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Um So, so who's here? What years are you guys pre pretty much 1st and 2nd year? OK. Very good. So, OK. All right. Explicitly. OK. I got you got you. All right. So, um I didn't bring any slides because I like to leave things a little open ended that way we can just have like, you know, a nice discussion. Um All right. So I'm James Toussaint. I'm the chief of the Foot and Ankle Division at UF uh Ortho, obviously. So, um my background is a little um different than the standard orthopedic surgeon that you'll find in academia. So I went to, so I grew up in South Florida and I went to the University of Chicago for undergrad. I studied economics there. And um I was premed too, right? So you do econ premed. It's already a little um uh atypical. But while I was doing um economics at the University of Chicago at that time, there were two trends that were pretty popular. It was either you go into consulting. So, um like management consulting companies like mckenzie B BCG, et cetera. I don't know if you guys heard of some of them or you do investment banking. All right. So the econ department at the University of Chicago is pretty powerful. Tons of Nobel Laureates. A lot of like, you know, cerebral stuff. And I said, well, if I have an econ degree at UFC, I should use it and see what I can make of it. Right. So I went to Wall Street for four years uh knowing that I had already been premed. And so when I was on Wall Street, I had to make an argument for why I did all this bio and like him and stuff. And so I said, I think I would be useful in health care, investment banking, right? So, uh and it was like, I would say a shoe in, I put it in quotes because back then, you know, hindsight is 2020. So it looks like it was easy, but I'm sure I was like stressed as hell, right? So, so, so, but, but I got in and I worked for this company that was a pretty major Swiss bank. They had like one of the most powerful healthcare investment banking uh divisions on Wall Street. And, and as I was there for four years in Wall Street, if you're there for more than four years, you might as well make a career out of it. So I ended up taking my mcats at the end and then I switched back to medicine because that's what my parents wanted me to be. And I'm sure some of you guys are in the same shoes, either a doctor or a lawyer. Otherwise it doesn't matter how much money you make, they're not proud of you. Right. So I said, all right, fine. I'll be a doctor even though Wall Street was amazing. I had an amazing time. So, so now um II, when I was in investment banking, I did some pretty amazing health care deals. I was traveling all over the world. Um I did some Ortho company things. I did some ophthalmology, like managed care, uh you know, like long term facilities, you know, like home health. I did a bunch of different things. So I was exposed to all, like all aspects of medicine, especially the business side. And so as I transitioned to medical school, I didn't want to lose sight of that. So I stayed in New York and I went to NY U for med school. And um and so while I was there, I maintained some pretty interesting relationships and I was, I was able to continue my um my sort of business background as I worked through med school, I was blessed that because I worked so damn hard on Wall Street. Med school was like, it was like a godsend, right? So I was like, this is amazing. Now, I can just study and read and not have to work and stay up all night. So, so I did really well in med school. AOA and all that stuff. And then, um and then for med school, I went to Harvard for residency and uh Harvard has a pretty big residency program uh about 12 per year. And so, depending on the personality type that, you know, you should know who you are, right? So you are either gonna do Ortho in a small program, let's say like 3 to 4 residents or you may thrive in a big program like 12 residents, right? And I decided that I wanted to go to a place that had just a, um I wanted to be in a big city. I was, I was sort of a big city guy, you know, Chicago, New York and now Boston, that type of thing. And I also wanted to uh make sure that there aren't gonna be any um questions about whether or not I'm committed to orthopedics, you know, like having that big h on my resume, just sort of like seals the deal for a lot of places out there, you know, they just stop questioning you. Um So, so while I was there, um I realized that there are no deficits in the Harvard program, right? All the specialties are like, well represented. I'm talking hand on pediatric Ortho. All the subspecialties are represented and for whatever reason, all of my um sort of cohort they're all going to do sports, right? So it's like, oh, I'm gonna do a sports doc, sports, doc sports doc and I was like, ok, well, um, my economics degree told me that the best way to build a good practice and not have a lot of competition is to essentially not have a lot of competition. Right. So, if I wanted to have the most ridiculous comp, uh, competition out there, I would do sports. Right. And, and it's like sexy, but then everybody wants to do it. So there's a sports doc there, there's a sports doc there. So how do I differentiate myself? Right. So it's hard to do that as a sports guy. And uh and so then I ran into some amazing hand surgeons and so I was like on the hand train and um and as I was doing hand, I wrote, you know, I did papers, I wrote textbook chapters, all these cool things. But what I realized was I loved hand because hand had a whole spectrum of cool things that you could do, you could do tendon work, bone work, deformity, work all these cool things and you have like all these weird pediatric things that you'd fix and all that. Um But there was one thing about hand that really annoyed me, it was that everything was urgent, right? So there's a little pus at the fingertip, come into the hospital in the middle of the night, you know, like somebody chops their finger off, come into the hospital, everything is in the middle of the night and then you work for hours and hours, you put the fingertip back on and the patient's like, I don't want my finger and then they take it off after you spend 12 hours putting it on, you know, all that stuff. And so I'm just like, God, you know, like, what else can I do? That is similar to hand but has like, none of those emergencies. Right. So, then, um, I started talking to these foot and ankle people. Uh the the foot and ankle tendons were like normal people. Well, orthopedics, they tend to be normal people anyway, right? But like even more normal were the foot and ankle people, right? So they were like, hey, yeah, we do all the same stuff that the hand surgeons do. But guess what if the foot needs to be cut off? The vascular surgeon does that, right? Like I'm not coming in the middle of the night because the reason it needs to be cut off is because it's either infected or there's a vascular problem. No, neither of which requires me to come in. Um And then, and then I can do things in an outpatient setting. So this is key, I'm doing the entire spectrum of orthopedics, but it's in an outpatient setting. So why is that important? So now this is gonna be controversial because I'm at UF right now and at UF, you know, obviously hospital systems want you to do everything at the hospital, right? So let's say you're thinking I wanna be Ortho. But I'm thinking maybe neurosurgery, if you're a neurosurgeon, you are the hospital's person. You are gonna be at the hospital, they're gonna own you. They're gonna say this is how much you get paid. This is how much this, how much that yada, yada, you are owned by the hospital. Essentially. If you're doing one of these orthopedic subspecialties where you can do everything outpatient, you, you don't even need the hospital, the hospital doesn't even need to exist. So if you're a hand surgeon, you could do your entire career at a surgery center that you own. Right. So if you own that surgery center, you're gonna say it's closed on Saturdays, it's closed on Sundays. It's open 9 to 5. If it's out of those hours, don't call me. Right. And if anything's urgent, send it to the hospital that's hand right in foot and ankle, we can do the exact same thing depending on how you want to set up your practice. However, um, remember the emergencies are this much, right? So, unless it's like your own POSTOP problem, I mean, I honestly, I barely know where Shanes is. Right? Barely, like, I'm at the surgery center, like three. Right, right. After like three or four times, three or four days a week, sometimes I'm operating like crazy at the surgery center and then once it's like 430 I'm home, right, five o'clock, I'm home weekends I'm not operating like it's just amazing. Right. So, so it's a combination of, and actually I didn't even mention this. So of the 12 people in my class, maybe six or seven were doing sports. A couple were doing hand. How many were doing foot and ankle? Right. Zero. Except for me. Right. How many were doing foot and ankle the year before? I don't even think there were any. Right. How many were doing before that? Maybe one or two. So the thing is, remember that what I told you about like, you know, the economics of like building a practice and being somebody that, that, that, that um is let's just say needed and wanted and appreciated. You wanna choose a specialty that obviously, you know, fits your values, but also minimizes that competition. So that way you can grow without having to worry about like, you know, being a used car salesman, like putting up a billboard here and all that. You don't wanna be like a plastic surgeon in Beverly Hills that's trying to do nose jobs, right? Because everyone's trying to do it, right? So, so then um so, so foot and ankle just fit the bill. So there's for me, minimize the emergencies. I'm not owned by any hospital system. I um II, minimize the competition. And um and, and the one thing that I truly love right now besides actually operating cause I love to operate, you guys have no idea. I hate clinics so much, but I'll be in the, or all day every day. Right. The, the, the, the other thing about foot and ankle is because it's been neglected for so long. In my opinion, we are aware, joints, like joint surgery, hip and knee replacements of which there's like four codes. You know what CPT codes are. CPT codes are like what you used to build. You either do a hip or a knee, that's one code and one code and then you do a revision, hip revision knee four codes, right? And like foot and foot and ankle, like it's just endless, like the stuff that you do is insane. So, um so then um like I was saying, it's been neglected for so long that in the in other aspects of orthopedics, the people who were like amazing, like doctors to the stars and all that jazz, they're all like 80 years old, right? Because that part of orthopedics was so sexy that they were doing it generations ago, right? Put an ankle is where that was like those other specialties were today, right? So, so it's my generation or the guys that immediately taught me, we're doing all the amazing innovation, right? We're like teasing out crazy things. We're like trying to um perfect like amazing surgeries, you know. Um I am involved with now, this is the part that's controversial because I'm at the University of Florida, but like I'm a consultant and a key opinion leader for a whole host of certain ankle companies that are doing things that seem like they're from the future, right? So we're, we're, we're, we're 3d printing bone out of like Cobalt chrome and titanium and we're replacing joints, we're um you know, creating these, like, you know, new nails, like all these like interesting uh material science that we're incorporating into our devices. Um I'm, I'm creating new anchors, I'm creating new Total Ankle replace. I mean, I I'm the one that's creating them, right? It's not my, you know, uh mentor's mentor, right? And so, and so I'm at a stage in orthopedics that is like truly innovative. And what that means is that the names that you guys would read about, you know, these old orthopedic guys from back in the day, they're the people in, put an ankle that are here operating now, right? So, um uh maybe it's been a little more than six months or so, but um I was the one that did the first 3d printed Total Ankle Total Talus Replacement at the University of Florida, which to me sounds in, it's insane that I was the first one to do that here. But it's because prior to me, that type of like mentality and that type of um you know, innovation just didn't exist here, right? So I was, so, so let me tell you a little bit more about my background. So I've been in Gainesville now. It's about 10 years. But I spent the first eight years in private practice. Right. So down the road, uh, remember I said I wasn't owned by the hospital and all that. Right? So, so I owned, I was, I was, well, me and like, let's say 10 other guys owned our own surgery center. So the harder we worked, the more money we made, we weren't like incumbent on whatever decisions the hospitals made. But then I was able to be innovative for my patients and do these things outside of us. Right? And so then when I sold my practice, um UF made it uh possible for me to come here. You'll, you'll, you'll learn that in medicine, there are these things called non competes and non competes, restrict how you can practice and where. But, um, but UF noticed that I was doing things that was attractive to the university. Um And, and that weren't being done here. And so they made it possible for me to come here and teach in front of you guys, right? And my residence and potentially a fellowship. And I was able to bring some of those ideas to the university and I know that they, you know, my patients appreciate it. Right. So, so, so that's why I'm doing foot and ankle. It's because of the um uh the, the, the, the position that the subspecialty is now in the history of orthopedics, you know, and so if you feel that, that is part of your value system. Foot and ankle is where you wanna be. It's not as sexy. Right. So, but, but ironically, um, when I was doing my fellowship, a lot of the professional athletes, right. A lot of the Olympians and et cetera that had foot and ankle injuries. They came to us anyway. Right. So then, um, you know, some of them are public, uh, but I don't have the name names, but nonetheless, so here I am doing foot and ankle here at the university and I'm still treating the Olympians, right? II have an Olympian who just had a, a personal best time. Um, I have, uh, a couple of guys that I've operated on that are, um, most likely gonna be in the NFL, you know. So it's not like I have to be a sports guy to do these things. Right. And ironically the sports people don't even want to deal with foot and ankle. Right. And so, uh, so they wanna either, either they, they don't have that training or they wanna spread the risk, right? And, and give it to somebody who specializes in that stuff. So, so my point is, um, think greatly about who you are rather than what other people might want you to be if you will. And, uh, and, and do what feels right. Yeah. Do what do, what feels right for your value system and if you, if you know that you're the kind of person that just wants to work all day and do all that crazy stuff, maybe do revision hip, you know, subspecialty, right? But if you like some of the things that I said about foot and ankle, you know, consider that here at your driver. So anyway, I'll open up with some questions. I, mhm. Yeah. Yeah. Yeah. So, so, you know, for some reason, uh, two things come to mind. So, um, I'll answer your question first and then I'll talk about something else that I didn't mention. So um the um the drivers in private practice are a little different. So, so in academia, which is where we all start, right? We all start in the same place and I started in academia, went to private practice and came back to academia, right? So, so this is not foreign to me being here. So, so the um the fact is in academia, you tend to have like three foci if you will, right? So you have to um treat your patients, right? You have to think about uh research, right? And then you have to think about teaching, right? In private practice, your goal is just patient care essentially, right? So that is like your thing. If you have time to do anything else, then you do those other things, right? But your goal is really to treat patients. And the end goal is to have excellent patient care. So that way you have a good reputation and then that translates to your bottom line. So, so meaning your, how much money you take home. So, so there's, there's no limit there. You work harder, you get paid more, right? Um And then your partners benefit. So if, if the 10 of us are in a surgery center and nine of them are working like crazy. And then I'm not, then I'm not contributing to that bottom line. I'm pretty much a free writer, right? So your partners don't like that. So if they're working hard, they want you to work hard. So that's like, that's like the system there, right? And so, um, if you're thinking in private practice, you know, be aware of those little things because it's not quite as much of a lifestyle play, you know. Um, but it's better for your retirement right now. Um, in academia, the, uh, the dynamics are a little different, not only because of those three pillars that I talked about, but also because you tend to be more or less salaried, right? And depending on your, um, your, your position and like the academic center that you're training in, there's something called sovereign immunity. Do you know what that is? Yeah, sovereign immunity. So, sovereign immunity for those of you who don't know is, uh, is where your malpractice risk is limited. So, in private practice, you're out there, you're doing your thing, doing your thing. But like you wanna make sure that you're very careful, right? Because the lawyers are circling, right? Because you've got some sort of malpractice coverage that's like usually like 35 or 13, meaning 1 million for, for incidence and 3 million cap or something like that. So like they're looking for that, but you're in a place like this, you're here literally only to do the right thing for the right patient at the right time. Right. I'm not saying that the private practice guys aren't doing that, but, but in academia, it's truly the case and I have less of a burden of like what the lawyers are thinking, right? And I'm really focused on taking care of these really difficult cases that the private practice people don't want because if the risk is high, they definitely don't want to like do a case and then have it fall apart and then have a lawyer circling. So, so you do some more complex things at the universities. Number one and then uh and then number two, what I'm focusing more on now is making great use of the resources that the university has, right? So, so I'll give you an idea. Um I had this um this sort of concept uh that was patentable literally for years, right? I had this like patent idea in my head for years. Um An inkling of it happened when I was a resident and I knew that Harvard, if you have IP at Harvard, they will take II can't say numbers because it is being recorded. But they'll take like, they'll leave you with this, ok? Because the system is greater than any one of us, right? So they'll leave you with this. So I said, well, let me try to do it in private practice. But the thing is in private practice, you're so busy doing what you do and you don't have the resources surrounding you that all of a sudden I could do it. And I would, I would, I would get this much of it, but I have no brains around me, right? Like I'm the only one who cares. So then I come to us and I have you guys all over, right? Amazingly smart people. I've got engineers right down the street. I've got an A I institute, I've got an institute for like wearable devices, but it's like inundating, right? And all of a sudden now we've got, I'm working on my second patent here, right? Like stuff like that happens. And so that's how it's a little different being in academia allows me to like, expand on all the other things that I love to do and not feel so constrained by only generating cases. It's phenomenal. But on the other hand, it's not like I go home any earlier or later, right? Because in private practice, I was the sort of um the steward of my own schedule. But in academia, I, if I'm only working with an engineer that dude is going home at four o'clock. I'm II can't work him past four o'clock, right? Like, so that's it. You know, you see what I'm saying? And so especially if you're in a salaried environment, you get what you gotta do, you get it done and then you go home, no one's staying beyond their time because what's the benefit? Right? Unless there's a patient care issue. So don't, don't, don't lose sight of that. But my point is like by and large, that's not your focus. Um So, so earlier, I mentioned that there's a second thing I wanted to talk about. So, um, when it comes to like the sexiness of foot and ankle, like, I think it's amazing, right? I think it's like really sexy, right? But, but here's, here's the, here's the difference. Some people just don't understand for an ankle anatomy or they think it's nasty, which for me is like, great because I'm like, send it all to me, right? Um, but then there's, um, there's another subspecialty out there which is podiatry. And so, so we have to, um, I'm gonna take a minute to distinguish between what we do and what they do, right? Ok. So, so for orthopedics, there's something called the A B Os American Board of orthopedic surgery. It basically certifies all the orthopedic surgeons and then you can like, have little nuances for subspecialty. But basically, if you have a board certified orthopedic surgeon, you know what you're getting period. If you go to a podiatrist, some of them are good. Some of them you have no idea. And the problem is there's all these random boards, right? And the, the way that they uh market themselves is, um, can be controversial, right? So then what happens is you may have a family member that went to a dedicated foot and ankle surgeon. But all they knew how to do were let's just say bunions, but your family member had an ankle fracture. Well, it's a foot and ankle surgeon. Well, now he's gonna experiment on your ankle uh on your family member's ankle fracture. Maybe they do it right. Maybe they do it wrong. But that's a risk that you're taking with podiatrist because there's no uniform board. Um you know, system that says these people are able to do XY and Z these guys can't. Right. So, so it's at your own risk. The other thing is um a lot of them are friends of mine. Right? And, and, and it's better to work together rather than to divide and conquer in scenarios like that. And so when I first got here, I wanted to make sure that they knew that the podiatrist in the community, that they knew that they can send me whatever they wanted and I could do their bailout. I don't want them to, you know, mess something up and then I get it right. And then I have to like deal with the consequences of undoing the badness and then making it. Right. Right. So, so, so I take the standpoint of being friendly rather than, um, you know, being sort of having any animus right now. Um The other thing is, um, things are changing such that we're focusing more on what we can do together and better for the patients rather than what they can do and what we can do. Um I would say when a patient comes to see us, they know that they're getting a more holistic approach, right? You can evaluate the knee, you can evaluate the hip, you evaluate, you know, basically the entire system. Um and, and whereas on their side of things, it's only the foot and ankle. So, so I've had patients that have come in and uh it did come from like I see an additional opinion and the problem turned out was around the knee and because the knee had a deformity, it created excess force on the foot in certain ways. But, you know, because they were getting primary opinions from podiatry, they failed to see what was going up approximately, right? So, so we used to say everything is a nail to a hammer, right? So, so whenever you get your subspecialty going, you're gonna have this tunnel vision where everything looks like it's what you do, right? So, so if you're a cardiologist, everything has to do with the heart, oh, you know, why is the foot swollen, it's the heart, it's, everything's the heart, right? But, but sometimes it's not right. So, so you have to have the wherewithal to know that as a doctor, you gotta use all that stuff that you learn in different systems to come up with a solution for your patient. You know. And so, so in essence, that's sort of the difference between us in podiatry, right? Um, but anyway, other questions. That's right too. So, uh what would you consider for bread and butter, cervical past? Um And then how did you get involved with? Yeah, so, so bread and butter. So, so this is what II found out um where you practice is gonna impact what your bread and butter is. All right. So, um uh so I trained in Charlotte for my fellowship and in Charlotte. Uh just about everybody you heard in the news that had a foot and ankle problem came through Charlotte to get treated or to get a second opinion, right? So these are like movie stars, Olympians, professional athletes, you know, up and coming athletes, whatever, right? Even some UF people when I was there, came, came, came up there and then I got down here and it was like farmers, right? So I was like, OK, so, you know, this Olympian is not here, this professional, there's no like professional, you know, there's no NFL team here. So, so it's like, OK, what does this farmer has? Well, this farmer is gonna have like, and let me tell you, farmers are among the toughest patients and you want them. A lot of doctors will say, well, I wanna treat, you know, Aaron Rodgers, right? But, but Aaron Rodgers is being treated by like 600 doctors, right? Everyone wants to, wants to treat Aaron Rodgers. Nobody wants that farmer. And ironically that farmer is not even gonna come see you until he has a real problem. Aaron Rodgers will come in and see you when there's like when he feels irritation from a stitch, you know what I mean? It's like, bro, come on, man. Like, but, but like that's, that's the difference, right? So, so the bread and butter up there was different than a bread and butter down here. So when I first got here, I had to do a ton of like deformity corrections and like joint fusions, total ankles, all these things. And then as I sort of made my way through that backlog, then I had a bunch of people from the villagers that started to hear about me and then all the sort of like ving villagers or whatever came up here and they're like, oh, you know, I wanna play pickleball but my, you know, my large toe hurts and then I had like this like pickleball, pickleball 4h where like they had like 4 ft things, right? So, so, um I remember where I trained the, the doctors that taught me they hated forefoot. Right. Because they were orthopedic surgeons and they were, like, the forefoot is for, um, a podiatrist. Right. Like, I'm talking about bunions and hammertoes and stuff and then I was like, well, I'm seeing a ton of these and I treated one and then I got, like, six family members. Right. And they're like, well, now I've got real problems, you know, my ankle was this one and I was like, oh sweet. So I do the low lying fruit which is like a hammer toe or a bunion and then I get all the cool things that I want. Right? So, so II II position it that way to say number one, it all depends on where you live. And then number two, I shy from nothing, right? II want it all because I'm happy to treat them all. And if I have that skill set, I'll do it. And if you don't have the skill set, do not be afraid to send them away because you do not want to get into trouble because especially if you know, I'm not on an island now, but I was on an island when I got here. And so if I screwed up one person, where are they gonna go? But you're gonna go to Tampa, right? And she's gonna send that farmer all the down to Tampa, Orlando. You know what I mean? Like that's crazy. Right? So, so, so just be very aware of, of what you're good at and aware of what you're not and just, you know, treat the right patient right now. Um, when it comes to industry now, that's, that's a good question. It's very controversial because again, when you're at an academic center, um, especially a state, like a public state run academic center, the there are rules against conflict of interest. Right. It's conflict of interest. It seems like nobody has a conflict of interest except for doctors. It's weird, right? Like, you know, like the hospital brass can do whatever and like, you know, this person can do whatever. But as soon as the doctor gets like a pen or like a donut from a company, they're like, oh, you know, like it's gonna influence, it'll influence how you treat patients, you know, I'm just like, are you kidding me, man? I'm like, ok. But anyway, so, so, so I preface it to say that like, um in my opinion, working with industry, especially in certain specialties is key because if you don't work with industry, how the heck are you gonna get some of that innovation out there? Right. And it's, as you, as I told you earlier, it's really difficult for me to do it alone, right? Like more the more heads, the better, right? So, um the industry relationships weren't very strong when I was a resident because at Harvard they had somewhat similar rules. Uh and Massachusetts itself had like really arcane rules that were, like, pulled back when they realized that a lot of the companies no longer were doing, uh, conventions in Massachusetts. They were like, well, why have a convention if we can't even talk to the doctors and give them a pen? And all of a sudden the financials dried up and then the lawyer, I mean, the, uh, the lawmakers were like, hm, maybe the ethics, uh, should be changed. Maybe it's not the ethics, right? So it's like financially driven, you know what I mean? So then all of a sudden they, they, like, pulled back some of those rules and then, you know, they, they let it open up a little bit, but most of it started to evolve when I was in fellowship because I was in fellowship at an institution that was, um, what, what we call private Dems. Ok. So Private Dems is where you have a private practice, but there's a relationship with an academic center, right? So, so the academic center and the private practice, the relationship wasn't like this, it was like this, right? And so what that meant was the private practice. People can be innovative. They have like a research institute that's funded by some, some third parties, some industry. And then all of a sudden all these cool things are coming out. Ok? Whereas if you're at an institution where the relationship is like this, right? Then the, the, the system can say, well, we don't want you guys involved in this type of, uh, of, um, you know, innovation, there's a conflict or if you are, then we wanna make sure that it's not going to interfere with your ability to treat patients. Yeah. Rightly. So, but the thing is sometimes they overstep. Right. And then they, they squash the innervation. So you have, like, then you have these engineers that come up with cool things but then they don't know how to use the cool things because they don't talk to the doctors that actually are in the field to use them or they have cool things that they created, but they're over engineered and I would never use that because hey, the doctor had no input. You see what I'm saying? So if you are of that type where you're thinking, I want to work with industry and be innovative, maybe you look for a private setting where you have a little bit more leeway, right? So, so crazy story. So when I was in investment banking, there was this company called Wright Medical. Um and Wright Medical was purchased by Stryker just like not too long ago. So Wright Medical when it was this big was one of my clients in investment banking. I helped them, I was on a team that helped them get their IP O so meaning that they went public, they're on the New York Stock Exchange, et cetera or NASDAQ. So, right. Medical. Guess what they did? They created foot and ankle devices and implants. So fast forward, 10 years here I am working with, right? Medical in the place where Wright medical used a lot of the surgeon ideas to create their devices. So, so it came full circle, right? So I helped them go public and then all of a sudden now I'm using their things, right? So it just made like it was just like, you know, I couldn't have like created a better story for that, right? So, so now as I was a fellow with those relationships of bright medical et cetera, they realized that I was interested in those types of things and as new devices and new companies were being born, they came to people like me because they knew I was interested, right? And so those relationships are still being fortified today, right? And, and so what you'll find is um it only takes a couple of these sort of relationships with, with innovative people, with engineers, with, with industry for you to get involved and then once they branch out to their new company or they have a new device, you'll be one of the first people that they call, right? And then you have key, key opinion leaders, what they call it AOL. And so as AK ol, then you are involved in creating the next new shiny thing, right? Or stopping the the weird thing from coming out to market, right? Like some some failures, right? So, so So, so that's how it starts. You gotta put yourself in the right place, you gotta make sure that they know you're interested and then you have to like basically put out some cool ideas, right? Show the engineers that, that you can think like an engineer but you're a surgeon and they really appreciate that. Yeah. Yes, I was wondering, it's based, kind of based on that. Um What do you think about starting your own? Ok. Yeah. Yeah. So, so you're asking the right guy? So, so here's the big, so this is what I would say. Um So, so I've done that, right? Um And the I, so, so first of all, I would say, be careful where the IP was generated, right? So if it's generated while you're here somewhere in your acceptance of being here, you signed away some of it just be aware of that. Um Yeah, so, so uh the old days of Gatorade and Exactech, those are done, right? The university has learned from their failures and, and so now now read, read all your documents, right? Um And then, and then what I'll say is, uh there's gonna be a part of your career where, um and I'll just say this and I know you guys are young and you're like 1st and 2nd years, everything's awesome. But there's gonna be a point where you're gonna say, you know what I need to diversify my experience a little bit like I'm in clinic every day. And then I go home, I'm in clinic and I go home, I'm in the, or, and I go home and I have all these cool ideas and I really wanna do something a little different and I think my patients are gonna benefit from it. That's key because it keeps you, let's say it keeps you in the game, it prevents you from being broke out and leaving medicine altogether. right? And nowadays, there's so many ways to um to, to like diversify, not only your income stream, but like how you, how you approach your patients and what you're gonna do for them, right? So, so if you have these cool ideas, I would say um number one patent it, right? So, so without a patent, it's, it's honestly, it's, it's values this right here without a patent zero value. Um And then once you have the patent, then you can form something around it. Um If you are too busy being a doctor, you can co license, right? You can say, hey, um I don't know, let's call it big. Hey, Amazon, you know, I've got this cool idea. Um Can you do you want to license it and build a company around it? And uh and I'll be your adviser, you know, I'll be the founder, but I won't be the CEO because I wanna be a doctor. So, so, so that's one way to keep being a doctor without actually like spending all of your waking hours outside of the clinic in or trying to build something that may not even come to fruition if that makes sense. Right. So, so as you progress through your career, there'll be points where you'll, you'll, you'll encounter some issues with like burn out and like mental health strains and you'll say, God, I wish I wasn't in this. I wish I was doing something else. But this is a way to like reinvigorate your, your, your interest in what you're doing because there's a reason you're doing it in the first place, right? Um And, and so, you know, for me, I found that foot and ankle was like that one where the, where the activation energy was much lower than like total joints. So total joints, we're at a point where like the research is like, what enzyme is in the infection, you know, I'm just like, well, I can't do that mess, you know, but like, but in foot and ankle, it's like, let's create a better joint replacement, right? And, uh, that was done like 20 years ago for total joints, hips and knees and that's being done today in total ankles, right? And, and I'm, and I'm part of it. So, um the, the, the crazy thing, this is this, this frustrated me when I was in your shoes. Literally going through maybe a little older. I was like a third or fourth year and I was going through like interviews it in the news, it came out that, um, uh, there were like these, um, like Sunshine Laws, you know, where they talked about, like, how much doctors were making and stuff from working with industry. This is years ago. Right? And, uh, and I was like, oh my God, I can't wait to do this. I have so many cool ideas and, um, and, uh, some of the people that were creating these implants, they were no joke making like seven digits a year in like passive income on it. What do you think happened by the time I started, they stopped it, right? They were like, oh, these doctors are doing too well, you know, bla bla bla bla blah, blah, blah, blah, blah, conflict of interest no more. So the rules have changed but but the ability to innovate and work with industry hasn't, right. So, so, so they kind of like made it to that way. You don't run away and be crazy with it, especially if you're working with someone else. But if you wanted to be the one that creates it yourself, there's no limit. That makes sense. Yeah. Yes, sir. Um I was saying where you your care now? Like you like, yeah, so OK, so, so great question. So I started an academia just like you went to private practice. Did my thing told the practice and then now I'm here, my goal, my, my true interest in being here is number one to make sure that I teach the next generation how awesome foot and ankle is. And, and I'm not joking, it sounds like BS, but it's like it's the truth. So, so our foot and ankle division at the orthopedics department was, uh, in my opinion, lacking some of the progress and innovation that our patients needed, that I saw other peer institutions having, but we didn't. So Gainesville being a small town, I mean, you know, since we're here, it's like, it's awesome. But if you're coming from New York, well, you're not coming to Gainesville. You know what I mean? Like if you're in Boston, if you're in LA, it's hard to recruit into a small town like this. You see what I'm saying? So a lot of the, like your peers are like your comparables and then whatever your peers are doing, it tends to be what you're doing. And so if you've got like, you know, whatever happening in California, the California programs all elevate themselves, right? But then like, if you're in the southeast and the only thing that you're seeing is like a small podiatry community there or whatever, that's what you're gonna get, right. So I wanted to change the division of foot and ankle surgery at UF. So I said the university, I said I would love to come here, but I wanna be able to be innovative, right? That's number one, I wanna be able to teach my residents and the students, what foot and ankle can offer, right? And I wanna keep bringing those innovations to the patients, keep bringing like the quality of care, the standard of care. I want it to be pristine for all of my patients, right? Uh Because ultimately they're, they're the the customer if you will. Right? And so, so what am I doing? So, so number one, I started recruiting, I recruited Doctor Wang. Um So she's my junior like before, it was like this wasn't happening. I'm telling you this is nuts, right? So, so I recruited Doctor Wang. So she's my junior attending. I um I'm now gonna have three pa s at what? Some, at some point there were zero. And then sometimes there were one, but now we're gonna have three starting in about a week and a half week. We'll have our third one. I have um I'm in the process of uh of setting up a fellowship for foot and ankle. So that way residents from other places in the US can come and learn how to do foot and ankle, the way that I learn how to do foot and ankle and how I'm still evolving as a foot and ankle surgeon. And then um and, and so that's, that's like my, my 5 to 7 year horizon, right? So once I set up the fellowship and get it up and running, I'm good now and, and I'll be happy to retire, right? But then um but then the next thing that I wanna do is I want to start and if this is happening now, II keep saying I want to like all this stuff is happening. So um the other thing that I wanna do is I want to establish UF as a center of excellence, right? Like I want it to be a destination for people all over, wherever to come and say, hey, I saw that you guys are doing the most 3d printed Xy and Z my doctor in Canada or you know, Slovenia isn't able to do it. Let's let's make it happen, right? And so, and so that's happening now, right? And um and, and I'll tell you some of it I couldn't do by myself, right? So the university is offering amazing resources. They've got like, you know, um pr they've got social media that's getting the stuff out there. And then I also have, have my industry relationships that are saying, hey, we can help boost, you know, your your search engine optimization, right? Like we can bring these people, we can, we can, we can talk to other surgeons to come and learn from you, right? Or we can take you and, and and bring you to like, you know, so balls and help teach this other surgeon how to use this new device. Like all that stuff increases our footprint, it makes us in Gainesville look awesome, right? So that's my part. Yeah, of course. 00, no. The so, so great question. So, um, they're doing very well and, and we're at a point where, um, we're gonna start looking at, um, uh, prospective trials on these, just Total Talus. So, so there's a bunch of different 3d printed stuff. So I'm assuming maybe the one that you saw is on, like the website or something. But, but there's different variations on that theme, but we're gonna start doing a prospective study on how they're doing. So, that's good stuff. Yeah, we talk a little bit about smaller. So you not too much. Yeah. Yeah. Sure. So, so, um, I would say a couple of things, number one where I went to, uh, to train, if you went to the same place today, it's gonna be different. And the reason is because my peers have all graduated. So you're gonna have a new, you know, sort of cohort of co residences, right? You're gonna have attendings that retired new, new attendings that came in all. So, a lot of it is, you know, it, it's sort of like changes over time, right? So, so we have to establish that now, um, at a residency with like four, let's say four residents, you're not hiding under the table, right? Everybody has to carry their own weight and you have to help your co residents who may not be able to carry their own weight. Maybe they're sick or whatever, you know, they gotta be on vacation. So, um if you had a small residency program, there's no hiding and you're gonna get, um let's just say a high visibility, right? High visibility at a larger program, some people may fall through the cracks, right? Because there's a, there, there tends to be some redundancy. And so you may have, um you may have a keen interest in some esoteric research and you're gonna spend a lot of your time doing that whereas somebody else is picking up some of the slack of your clinical work and some of those programs are OK with it because they are research powerhouses, right? And they're like, man, he's got an amazing thing about whatever, let him let him, you know, sort of prioritize that a little bit while he's also doing patient care. Um It's much more difficult to do that in a, in a small program, you know. So, I mean, that's just one example. Um the, the smaller programs, you tend to be a little bit more compact in your experience. Um OK. So when I was in Boston, uh I would, so I covered three or four level one trauma centers, right? Uh One of which was I was the chief of trauma during the Boston bombings. It was, you know, crazy, right. So, so MGH Brigham, the bi children's, you know, and they're all in Boston. Sure. But I'm doing a lot of like moving around and then there's like peripheral suburbs where I gotta go to like a surgery center and help cover this and that in a small program they need you here. Right? So, so you're not gonna be like going all over the place, doing whatever, you know. So, so your, uh, your relationships with all the key people, maybe a little stronger and this is generalizing, you know, but that's just like one sort of generality that you might think about. Whereas in another place you're gonna have a couple of key relationships with the people who you bond with the most and some others may not really know you at all, you know. So, so as your, you know, if, if you're a top candidate and you have those options between those two programs, think about some of those things, what else do you guys got? Uh Yeah, I see. And then um also if let's say you have to contact you, that's not. Mhm What does it take? But you're working? Yeah. So, so I'll into the second one, first. Um The important thing is that um well, first it has to be a product that is safe, right? I mean, that that goes without saying, right? Like it has to be, there's no experiments, right? Uh Unless it's explicitly said it's an experiment, but there are no experiments and then, and then there's something called a Value Analysis committee that committee and what they do is they wanna make sure that you're not gonna break the bank for every one of those cases that you're doing, right. So, so they can either do a one off approval, you know, because this, this, this is a special case and there's no other way it could be fixed and done. So that's a special 11 off or uh they realize that there's a huge need for this and what we currently offer doesn't meet that need. And so the Value Analysis Committee will come up with some sort of structure to make it uh make sense from a financial standpoint. OK. Now your, your, your first question was how do you like from from beginning to end? How does the patient go through that process? Product concept ideas? What is the process of benefit? 00 So, so that, that's, that's a, that's a big question. But here um what you wanna do is um so I went through this recently, so I'll just, I'll just give you an idea. So um the first thing you do is um come up with that concept, maybe draw it down, have some sort of documentation that that concept exists. So that way later on, it's not like, oh you never thought of that, like, you know, we had that, you know, this already exists or whatever, right? So, so, so write it down and then once you've gotten it written and uh written down, um I tend to avoid having like one on one convos like this, you know, you wanna have like an email or some sort of like paper trail that, that it exists. Ok. Uh And then once you, once you have that like concept, sort of like, you know, written out, uh then you have to figure out who is the, or who or what is the best way to get it to the next stage to prototype. Um So, so in my case, um we had some engineers that I've worked with in the past. And so, and you're talking about UF or you're talking about like third party stuff? Oh, well, third party, it's easy, right? So I'm just saying like, where are UF? So it's not about UF. So, so, so what you do then is um the university um again, has a slew of resources. So let's say it is a um uh a device for a put an ankle. So look online, find out which material scientist or like, you know, wearable scientists might be the right one to talk to send them the email, set up a call and go through the ideas with them. Usually they'll have some underling, right? Some sort of like post do. That's like really good ho about getting something done, right? So, so you talk to the chairman, but the chairman's gonna bring in his underlings and then have meeting after meeting, after meeting prototype prototype at some stage, you're gonna have that prototype where it's gonna be an algorithm or some sort of process that's actually patentable. Maybe, maybe it's not the device itself, but you'll have like patents along the way. Once that's sort of done, then if you have a prototype, then you can consider co licensing it with wherever, right. So let's just say it's a cool running shoe. Nike or Hoka might be interested. And what's beautiful about the University of Florida is that they have an excellent tech transfer department. So tech transfer, if you guys are familiar, tech transfer is that group of lawyers and engineers whose job it is to take an idea or a concept or a prototype and get it out there, right? So, so let's say you created this really cool new shoe that like, you know, really shock absorbs anyone can walk on it or whatever. Um They're gonna say great. We're gonna file the utility patent now that's out there with the government. And uh and now we would like you to talk to Nike to co license it. It's from our standpoint, it's much easier to co license than to create like a whole new warehouse and start making the shoes and all that. And then ask Nike, hey, are you interested? You know what I mean? Have Nike do that, right? Because they to do it right? But, but the, but the concept can be co license and sometimes it's exclusive. It's only with Nike, but sometimes it's nonexclusive. So you could do Nike HOA or, or, you know, Brooks or whatever, because that idea, that concept that you had is attractive across the broad spectrum of potential licenses, right? So, so that's how you do that and that's like a 30,000 ft view. That's how you do that. Yeah, of course. Yes, sir. Yeah. Yeah. Ok. Yeah. Great. Yes. Insightful. So, so he knows a little bit more about me. So, um, so, uh yeah, I got you. So, so um so, so this is, this is important as you, as you go out into the, the real world and you become a doctor that's been, you know, that's efficient and gets things done and you have like good outcomes, some of the things that you learned in residency and fellowship helped you to be that kind of doctor, but the world in which you're in evolves, right? And then the standard of care sort of evolves. Ok. So what's gonna happen is um you are gonna be in a position where you can kind on whether or not other doctors are doing the right thing or the wrong thing. All right. And, and that's helpful because number one, it's protecting your specialty, it's protecting your patients. And then ultimately, it's teaching you how to do the things correctly and how to avoid the badness. So, so let me be a little bit more specific. So, um in the medical legal world, you can be an expert witness for your doctors or an expert witness against your doctors. Right. That's really oo on, you know what I mean? Like an orthopedic surgery, if you wanna be ostracized by your society, start suing the society members. Trust me. Bad idea. But, um, but if you want to, um, get into the medical, legal landscape and, and, and help protect doctors, uh, there are multiple, it's called, they're called MPL. Um, either way these companies are the ones that give you malpractice coverage. But in order to know if they're doing things right or wrong, they need doctors like you to be able to tell them in your specialty. This is how things are done, right? And so what I learned is like, what are one of the top reasons why doctors even get a claim filed against them? Right? So an orthopedic surgery, it's not because you're a bad doctor. It's because you just don't listen, right. The patient has the impression that you're in there to just say, hey, hey, you need surgery and then you leave. So now they have this impression that like you weren't listening to them. So if something goes wrong, they're gonna say, well, he wasn't listening to me anyway, I'm gonna, I'm gonna try to sue him. Just the fact that a claim is filed against you is painful, right? Because you're like, what I'm a good guy. I don't know why they're doing this to me. And like, I didn't do this on purpose just the very fact whether or not you win that malpractice suit, whether or not you win. It, it's very painful. It's a hit to your ego. It like it, it, it's like an existential crisis. You're wondering, am I doing the right thing and all that? Right. So, so me being, uh, I'm no longer on the board, but I was on the board of one of those companies and I saw and advised and all of these medical legal claims I learned like, how people are getting themselves into trouble. What subspecialties are very litigious? Like what areas in the United States are in trouble? Where is it tort reform? You know, like, where, where are we protected and, and, and what other areas like, would doctors not be advised to be in? You know what I mean? Like, for example, you know, and I'm, I'm not as much into it now, but like Florida and Texas used to be really friendly and then they became not friendly and then, like, you know, all these things keep happening, right? So I remember when I was growing up, OBGYN S wanted to leave the State of Florida because like the lawsuits were, you know, disproportionate to what they had covered. And then they started to realize that all, all the Ob GYNs were leaving the state and then all of a sudden they changed the law, you know, like all these things impact you, right? So, um what's happening right now and it seems like I've been beating up on sports but like, but, but the, the there, if you look this up, you'll, you'll, you'll find that there's been some pretty huge legal findings against sports doctors in favor of the patients. Right. So, so when you do something inadvertently, whether or not, you know, let's put it this way. If we get a claim filed against you, the people on that jury are not doctors, they're gonna be that farmer, they're gonna be like, you know, that nurse, they're gonna be this or that. Like they're gonna be like normal people, they're not gonna understand your specialty the way you do. And so, um, and so it's good to know why people are getting in trouble. So that way you can avoid it yourself, right? So when I go into a patient room, now, 100% of the time when I go into the patient room, I sit down, right. If I sit down for one minute, it seems like I've been there for 10 minutes. If I stand up over the patient for one minute, it's like I was there for 10 seconds. You see what I'm saying? So like you do all these little things as you learn about the medical legal landscape, you do all these little things to like help the patient. See you as the person that you really are, which is somebody who's trying to help them. Not somebody who's trying to hurt them. Yeah. Yes. Yeah. Thank you. I appreciate it guys.