health care changes in the systems around you and cultural changes that occur in your practice. And all of this can make you think about whether or not the practice you're in is still the right one. Obviously, personally, you have to think about weather and geography. You've got to think about the family. If you have kids, if you have a spouse or a significant other, are they up for potentially changing where you're going to practice and where your life will be built? And then you think about schools and lifestyle. So self-assessment before you even change is important because you have to think about your motivations. Why are you trying to move? Do you want career advancement? You're looking for better work-life balance. Are you looking for a renewed sense of purpose because you've burnt out from what you're doing? Are you looking for a place where you get better support, better mentorship, better support for your clinical endeavors? And is your family not necessarily happy where you are? And so when you start off with this path, you have to have three people behind you. I think you have to have your spouse or your significant other absolutely behind that change because if they're not ready for it, you're not going to be happy and they're not going to be happy. You have to have a good lawyer, somebody who can review the contracts that you're going to be vetting through the different practices. And you have to have an accountant or a financial planner who can make you understand the financial and lifestyle impacts that may be coming your way with the decisions you make. And so when you start this process, you've also got to think about what kind of practice setting do you want to be in? Is it academic where there's research, training, education? That's all part of what you need to be doing. Are you looking at a private practice that's solo, which is a dying breed in the U.S.? Or a large group practice, but those are the ones who are still trying to survive a lot of the mergers and acquisitions that are happening. Do you want to be employed where you just check in and check out every week and you don't have to worry about anything else after you check out? Are you in a situation where you're looking at a group that's been recently acquired by private equity and the business implications of that are much different than a group that has not undergone a private equity event? Or do you want to be in a multi-specialty organization, which is a lot of different specialties and you happen to be one of the orthopedic surgeons amongst many orthopedic surgeons in that multi-specialty group. So you've got to do a lot of research on the different settings that you may or may not want to be part of. You got to think about geography. You got to think about demographics of patients you're going to see. And you got to think about the subspecialty representation for what you're going to be bringing to that practice or that region. Think about patient profiles, healthcare infrastructure, the orthopedic service demand. Is it in over demand, under demand? And what is the existing competition in the local area? Now, how do you find these opportunities? Right, because it's one thing when you're just getting out of fellowship and your fellowship director can help open these doors. But what happens when you've been in practice for a while? It changes a little bit. You now have an established network. Not only of friends from around the country and coming to meetings like this where you can connect and hear about opportunities, but you've also got the industry folks that you've likely worked with through the years who can tell you about different opportunities and different geographies that you may be interested in. You do want to still rely on your mentorship director. You do want to rely on co-residents, co-fellows to find out about things, as well as ads and headhunters. They can all help you. You got to think about the motivation for the practice to hire you. Are they looking for a new skill set to bring to the practice? Do they need just a body to share a call? Or are they trying to build volume for the group to really enhance the care for the patient population that they are servicing? You want to understand the history of the group you are being part of. How many people have left recently? If there's a lot of turmoil, you're going to see a lot of exits in the last few years. That may not be the best situation you want to be part of. Were physicians denied partnership in private groups? If so, again, it may not be what you want to be part of. How is the group viewed by the community? And is leadership based on seniority or equality amongst all the partners? You've got to think about ownership and what you can buy into. How do you buy in? What time frame is that within? And all the things that you potentially can buy into. You've got to meet with the financial people. And this may not be what you understand. This may be an alphabet soup of financial statements, balance sheets, cash flows. But you can ask the business guys in the group to provide you this information, which you provide to an accountant, who can help you dissect out the financial health of the group that you're about to be part of. Think about your compensation. You can be straight salary. You can be salary with a bonus based on RVUs or targets. You can be based on an RVU per dollar or dollar per RVU reimbursement or compensation scheme, direct collections, ancillary revenue that you may be part of your compensation. And remember, you're changing practices. So there's a different culture that you're going to be part of. As you transition, you will have to adapt to the variety of different environments you're going to be in. If you're going to multiple hospitals, multiple ASCs, different clinics, there are different personalities that you're dealing with. And you have to change. They're not going to change around you. They've been there for a while. You're the newbie in town. You've got to think about regulatory and licensing considerations. If you're moving out of state, I had to get fingerprinted. I had to do additional training on different topics that I didn't need to do in North Carolina. But all of this was important to understand as I wanted to get licensed again. And when you get to where you're going, network, network, network and build relationships, whether that's through professional organizations and groups and the state orthopedic societies or through the medical societies, your kids' soccer teams, the schools themselves, through the religious organizations, whatever it may be, you've got to be part of the community because if you're not part of the community, you don't get credibility and you don't get that visibility that you're going to want. So one of the other things you've got to think about is what happens to all those patients that you're caring for? How do you transition those patients? You've got to look at your contract that you're leaving because it'll be spelled out how you will communicate with patients. And there's going to be timelines and what is acceptable for you to say and not say. And even what you are able to put on social media about when and how you're moving and what you can put out there. So you need to make sure you take a look at your contract to understand these. But you've got to make sure patients have seamless care. So you make referrals to different providers within or outside of your group to make sure that happens. You've got to navigate administrative changes. You're going to be working with different people, different protocols, different systems. And you've got to understand these differences so that you can be successful and thrive in your new practice. You've got to balance personal and professional considerations. You've got to think about family factors, cost of living, educational opportunities, amenities, the overall lifestyle impact that you're going to have for your family or the significant other that you're with. And you've got to be committed to ongoing learning so that you continue to grow as an individual. So that will help you. It'll help your mindset, but it'll also help the patients that you treat. You've got to market your practice in this new location. And it's not the old school billboards, radio, newspaper. It's like the morning sessions. You've got to go to social media. You've got to be out there. You've got to conduct community seminars. You've got to meet people because they've got to learn who you are. So for me, the keys to success, you have to have dedicated OR time, clinic time. You've got to have preference cards in place to make you efficient so they know what you need before you get there. You've got to understand how you're going to be compensated so you know what's fair and equitable for you. You've got to think about what non-compete clauses you may be dealing with. And you've got to understand how you get paid through E&M coding and billing and coding effectively. Monitor yourself as you go through this. You've got to do self-reflection to know where you are so that you know where are the opportunities to keep improving. The keys to success in my mind really boil down to three things, being available, affable, and able. And if you can do that, you can be successful. So for me, I moved to Princeton, New Jersey, a university-based town. I went from being a blue devil to a New Jersey devil. I went from just having my nuclear family around me to having my extended family around me. Went to Rothman Orthopedics, four states, multiple locations, an emerging athletic program, a large division of foot and ankle where we take care of simple stuff to really esoteric stuff. And I've been able to continue to follow my passion with emerging technologies, complex reconstructions, and taking care of pro athletes. Can I get one minute? Because I think this one thing is important. Ten seconds. Oh, you don't get the volume. Well, the point is, Dion's making an immersive change at the University of Colorado, and he's changing things like crazy. And he talks about staying true to who you are and knowing what you are. Remember, you've been in practice for X number of years. You have a brand. You have knowledge. And you know how to take care of patients. Use that and leverage that as you go talk to other practices and seek other opportunities. Thanks. Thanks, Dion. Changing your practice is not easy. So it's very complex. Thank you for that. Our next speaker, Tim Daniels, fresh off the airplane from Toronto. He's going to talk about his passion for mentoring. Thanks, Tim. And tired and jet-lagged. But so I would, you know, I've done reading on mentorship to prepare for this. I don't have any slides. I could go through slides and talk to you about conversation, connection, community, and culture, those are the four C's of mentorship. But as I was reading these articles about mentorship, which I have to admit I haven't done before, to me, it all came down to one word, and that's relationships. So just to tell you a bit about myself, I'm actually quite surprised I'm up here talking about this, because as far as I'm concerned, I was awful when I started my practice. Like, I was impatient, I was not engaging, I was hyper, I was so concerned about making a mistake. The residents just roasted me. Like, I walked into the chief's office, and the first thing he said to me is, Tim, if you can't teach, you're out of here. So then I thought, well, you know what, I'm going to change myself. So I'm going to be a different person. And it was worse. Like, when I tried to be nicer, when I tried to, it like, they even roasted me more. And so finally, I decided I got to find a way to just be myself and move on to having relationships with all these young students and young people who do consider us as mentors. Just to tell you a bit about myself, I was born in Saskatoon, Saskatchewan, which is in the middle of nowhere, it's in the middle of the prairies. And I grew up on a small farm next to Saskatoon, which is in the middle of nowhere. They say, you know, in the prairies, you can watch your dog run away for days. And I spent my, I've got a Mennonite background, and it's all work. I thank my dad that he was religious, because if he wasn't, I wouldn't even have got Sundays off. I mean, it was just work. You got up in the morning, you got on the horse, you went to get the cow, you milked the cow, you separated the milk, you had breakfast, everything you had, you grew, you went to school, you came home, the next thing, you'd spend two hours feeding the cattle. It was work, work, work. My dad, bless his heart, when he was sick and passing away, I asked him, dad, what do you remember about me? And he wrote me a nice, long letter, but he said, you were my hired hand. All I remember about you is work. I really didn't have a mentor when I was growing up, except I had relationships. My parents really left us alone as children. If I would have gone to the kitchen table when I was in grade 12 and said, you know, I've decided to go up to northern Alberta and work in the oil fields, my mom would have said, well, just make sure you write. You know, like, it was, there was never these expectations about, oh, you've got to go to university, you've got to become a doctor or surgeon or whatever. I had made a decision in grade 10 that I did not want to farm, and I made a decision at that point. I was an average C student. I made a decision at that point that I wanted to go to university, and I, you know, graduated at the top of the class, which was 35 people. There were 300 people in our entire school from grade 1 to 12, and I was actually one of the first to go to university and certainly the first in our community to get into medicine. And I went back for a gathering last year, and Gary Forreiter, who always used to pick on me when I was a kid, all he could say is, who would have figured? Who would have figured? Anyway, I was incredibly shy, and I had trouble developing relationships with people. I didn't know how to start a conversation. I didn't know how to maintain a conversation. I didn't know how to end a conversation. The first thing my grandfather said when I got into medical school, he says, how the hell can this guy be a doctor? He doesn't say anything, and I didn't. I was very quiet. You wouldn't think that now, but the, you know, gradually, I would say I was very self-determined. I mean, I never had anybody sit down and say, I'm your mentor, and here's, you know, here's the things you should do to take care of yourself and get through life. Never had any of that, but, man, did I have a lot of relationships. And when I look back, they were very fond relationships. People, you know, we had this session at the university where they were talking about the trauma of residency, and I just raised the question. I said, I actually had a great time in my residency, and I'm actually still friends with the, you know, the mean professors that taught me. And the two giving the presentation couldn't grasp that comment. They said, well, we didn't, and we don't think anyone else does either. But I actually, I actually had a really good time learning. And my, I mean, Dr. Yong King was the chief of our division. He was trained in U.K. You had no conversation with him. It was all work. He was very critical, but my goodness, did he care. And, you know, if he stopped talking to you, something was wrong. He'd given up on you. The last total HIP I did with him, we never said a word from the beginning to the end. He said, that's the best total HIP I've ever done with anybody. But nonetheless, the point that I'm trying to make is that if I look back and say, this person was my mentor, this one was my mentor, that I would be labeling them in a way that I think is unfair. I think we're in a portion of our development as a society where we label too many things. I mean, how many here had a weird relative, right? They're just weird, but now they've got a diagnosis. You know, now we know they've got a certain personality disorder, they're borderline schizophrenic, whatever. But, you know, back when I grew up, it was just like, yeah, Betty's a bit odd, but man, she's fun. So the whole thing about mentorship, I think, can get over-defined. It really is about developing relationships. And the tricks that I've learned to developing a relationship, because it didn't come naturally, was, first of all, you can really get people talking if you ask them about them. I mean, how many parties have you been at where you tell a story and the next person's almost interrupting you because they got one story above yours? They've stopped listening about halfway through your story. They're just waiting for their moment that they can tell the one-upmanship story. You know, if you ask people about themselves and just step back and listen, it's surprising the things that you learn. You know, one of the questions I ask my students is, what got you interested in medicine? Or how did you get interested in orthopedics? Or, you know, what did you do before you got into school? What were your summer jobs? Just trying to develop a relationship, just a form of just mild or moderate trust. The other thing that I've learned with mentorship is to explain your situation. So we've got a lot of time restraints at our hospital. I mean, if I don't move through the cases, I don't get the last case done. And in our system, if I don't get the last case done, good luck trying to find a spot to fit them in to get it done. I mean, we've got a 3.30 stop clock or a 5.30 stop clock on our OR, and it doesn't matter how much they need surgery. Unless it's urgent, you're not going to get the case in. So, you know, if I've got a day where I'm worried that I'm not going to get through the day, I turn to my residents and my fellows, and I say, look, today's not going to be a great, I'm going to teach you how to operate day. I'm under pressure. We've got to move forward. Let's just be a team. You know, Tony, you're in charge of the tourniquet. Shaheen, you're positioning the patient, and we're going to get the day done. I never leave the OR feeling good about that day, but I found that I can feel better if I've at least described the situation and let the students understand what I'm, what pressures I'm under, and the other thing, too, is to try to get them engaged as if it's their patient or it's their environment. You know, I always tell my fellows and residents, you're like the white shark. If you don't set the standard in this room, nobody else will. You're the only person that's going to be following this patient from the beginning to the end. So if you're going to lower the bar, the bar is going to be lowered, all right? And everybody might think, oh, you know, and this is the part of the mentorship thing that didn't work for me. Everybody, you know, you're worried, well, they're gonna hate me because I'm just, you know, I'm telling them what to do and I'm being such an ogre. But, you know, if you don't set that bar up here, nobody else will, and things can quickly get under control, out of control. I've had so many of my fellows tell me that they still hear my voice in the operating room. And it always bothered me a bit, because I thought, you know, this is, I'm probably over, I had one resident tell me, you're the only surgeon I ever worked with that makes me nervous about putting a stitch in. But, you know, I'm overbearing, you know, and one of my fellows said to me about 10 years after she finished, she said, no, Tim, it just means that you're a good communicator. I thought about that and I thought, you know what, that's probably right. It's easy to be hard on yourself, isn't it? So, really at the end of the day, I feel that mentorship is relationship. You need to learn how to develop relationships. And it's a learned response. I was, you know, if you met me as a little kid, you'd probably think this guy's borderline autistic, because I just didn't say anything. I was just a silent person, taking it all in. It really took some time to learn how to carry a conversation, and I really didn't get good at teaching or mentoring until I was confident in what I do. So, you know, if you're early on in your career, maybe you shouldn't be considered, you know, put yourself on the mentorship program. Maybe you should wait until you're a little bit more confident in what you do, because it can get discouraging. There's nothing worse than sitting down at the end of the year and seeing that half of your students have given you a failing mark. I mean, that really hits core. You know, that's an ego diminisher. So, you know, for you out there that wanted slides and me to go through all the steps of mentorship, I apologize, but as I said, the more I thought about it, the more I thought, you know what, this is all about relationships. So all of us are mentors. Every single person in this room, no matter what stage you're at, when you go back to your institution, think about developing relationships and you will be an amazing mentor. Thank you. Thank you. Thanks, Tim, wise words indeed. The next speaker is Steven Neufeld. He's gonna talk about a topic that's dear to my heart. Anybody middle-aged and older loves new technology and adjusting to that new technology. So Steve's gonna tell us how to do it smoothly without effort, right? Thanks, Brian. You know, when I was asked to give this talk, my initial reaction was, I'm insulted. I mean, mid-career, are you kidding me? You know, in my brain, I think I'm still 22. But then, of course, I grew a beard and it came in gray and I'm like, oh, geez, I guess I am mid-career and I've been in practice for over 22 years. So I did some reflecting. So that's a nice part about this series of talks is that I think a lot of us up here got a chance to reflect on our lives a little bit and think about some of the other things in life that are important. So when I came up with this talk and I was thinking about the last over two decades of practice, I kind of went back to the beginning. You know, my fellowship back in 2000 up in Baltimore. I started out in the University of Pittsburgh as an engineer, went to Hahnemann, then Ohio State, then Union Memorial. We started a fellowship. I've been involved in the OFAS over the years, review journals, publish, give talks. And over 22 years, my practice has changed. And then I realized that I guess I am mid-career. This gray beard maybe is relevant because I have changed over the years. And I started thinking about, well, what do you have to do to make changes? In my practice, I left the multi-group practice, started my own practice in 2001, and then expanded it, and then finally formed a big super group in 2013. So here's my disclosures. This quote kind of summarizes, as I look back, really what motivates and what drives change. And it's really an important quote, I think. It says, do the best you can do until you know better, and then when you know better, do better. And that kind of, Maya Angelou kind of summed it up. And that really has been the driving force for how I've made changes over the last two decades. And I think it's a nice theme for how we can make changes in our practice. So there's a couple steps that I went through as I was implementing these changes over my life. So first of all, realize that what you learn early in your practice may not be perfect. They're good, but they may not be perfect. And just because you learn them in your fellowship and they're working for your fellowship director or your colleagues, they may not always work. And as you're going through your cases and through your patients, realize that a change should be and can be made, and you need to be open to change. If you're a very rigid person and you were taught this is the way to do it, or you teach others this way to do it, and don't open yourself to the opportunities of change, then I think you're selling yourself short, and I think you're selling your patients short. So once you're open to change, then you need to be curious and you need to start asking questions. So where do those questions even come from? Well, you come to meetings like this, you meet with your colleagues, you meet with your friends. I would encourage everybody to read the journal that comes out once a month, read a second journal, watch webinars, and just ask your friends. Pay attention to what's going on in the industry. When reps come to the OR, they come to your office. Don't just ask for that free lunch or free dinner, but really take a look at what they're looking at, and there's some interesting and innovative stuff that our colleagues are developing, and you need to be open to those changes. Once you realize that there are better ways out there, you need to invest some time and money into making those changes. That may require financial, you may need to slow down your practice, you may need to spend nights and weekends learning about stuff. And then after you make these changes in your practice, you need to slow down and just reflect. Hey, was this change a good thing? Was it a bad thing? And if it's a good thing, then market yourself, you know, use those things. So I'm gonna give a couple examples of what I've been doing over the last 20 years and how I've made some changes. So some examples. When I was taught in my fellowship to do ankle replacements, it was the agility ankle, and that was the only solution. I did many cases in my career in the beginning. But there were problems, there was loosenings, there was subsidence, there was failures, and we really had very poor revision outcomes. So something had to be done, we needed to make some change. So my solution was find new implants, find new solutions. There are now more options, better surgery, better outcomes, and happier patients. So now here's a better way. Osteochondral defects, we all see OCDs. Early on in my practice, the only option that I learned that I thought was appropriate was microfracture. But as time goes on, if you slow down and look back at your cases, you realize that not all cases were amenable to microfractures. Larger defects failed typically. We did some oats for revision cases. Those are difficult cases, lots of morbidity, lots of cost. So the solution is, there must be better solutions out there. What are some of the newer options? Cartilage transplants, things like that. So old ways, think about the new ways, and now there's newer stuff like transplants and de novo and cartomax. As time goes on, we learn more things. So just be open to these changes and my results have been much happier. How about flat foot reconstructions? Early on in my career, I was taught that everybody gets an FDL transfer and a medial calcaneal osteotomy. I did tons of those. But as you go back and reflect on your patients, you realize, well, there were some inconsistent results. Some of the deformities didn't get corrected ideally. There were some failures. And the options for revision are very limited. If you do an FDL transfer and an MCO, you can do a triple orthodesis. And that's kind of it at that point. So there's newer solutions. There's lateral com lengthenings. There's spring ligament repairs. So again, there's more options. There's better surgeries. There's better outcomes. And that ultimately leads to happier patients. So there's the old way, and here's the new way with spring ligament reconstructions. And the stuff I'm doing now is very different than I did 20 years ago. How about chronic ankle instability? Initially, if you have a bad case of chronic instability, you can use allografts. You can use sutures. But sometimes you could have over-tightened repairs. You've got painful hardware. Revision options were difficult. Allografts, they were big reconstructions. So as time went on, I opened up my eyes to other options, and now there's synthetic grafts and different types of techniques and different technologies that are leading to better and happier outcomes. Chronic achilles tendinosis. If the standard repair didn't work, my only option back then was an FHL transfer, which we still do today, but there's a lot of morbidity. There's weakness. There's prolonged recovery. And if it fails, the only options we really had was allografts or big reconstructions. So as time went on, I realized there's more solutions. There's newer stuff. There's synthetic grafts. There's better ways to do things than I used to do. So we'll spend a few minutes looking at my evolution and bunion surgery. So when I was taught, there was really proximal or distal osteotomies. There were big incisions. There were long recoveries. Many of these joints were stiff. Infections and pain were a problem. And really, the option for a vision back then was really lapidus. So my solution over time became minimally invasive bunion surgery. And I wanted to take you guys through how I incorporated this particular technique into my practice. So I thought it was a better way. So here's a quick few slides on my MIS journey, how I incorporated a new technology into my mid-career life here. So number one, I realized that not all bunion patients were happy. Many were stiff. Many had long recovery. Many recurred. I realized there must be an alternative, and I should try something. So I became open. As the years went on, I started looking and reading and talking and listening to my colleagues around the country. I read journals. I asked colleagues. And finally, I heard about this group called GREPNEC, and I went to a meeting. Minimally Invasive Financial Society. It's an international group. We learned about percutaneous solutions. It was created in 2002, this group, and now they have meetings and international members all over the world. So this became interesting. I became curious. I went to a meeting in Marrakesh. I learned about the techniques, what the Europeans were doing. Again, I'm open to change. I'm thinking about change, and this seemed to be an option. So then I agreed to spend the time learning new techniques. I slowed down my practice a little bit. I reached out to industry. I went to courses. I read journals. I bought a textbook. And then I practiced. And I practiced, and I practiced in a lab. I went to courses, and I got cadavers, and I practiced some more. And I started using it, and I noticed that my patients were doing well. The results were good. So then I slowed down. This is the sixth step in my outline, and I reflected back on my first hundred. I said, how did these guys do? I mean, in your mind, you think everything is doing great, but if you're gonna adopt a new technology, I think the onus is upon us to reflect back and see, did we make a difference in our patient lives? Are the outcomes better? Was there a reason to change to this technique or not? And when I went back and I reviewed and I published the paper, I realized this actually is working, and this was an answer that I needed for my bunion patients. So then the seventh thing was just starting to market myself. And once I started doing that, the practice flourished. The volume has increased, and it's really become a big part of my practice. So in conclusion, really, in any field, orthopedic surgery is constantly changing. There's always research. There's always changes in patient expectations. There's changes in our expectations, burnout, moving jobs. All of this sort of ties together. When you're in practice, just keep your mind open to options and changes. And it's very possible and very likely that as you make changes and you keep up with it, you'll be satisfied. So again, my eyes, Angela said, do the best you can do until you do better. And then when you know better, do better. Thanks. Thanks so much. Thank you. All right. Thank you. Our next speaker is Pete Mangone, currently from Asheville, North Carolina. He's gonna talk to us about being a patient as a physician. Pete? All right, thank you, Brian. And thank you, Becky, for the opportunity to do this. And I'm here very casual. If you guys spot me in the crowd, I've got the donation T-shirt on. You can scan me to donate to the foundation. So don't be afraid to do so or come up to me when you're out in the hallway. So I appreciate the opportunity to speak when the doctor becomes the patient. How do you juggle health concerns, being the doctor and the patient at the same time? I have nothing to disclose as far as this goes. And so the first thing I wanna do is thank this group of people here between Becky Serrato and Mark Easley, who sat in emergency rooms with me when I was out of town. Casey Humbert, who was very calm when my pulse was 25 in a Chicago restaurant. And she was just like, I think we should call 911. Cesar, who moved my car when I was on the way to the emergency room at Duke. And then Elaine and Kathy putting up with me while I was in and out of meetings and things like that. And then the entire AOFAS and OFAF board, happy to announce, and obviously just kidding here, that all board members have to be certified in ACLS now so that if I collapse or anybody else collapses, they know what to do. And then especially thanks to my wife, who's not here, but having a partner to go through this, it was very difficult. And my wife was by me the whole time, and that's so helpful during that was a pretty stressful journey. So what did I learn during this patient journey? Well, the story starts in, I think that you guys, I don't know. I'm missing a few things here. Hold on a second. I'll tell you the story here. So the story's in February, 2002. I think my new version didn't get submitted or put in there correctly, or it didn't get saved correctly. So February 9th, 2022, I was getting ready to work out. I got up, I put my shoes on, and as I was putting on my tennis shoes, I suddenly developed pretty significant chest pain, left-sided chest pain. Felt like there was just a twisting going on in my chest. I'd never had anything like it before. I went, sat there, and I'm going, really, what is going on here? Should I even work out? Then I got worse. Then I started to get radiation in my jaw and into my arm. And I was like, this is not good. And I started to think about the fact that maybe I should have taken that Lipitor for the last five years when I hadn't been, and kind of cursing at myself. And so go over to get an aspirin, and I'm standing up, and as I'm trying to look around for an aspirin, literally, my heart felt like it stopped, and I nearly hit the ground. So I went almost near-sinkable, barely avoided hitting the ground, stumbled into the room, called 911, go to the emergency room. And basically, everything was normal at that point in time, right? Troponin's normal, all this sort of stuff, right? So then you're sitting there. Next day, I had a stress test that was pretty normal. Then I'm off to doing things. Then I gotta go to a meeting. So then I'm out in Phoenix at the meeting. I'm trying to maintain as normal of a life as I can, while in the back of my mind, I'm like, I have no idea what happened, and I felt like I was gonna die. And so it was very stressful, anxious kind of process going on. I then had another episode of near-sinkable episode a couple weeks after that. Holter monitor showed a little bit of something here and there, they weren't sure. And then they're like, well, maybe you just have coronary spasm, which is not something you really wanna have, by the way, because there's really nothing they can do for it, and they just tell you that you never know when your coronary could just spasm and just take nitroglycerin if you need it. So I'm running around trying to be a doctor. At the same time, I've got these episodes occurring of atrial tachycardia is what it turned out to be. And I would get lightheaded in the OR and things like that. And then I had another chest pain episode in a big chest pain episode in June when I was in the operating room, and one of my former partners who's here, Shannon Alejandro, had to come in and finish the case for me. At that point, I started to get really anxious, not only about what's happened in my life, but also my career as well. And as I'm going to cardiology, and they're telling me, well, it's probably just arrhythmia, but don't worry about it, it won't kill you, it's okay, don't worry about it, right? And in the back of my mind, I'm pulling out my disability policy and trying to think, am I gonna be able to do this? And at the same time, I heard Casey talking earlier about when you make a mistake, and the shame, and people are hard to hide it. At the same time, I'm trying to practice medicine. I'm, in a sense, trying to go about my day-to-day life, while at the same time, I'm trying not to let on to the patients that there's anything wrong because if you're a patient and you're in somebody's room and all of a sudden they start to get syncopal, that doesn't really provide a lot of confidence that they're gonna be able to take care of you now and in the future. So it's this constant battle for the next six months going on between symptoms occurring in the clinic, in the OR, fortunately didn't have any more major chest pain episodes, and ultimately, I had never been, I hadn't been in ER since I was like seven years old. I was to six ERs in the span of six months, basically, between episodes, and in Chicago, and at Duke, and other places. Eventually ended up getting, I had to buy my own monitor. I bought my own heart monitor, watched it, was able to determine that I had some sort of arrhythmia going on, got to somebody who was able to like say yes, as a matter of fact, and you know, the guy said, you probably had a sinus pause when I originally almost passed out. He said, you know, sometimes when these, if you're in a-fib or some sort of full arrhythmia, when it pauses, there's like this reset and you can get near syncopal. And that was a tremendous relief to hear that because that was the first time someone had actually explained what had occurred in the original event, because it's incredibly anxiety provoking and difficult when you have no idea why you felt like you were not gonna live, you know, two seconds later. So a lot of things, you know, that whole time going through it, at the same time trying to maintain a practice, I had to, you know, I tried to back off as best I could in terms of slowing down, quote unquote, but the reality is it's very hard to stop that moving train. You know, there's a lot of people, depending on me as an individual, to take care of them and are waiting. And so I went through all that, eventually was diagnosed with atrial tachycardia, was put on verapamil in March, and since then I've felt like a godsend. I mean, I feel like I'm back to normal, but for 13 months, basically, you know, people would say to me, what's wrong with you? And I'd be like, I really don't know. I just know I don't feel normal, right? So with that, you know, over this last 15 months, I've learned some lessons about, you know, how do you be both of those? How are you as a patient? How are you as a doctor? How do you try to do both at the same time? And some of those lessons are, number one, take care of yourself first. So without a doubt, you know, I think I, I take my medications now. I, you know, I get good sleep. I try to get six to eight hours of sleep every night, whereas I used to routinely just go and go and go, and then go to sleep and get four hours of sleep. I try to get sleep. And I've noticed when I do have little episodes, it's usually when I haven't slept enough and I'm running ragged. So really try to get good sleep, take care of myself. I schedule time out for my doctor's appointments. I just take the afternoon, make sure I get to the doctor's appointment. All those sorts of things that we tell our patients to do, but in many cases we don't do while we're taking care of them. Two, when you don't feel right, and this goes for when patients tell you that when you trust you don't feel right, there's something wrong. You know, you may take a while to figure it out. Don't give up on it. But I'd also encourage you with your patients, if they tell you there's something wrong, there's something wrong. Now us as orthopedists, we may not be able to figure that out, but we can certainly help guide them in the pathway of doing that. Ideally, if you can see doctors that don't know you personally, I think that's better. I live in a small community. Fortunately or unfortunately, I can have a lot of access to the system and I can say, hey, yeah, can you see me? But at the same time, there were times where I felt like I really wasn't being taken care of at the level that I would have been if I hadn't have been their friend, right? And just, oh, don't worry. Or a doctor, if they'd have just known me as a regular patient instead of a doctor. And so trying to find objectivity in that process can be difficult when you're in the system. The healthcare system is a mess. It's a maze. Do your best to help your patients navigate the system. Just letting them, just saying, there's nothing I can do for you. Sorry, don't worry about it. You'll be okay. And then just letting them float out there is not a solution. And I can tell you, as a patient, it wasn't a solution for me. Give your patient hope, even if you can't solve their problem. Try to help them. Get them to the right person, or work with them, or talk to them, or get them to work with you. But just kind of leaving them out there hanging in the wind, I don't think is helpful. As a patient, it wasn't helpful. And I would encourage you, as a doctor, not to do that. Anxiety is very powerful. I was always a person who would say, mind over matter, oh yeah, yeah, anxiety, I can deal with that. It's not, it is tremendously anxiety-provoking when you have things like this happen, and your health is, your immediate health is in jeopardy while you're doing other things and trying to maintain your job. Make sure you take care of that. And then it's very helpful to have family and friends in the pathway. Make sure you have a good support structure for these times where these events come up, because without a doubt, I would not have been very successful trying to do this on my own. Thanks a lot. Thank you. Thanks, Pete. Our last speaker is Judy Baumhauer. She's gonna talk about how she manages a successful practice. Thanks a lot, Brian, and thanks a lot, Becky, for first of all, calling me a mid-career, just like Steve said, and secondly, for saying that I had a successful practice. I appreciate both of those comments. These are my disclosures. So this is an early picture. This is actually me when I got my very first paycheck as a resident with our dog, Boo Boo. And that paycheck was the beginning of my orthopedic residency, which I did in Vermont, actually. But the successful career or your practice starts, of course, where you begin your journey, and this was certainly my journey. I think we picked orthopedics, so we were already on the road to success. After fellowship, I went through residency at Vermont and then went to fellowship in Wisconsin with John Gould and then, and Jeff Johnson, who's here, and Mike Sheriff, and then joined the University of Rochester in 1995, and I just stayed put, because I felt as though the successful career that I was going to be able to build needed to be built at a foundational level, and I thought Rochester provided that for me. I did look around Seeland. I looked around, but I didn't see anything better than what I currently had. The division at the time that I entered was just me. I was the foot and ankle division. Shep Hurwitz was there a few years earlier, but really, it had dwindled to nothing, and all the other subspecialists were juggling the foot and ankle stuff, so it started with me and stayed with me for about seven years before I was able to hire my first partner. My goals at that time, and I think this is a key to having a successful practice, is to always have goals, no matter where you are in your practice, so my goals at that time was to be an excellent clinician and surgeon and to be able to have patients want to see me and fill my clinics and my OR. So another part of your support team is really important. This is my husband, Ted. I married well, I always say, because he was unbelievably supportive and made a successful career in practice for me. So in your early career practice, you need to have goals, like I said. So I had my initial goals, and then as I developed my clinical team, you need to build a really successful clinical team. In your clinical team, you need to have a secretary or some administrative assistant to help you offload things that you shouldn't have to take on yourself. And also, I had a nurse practitioner at the time, or a PA, or whatever you may have, because you need the support system when you're a solo practitioner in an academic practice. And then I recognized how important it was going to be to build a research team as well and innovative collaborations. So I had a PhD buddy, Deb Nowazinski, and I did research together for over 20 years. And that allowed us, during the time that I was busy in the clinic or in the OR, she was working on the research ideas, and when she was busy doing teaching for the physical therapy school at Ithaca College, they had a Rochester campus, I was able to pick up where the research needed to go at that time frame. So that working together really worked out for us. We could also share resources, and we could be partnering up with each other when you were kind of down and thinking things weren't going in the right direction. That person was up, and they were supporting you. You also needed to make sure that you worked towards common goals with other collaborations, MD partners. I said yes a lot, and I heard earlier today, you know, don't say yes to everything. I kind of said yes to everything. Now, I don't know that that was a good strategy or not, but I built a community of people that I'm proud to say I still call friends today. When I was young then, and I applied for all the young stuff, because that's where resources are, so there's a lot of opportunities when you're young to get early research awards and foundation grants and things like that, traveling fellowships, apply for those things if that's part of your goals, and that was part of my goals. Get on committees, that was part of my goals as well, because I wanted to learn from really smart people that I was sitting next to, you know, like Tim Daniels. I did it locally, and I also did it nationally, and I also advanced into international things. I watched, I listened, I learned, and I was sitting at the table so I could be seen. So mentor up with others that can help you. So there's John Gould on your left and Saul Trevino on your right, and there I am sitting in the middle between the two of them, and they took really great care of me and watched over things that I did and gave me great advice, but we're not overbearing mentors. They were actually very gentle mentors. I enjoyed our relationships, Tim. Somebody said, you know, that it's all about communication, it's all about recognizing others and doing all the good things that build a team, and you know, it's the age-old thing. It's all I really needed to know. I learned in kindergarten. It's so true. I don't know how many times I've used this slide, but every single one of them is true. I talk about knowing what your goals are or where you want to go. I have gone out to dinner with my husband many, many times with a yellow-lined pad of paper where we've sat down and talked about what our goals are, and then made some goals, and then made trajectories to get towards those goals. So as we advanced towards early to mid-career successes, I needed to grow the division. I couldn't be by myself. It was like almost seven years by myself, not because I wanted to be. It was difficult to recruit to Rochester when you only had one person there. So I needed to grow the division, so we ultimately added on partners, and we're happy to say, you know, we have seven partners now. We added a fellowship on. Sam Flemister came to join us. He said, we need a fellowship, and that was the next thing we did. We added additional PA and nurse practitioner support. We also aligned ourselves with the ancillary services that we knew we were going to need, and I have to say, at Wisconsin, at Milwaukee, where I was, they had a fantastic orthotics and prosthetics relationship, and I took that into our practice as well. So our relationships with our orthotics and prosthetics experts is really excellent, also with our physical therapists. One of our physical therapists has given a couple talks this morning. So building your relationships with your ancillary services are really important. They become part of the team. And then take advantage of free stuff. I was in the back, so I couldn't see the hands up for those who are in academics. Is anybody in academics out there? A few hands. Now, private practitioners. So in academics, it's kind of a strange thing, but you can take advantage of a sabbatical and be paid for taking six months off to be able to grow your ideas and goals and advance yourself, which is awesome. I think in private practice, it's much more difficult, but you can certainly do some things that can carve out some time. I also took advantage of tuition credits. So I'm at an institution, so I get tuition benefits, and I took it, and I got a degree for it. I figured it's free. Why wouldn't I go do that? So take advantage of free things to build the success of your practice. So again, back to the yellow line pad of paper as you start to expand and leverage your success and expand on your brand. Clinically, we heard earlier about innovation and industry collaborations. Very important because you're advancing your ideas and the ideas of others, and you're working together. It also allows you to expand patient referrals. Patients do like to be involved in clinical trials and things like that, so that's important. With research, although I was pretty successful with Debbie Nowozinski, multi-centered research really was the next higher bar in making sure you develop relationships so that you can work together with other like centers that want to work with you. Education, equally important. Teaching, mentoring, all those sorts of things. Going out there and presenting your research, presenting topics that might be informative to others. So all really important stuff. Politically, you have to get involved politically as well to advance the importance for your patients. Anyone who knows me knows I love patient-reported outcomes, and I feel that the answer to whether or not something worked is coming out of the patient's mouth. So us telling them that it worked is no good anymore. So making sure you advance the politics of changing the paradigm, perhaps. And then socially, networking and having fun. So I would tell you that I had to give some thought to what I think would be a successful metric for social relationships. I would say people want to talk with you. People want to meet at the bar with you. That always happens for me. People want to sit at the table by you if you're out for dinner. People recognize that you're going to give them a belly laugh and that you're not too serious and that I like to think I'm positive. I like to think I'm kind, and I like to think that I ask others about their lives and try and keep any of the negative drama to myself. So I think those are metrics that I thought made things successful for my clinical practice so that I could keep my social relationships going as well. So as things started to tear towards mid-career to late career, be a mentor to young partners as you're growing your practice and the division. Empower others with opportunities that you've been offered so that I step away and hopefully offer up those opportunities to others because they still come. And then bridge succession planning. Make sure that your successful practice moves on to provide a successful practice for others because there's a lot of room for everyone, and that includes leading the fellowship, any research opportunities, industrial relationship opportunities, speaking engagements, and everything else. So you really know you've had a successful practice. And you've had the same secretary for 27 years. That means you must have been a nice enough person that they liked you. The patients say they'll miss you. Your patients are happy with the partner that you suggested because you're stepping down in your clinical exposure. Your OR staff gives you a party, a cake, and an excellent reserved bottle of wine. Your partners don't hate you for stepping down and perhaps burdening them a little bit. And your family's happy to have more time with you. So those are my metrics of success, and hopefully it was helpful. Thank you. Thanks, Judy. I want to thank all the speakers for sharing with us their crystallized wisdom of a lot of experience over the decades. And I think we do have about five minutes for questions. So if you want to come, any questions for the speakers, come to the microphones, please. Seeing none, I will throw a question out to Celin. I think your talk was very good. Having personally moved my practice three times in my career, this is a talk that's probably very near and dear to my heart and part of some major frustrations, too, the last 10 years or so. But you talked about getting involved in the community. When you move, you have to get to know people and reach out. And one way that I find that, especially in mid-career, if you still have high school or junior high children in your home, that's a great way to get out and meet not only people in the school that your kids associate with, but their parents and their friends as well. So that's a great way to get involved with that. But besides going out in the community, what would you say, if you had to kind of give an overview of what are the maybe two or three most important things in deciding, number one, to move your practice, and then number two, once you move it, what's your recipe for success in that? I think in deciding to move, you have to get alignment and buy-in from the entire family, if you're married. Your spouse or significant other has to be behind it. And we actually had multiple family dinner table discussions with the kids to make sure that they were okay, that they understood why I was looking, and that it was okay for them to be anxious, and that they were going to be okay on the other side of it, and that they were all right with the move. I think that's so important, because if your family unit's not happy, I don't care what you're doing in your own practice in the new location, you won't be happy. And then I think the second thing that's so important, in today's day and age, once you move to a place, all of us are on our phones and social media and devices, but there's so much value when you're in a new place of meeting people personally. I think that is so tremendous to make an effort to go meet with other people and have one-on-one, stop into offices, stop at the physical therapist's place, talk to infectious disease people, the rheumatologists, the churches, the sports teams, just meet people. It's old school, but it is so effective to make sure you are part of the community. You can't be somebody who's just on borrowed time in the community. You've got to be an integral part in creating value to the community, and I think the only way you do that is actually being part of it and personally going out and doing that. I think that's a great point. Just because you think you have a lot of clinical experience, and maybe even some national renown, when you move into a new practice, your partners don't really know you that well, or the other referring doctors don't know you that well, if at all, and so you have to take the time to build those relationships. Tim, I really appreciated your talk as well. I never thought of mentoring as just good old-fashioned building relationships, relating to people, asking them where they're at in life, and maybe sharing some of your wisdom with them as you walk along the journey together. Is there a certain time in your career where you felt that you had enough experience to share with other people, and you felt like there was a... I think you shared why you reached out, but you're not exactly an extrovert. I know that, but I think the point that you brought out was excellent, and I guess you felt a need to do something maybe different, and to be a really good friend and a mentor to somebody is getting involved in their life and sharing with them your experience as well. Do you feel like you had to get a certain amount of experience with your practice? You're a hard worker, you're doing a ton of cases, doing a lot of research. Is there a time when we should say, hey, we've learned some things over the years, and is that when you want to say, hey, I really want to put an effort into, a conscious effort, and to relate to the people that we work with? I can remember more clearly when I didn't feel like I was ready to mentor. Certainly in my first five years of practice, I was struggling to find my own footing. After ten years, I felt confident enough to start really focusing on the skill set of the trainees. But to be frank and honest, I still feel like I could improve. I still feel like I have some deficiencies that I could work on. I think it's easier to answer that question by asking yourself, do I feel ready? If the answer is no, give it time. Some people are just natural at this type of thing, but I'd say it's a small percentage. Most of us have to work at it. It has to be a purposeful effort. But there is so much benefit to being a mentor, and in return, you get probably more than what you give. I think that's what I found in my practice. Judy, I think one of the reasons that you have been so successful in your practice is that you stayed in one place. You built a good practice, a great reputation, and I don't think any of us can underestimate the value of that. Having support at home, doing good research, reaching out to other people around the country and saying, hey, let's develop this network of people that we can talk to each other and mentor each other and so forth. Having that support group, I think that has a tremendous effect on how we manage our practices and how happy we are and avoid burnout and so forth. So I think that's, if you give us some good words of wisdom there, but I think you've done things well, and for those of us who've jumped around to different practices, we've had probably more frustrations because of that. But to plant in one spot, if you're happy there and you've done everything you can possibly do to make it work there, it's probably hard to leave, and you probably shouldn't leave. Because, as Selina and I know, that moving practices, it's a big disruption on a lot of different levels. So Steve, I liked your talk as well. I mean, as an older physician who's getting close to retirement at some point in the next few years, I mean, I've done certain things certain ways for my whole career, and for me, I've learned to look carefully at where the pain is in my practice and say, okay, I need to do something different, because what I'm doing right now is not making my patients happy, and if they're not happy, they let me know about it. So I love the way you rolled out the, look, you have to be self-critical and say, if there's something you need to do differently, and you do embrace it, and you say, okay, go find out about new technologies that might be out there that may help me ease that pain that I feel in my practice. So I mean, is that hard to do for you? I mean, is it, especially since in fellowship, you learned a certain way to do things? I mean, I don't do anything now that I did in my fellowship, as far as techniques, but. I think all of us as physicians, just to be in our role, we have a certain amount of an ego and a self-assurance, and you think that your way is the way to do it, and the way you were taught is the way to do it. Half the fights with my wife are over I think I'm right and she's right, and the reality is there's lots of ways to get things done. There's always something better, and you just have to be a little humble, and don't get stuck, and just ask questions, and always looking to be better. I think it's a hard thing to do. Yeah, I think you have to be open-minded. I mean, I think, you know, Kent Ilion talked about his desire for innovation, but, you know, not everybody has that desire for innovation, and expanding your mind and say, hey, how can we do things differently, and then put things down on a napkin, and approach an engineer and so forth, or just in your own practice say, hey, let me try something different. It's got to make sense financially, it's got to be something that will make your practice more successful, but I think it's worth the effort to do that. So Peter, are you a better doctor now? Are you a better doctor? Am I a better? Oh yes, I'm better, definitely. I'm a better doctor just from experiencing all that and really getting a better, I mean, you think you have an idea what your patients go through until you go through it, and then you really understand, you know, how complex and frustrating the healthcare system is. It's not easy, and I know the system, right? I know the system backwards and forwards in a small town where I know everybody, and it was still very much of a struggle to do that, and I have great appreciation for those people out there who are, you know, they have healthcare problems too, and they're, you know, serving dinner to you somewhere at a restaurant, they are, you know, reading whatever attorney files they need to read for you. There's all sorts of people who are having these things, and mine, although I didn't know what it was, can you imagine if it's terminal, or if you know for a fact you have a terminal illness or something like that, I mean, the amount that it must weigh on your mind is beyond what I can even think right now. So, yeah, definitely much more appreciation for patient experience. Can I make one quick comment? Yes. Because I know you touched upon this, Pete, but it's so important. You said you took out your disability insurance, you looked at it. When's the last time anybody in here did that? Most of us get our disability insurance when we were younger, and I did too, and after the second COVID vaccine, I actually got hospitalized for five days, there was a concern that I may not be able to operate again, and I was looking at, is this it, and will I be able to care for my family? And I pulled out my disability insurance out of it, and I was under-leveraged, and luckily everything went away and I'm fine, but I realized that I wasn't where I needed to be to support the lifestyle that I had evolved into with my family. And that is so important that if you haven't looked at it, you want to make sure you take a look at it and make sure you look at it.

mid-career success

challenges in the medical field

technology impact

patient expectations

importance of mentorship

building relationships

openness to change

implementing new techniques

embrace change

continuous learning