Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

I been doing for a while. I uh grew up in Pittsburgh and uh went to Penn State and then I went to uh Pitt as an undergraduate, did MD phd there and then um became uh interested in orthopedics through some of my research work. My phd was in uh neurobiology and I was interested in nerve regeneration type of things and got interested in hand surgery and decided to go to orthopedics and did my residency at Johns Hopkins. And there I really became interested in problems in older people and they tend to break a lot of bones and need a lot of replacements and need kind of both things sometimes at once. Um And uh so with that in mind, I did two fellowships, one in orthopedic trauma and one in a joint replacement. And that was at the shock trauma and the mayo clinic. And then I came back and worked at Hopkins for about 10 years for the last uh about nine years. I've been working at University of Arkansas and Little Rock and now I'm in uh Gainesville. And uh so I do mostly joint replacement now, um including hips, knees, so lots of primary replacement as well as revisions and infections and broken bones around implants and all those types of things. So, that's, uh, a little bit about me and my pathway. Um, I'm happy to kinda talk about whatever you guys wanna talk about having, um, experience working with industry and developing new implants for adult arthroplasty. Yeah, I haven't been big into development of new implants. You know, one of the problems we've seen over and over again is that any of the, uh, most of the new implants that come out, you really have to worry about it. They make little changes but often, um, the changes are bad and you don't find out for five years later. So we went through the whole metal on metal debacle a number of years ago where that was thought to be better and it turned out to be much, much worse. Um, you know, most recently there's been this debacle with the exact implants, one of the companies where they didn't process the plastic liners. Right. And led to just all these recalled implants and terrible revisions to do. Um, you know, so II haven't done a whole lot of work myself on that kind of thing. I'm not too industry related and there's pros and cons about those ways to go. But, uh, that's just how I work. What is a week in your life look like since you've become the chief, uh, of the depart of the division. Um Well, II don't know if that's a whole lot different. Um If you guys know much about our division here, four of the surgeons left over the past year. And, um, so I'm kinda recruited to rebuild that. So there's a lot of work to do. Um, uh uh I uh do clinic at least twice a week and then operate two or three times a week depending on the week. And I've just started so building up, uh, cases and things like that. So, uh, my week, uh, currently, um, and it changes week a little bit, week to week, depending on our availability. But usually I operate on Mondays and some Wednesdays and some Fridays. And then I have clinic on Tuesdays and Thursdays. You like to use the computer guided jigs and stuff like that for the knee arthroplasty or do you prefer to the free hand or? I know I'm not too big into those. Um, you know, from my, from my viewpoint, they haven't been shown to make any difference. So there's no paper that shows they're better, there's no better outcomes whatsoever. They're a lot more expensive to use. Way more expensive. They take longer to do the cases. Uh, so I don't personally see a whole lot of benefit in it. You can call me old fashioned one day. That may be wrong and it won't be that way. But currently I think it's more of a marketing tool that people like to use and companies like to use, uh you know, you have to pay millions of dollars to get the whatever robot or whatever it is, then you're stuck. It only works for one company's thing, you know. So you can't, you know, then they have you over a barrel. So then they wanna charge you more for the implants, things like that. There's all this craziness to it. Um One of the interesting things, training, you know, fellows and different people over the past five years or so, particularly, we'll, we'll interview people for fellowship. So these are people who have gone through orthopedic residency and then wanna do another year, just a joint replacement. And some of them will have never seen a joint done without some type of guidance. And uh you know, to me this is a disaster because, you know, the thing doesn't work half the time. So then you're, then you can't even, you're not used to doing a knee the regular way if you can't do that, I think you miss a lot and I see a lot of Revi revision cases that are done with guidance of some sort and people forget about how to balance the knee and just they get away from the basics of what they're doing to get a decent, decent joint. And so it's not all uh roses, but uh that's my opinion on it. You can ask other people and they'll be completely gung ho the other way. But II, they can't show me any data that shows it's better and it's a lot more expensive. One of the problems with joint replacement is we're getting paid less and less and getting reimbursed less and less and less every year. So to do something that costs a lot of money that you don't get paid for. Right. And doesn't show it and isn't beneficial. I find very hard to swallow. Sorry, sorry to popcorn around. Uh Thanks for being here. I had a question um at your prior roles as chief. Uh also at John Hopkins. Did you have anything that you like or things that you didn't like and how that will apply to your new position here uh for the joint division? Um Yeah, I was uh so at Hopkins, there were several hospitals and I was the chief of orthopedics at one of them, the baby hospital where II worked at and there was a lot of geriatrics and we did most of the joint replacements there. So that, that worked out uh well, but it was uh you know, exciting the time to build the department there and work at growing things and there'll be similar sorts of things to do here. One of the exciting opportunities is to work across UF health which now owns, you know, five or six hospitals and here there was just, you probably saw the email this morning about the new one. It's gonna be built outside of Jacksonville. And so, uh, to me, there's a lot of excitement in that and how can we think about something that hasn't been done and that's worked more as a health system, especially in what I do. So how can you figure out where should joint replacements be done at every single facility or who and who should be doing them? Should over time? Should these be UF physicians, should these be private people that work there? Which has been largely what's happened up to this date in some of these facilities? And um how do you measure what people are doing? How do you look at what costs they have? How do you look at uh their outcomes? You know, are they the right person to be working with each of these people? Should be, we be recruiting our own people and not using more private people or is it fine the way it is? How can you work more together so that you can do research at outside s sites and include some of those people and patients in, in trials and so forth? So there's a lot of really exciting things that um part of the reason why I joined. And uh so hopefully some of my previous roles will, will help in that. Yes, sir. Thank you. Um Once again, thanks for being here. I just have a quick question regarding like when you're screening through medical student applications for residency. Is there something that particularly stands out to you like a national conference or step two score. Like, what are you looking for? Like, is there one thing or it just, obviously it's a multitude of things, but is there like any more specific though? Yeah, um obviously pretty relevant for uh everybody here? Great question. And y you know, when I'm looking at people, it's um uh one of the most important things is consistency across, across time and consistent excellence. So the best applicants are excellent in everything they do. They, they got great grades, they do. Well, you know, now step ones pass, obviously you have to pass that and you wanna do well at step two and then you, you know, you need to be involved in something with orthopedics. So people know you and really, I think, you know, writing papers and getting involved that way is really important, not just for your CV, but it helps you build relationships with people over a number of years so that they can write you better letters. So if you have somebody who's known somebody for the three years or sometimes even longer, you, we know a whole lot more to write a much better letter than if I've known you for two weeks. It's pretty hard to write a really great letter about somebody, right? That is more personal and mean something and those letters, um, they mean more, you know, they, they've made all these rules to try and, uh, get rid of tests, the tests are biased and all this. But now it's so it's more up to letters, which I can't think of anything more biased than people's personal opinion. But that's what they, that's what's happened. So, those things are really important now. And, uh, so, so you wanna have all those things going your way and then the other thing is really getting to know residents, um, and knowing what they're doing and figuring out how you can be helpful. So how you can help them splinting and in the emergency room and how you can be useful when you're in the operating room, not just standing like you don't know what's going on. So that when you get to your fourth year sub eyes, which are so important that you can be excellent. Uh And that's really, really important. If you, if you do terrible at your sub eye, you're, you're not gonna match it, the places that you do it at. I mean, that's just not gonna happen. So, you know, it's your greatest opportunity to do well, but you, you have to know what you're doing and that's hard because they don't teach you that in any of your classes. This is practical stuff. This is, how do I be interesting but not annoying. How do I, if I'm standing there in the operating room and the surgeon is there, how do I know enough to be able to answer some simple questions. Um And, and look good and you know, how do I do that across a range of people? Not just the attending but you know, maybe the fellow or the, the resident or stuff like that cause they'll, they'll give us their opinions on how everybody's doing as well. So it's fairly complex, right? All these things. Um But II think those are all important. So it's not just one thing that we're, we're looking for is that happy to take more questions on that topic? Oh, good. So, here's a little bit just for our Subspecialty series. Would you mind talking about, um, kind of joint replacement as a Subspecialty? What kind of indications do you consider for primary versus revision? And, um, kind of what surgeries? You guys do? My, my, not sure. Yeah. Uh, you know, you can think of it. Oh, pretty simply, right. All those guys do primary hip, primary knee revision, hip revision knee, you'd think that would be pretty easy, right? But, um, of course, it's not, um, you know, in terms of primary joint replacements, those are most commonly for osteoarthritis, but they can be for avascular necrosis. Uh, they can be for posttraumatic arthritis, rheumatoid arthritis, all, you know, different, different conditions, sometimes dysplasia or childhood problems can lead to severe arthritis. So, th th that's pretty much what primary joint replacements are for. And when you look overall at different people's practice in joint replacement, especially as you go more private. There'll be people, that's all they do is primary joint replacements. They, they may also do partial replacements. They may do a little bit of arthroscopy. You know, they may take some trauma call at their local place, but primarily they're trying to do primary hips and primary knees. And if you do that, you can get quite a few cases done a day and so forth. What you, you know, I've over many years done a lot of revisions. So in terms of revisions, what are you doing those for? Well, uh loosening of implants. So things can not take or get loose right away. They can get loose over time. Plastic can wear over time, hopefully a very long time. But it, it can, you know, with hip replacements, they can pop out of stock socket, become unstable, need revision. Um people can fall and break around the implants and, and need revision surgery for that. Infection is becoming increasingly a bigger and bigger problem. So if a joint replacement, either hip or knee gets infected, the bacteria stick to the metal and they form a biofilm and they kind of go stagnant and it's extremely hard to get rid of them. Just giving antibiotics doesn't get rid of it. So you have to usually take out the whole replacement and then we put a spacer type of replacement in. And this has been one of the fascinating areas over the past, you know, really 5 to 10 years, we've gotten much better at putting those spacers in. So for most people that can actually be a pretty good replacement that we may not even have to go back and redo. But most commonly you go back after the antibiotics and redo that to a kind of permanent revision replacement. Um Similarly with the fractures around implants, you can imagine there's all this metal there. So it's harder to just plate it. It's not like the regular bone where you, you can put screws anywhere. You can't put screws through the metal parts, right? So, we have to figure out how to anchor plates around stems and different things. And there's been a lot of technological advances on that, that have been exciting to let us do that, that better. You know, my practice. Uh and I don't know, it'll end up here, but probably it will be per pretty similar. I mean, I've been doing kinda 40% revisions, which is a lot uh for most people, but I'm pretty good at those and can do them fairly quickly. So that's a large portion of my, of my practice, but not that wouldn't be typical for most joint replacement surgeons. Do you have any different preoperative uh planning? I guess guidelines for a sort of a younger patient that requires uh a say total hip replacement like post skippy or herpes disease where, you know that the implant is probably gonna not last the rest of the patient's life. Yeah. Um, you know, that's been debated over the years and people have tried different things. So, with the advent though of highly crosslinked polyethylene now, more than 15 years ago, the life expectancy of the implants gone, gone way up. I mean, they're really wearing at very low rates. So, uh, from almost everybody now they get a ceramic head in the, in the hip with a, with a plastic liner, the metal on metal, I don't do. There are a few people that still do that, but there's been so many problems. I wouldn't be excited about that. You can do ceramic on ceramic in very young people. Um, but there is a, there is a rate of it having a squeak which I is audible. Um, and that, that's a big problem. You can imagine if you were just walking around at every step, your hip squeaked so that somebody could hear it. You might not be thrilled about that. Um, and they're a little harder to put in technically. So there hasn't been shown to be huge advantages that way, but some people will do that for very young patients. Yeah. You know, overall when we talk about getting ready, people ready for surgery, that's another thing that's really changed over the past 10 years. And, uh we, so we really try to get people maximized for surgery both medically and physically. And that, that means a lot of things that we didn't used to do. So we now really make people stop smoking. We make them lose weight to get their weight down because if you're extremely heavy, it's just much harder to do surgery and there's higher rates of infections, dislocations. All these bad things, we really look at diabetic control. So if you have diabetes, you have to get your hemoglobin A1C below eight, you have to have reasonable control to get a joint replacement and, and we got some other, there are some other things as well, but I think actually joint replacement surgeons have kinda raised the bar for all of medicine, for getting people ready for surgery and for getting the medical doctors to pay more attention to some of these things that were, were slipping through the cracks before. So that that's really been a big change and, and I think a positive thing across of me, all of medicine, really not the joint replacement surgeons have saved the world. But I think we have uh really improved uh health care. Another question kind of standing off of that, like um the young patient preoperative planning. Do you have any like experience with or any thoughts on like the new bearings coming out like Vitamin E like infused ones or like like the ceramic size metal ones? Like, do you think that those will be more popular than ceramic? Uh So I think the question was do the about Vitamin E poly mainly I mean, I don't know if it's better or not. They haven't proven it's any better than just the highly cross linked poly. So I'm not, I'm not quite sure some of the companies you can't buy anything else but that, I don't think it so far has been shown to be worse. So that's good. But I'm not quite sure if it's actually better or, or not. I don't know that we know that really at 20 years or some time point that would, that's the problem you're asking for. Uh, this is a 20 year question, right? And one of the problems is that all the companies wanna sell something new. So it's hard to find something that you could actually use. That was around 20 years ago. So even if you knew the answer the material would have changed, you don't know if you're using the same thing that, uh, you know, that's a long time period, right? Uh, but that's the kind of data you need to make an informed response on outcomes in young patients. So, not, not as easy to answer the question, I guess as you would, might think it would be, um, uh, I had, uh, kind two questions mostly with, uh, in regards to your research background. So, um, as a phd, somebody that has more extensive research background than maybe some other surgeons in our department. How do you view research in a medical student, application for residency in terms of like positives and negatives. Um And then in your background in neurobiology, how do you use that to inform your clinical decision making as a joint surgeon? Sure, great questions. Um y you know, one of the issues is that you don't have step one anymore to show how good you are. So there's just very few things to distinguish you from somebody else. So research is one of the things that can distinguish you. I mean, if somebody has written eight papers on some orthopedic thing or they've written something really good and somebody else has written nothing. II mean, that's just right there. Right? And, you know, not everybody cares about that and not all programs are looking for people who do research or who are gonna move the bar, you know, some are just trying to, to train good, good clinicians and there's nothing wrong with that. But if you're looking at trying to go to somewhere that is more at, you know, University of Florida or Johns Hopkins or, you know, I don't know, University of Michigan or you can list, you know, another 100 places. Um, they are gonna be looking at that and you're trying to distinguish yourself from your peers and that's one way to do it. Is it, is it the only way? Uh, no, but there aren't really that many ways to distinguish yourself. I mean, you know, you know, you can be a world beater at some other topic, you know, maybe your, um, you know, we all talk about other things that you can do outside of medicine or, you know, so maybe you're a business person, you've done something else or maybe you've started a charity and done amazing things. Um, but that can also be a, a little bit w, well, if you're so good at business, then why aren't you going into business? Why are you going into orthopedics? So, you have to, you know, those things are always, always raise questions, not necessarily in a bad way, but uh so you, you, you know, you wanna be doing something, you have something on your CV. And that's just one way to, it's probably the, the most commonly done way to try and do that. And, and as if these things have changed to get rid of part one scores, I think it's just really kind of necessary to have a few papers or something to help distinguish you and to help people write letters about you, as I said, that that are better. Um, does that help answer that portion of your question? Yes, sir. Thank you. And, uh you know, on the other one, you know, II got into neurobiology, you know, interested in nerve regeneration. And then 20 years ago when I was a resident that, that was kind of, as I saw what was happening clinically, it was kind of a gloomy area. These people had chronic pain. This was in the middle of everybody getting way too many narcotics and you don't see a change for at least a year, sometimes two years. Uh And then I just, I wasn't cut out to be a hand surgeon. They love to memorize like the 1900 different little filaments in the finger. And II don't know, it just wasn't really my speed and the joint replacement surgeons and the trauma surgeons kind of were my speed and joint replacements great because you see changes, you know, in two months, somebody's a different, can even be faster. Sometimes they're a different person than they were. You know, you, you can really see progress and do some exciting things and really help people. And uh so II got interested in, in, in that. And w what has been interesting though, and one of the reasons I have come to the University of Florida is there's an unbelievably great group here working on nerves in bone. And we really don't know much about nerves in bone, but there are lots of nerves in bone. What they do isn't very clear. I mean, you, you, you guys have been to anatomy class and neurobiology class, what they teach you that a nerve does in bone. There was probably a one line or maybe a best, right? Um, because nobody knows, well, they're filled with nerves and it's unclear if it's all pain, if some of it's p reception, it is some of it regulating the homeostasis of the joint and the bone so that the nerves are actually signaling different cells and releasing different factors that do this or that, that may be more of what they're doing. So there's a, a group here led by Kyle Allen who's in biomedical engineering and they have, you know, three different R one grants about this and they are taking um pieces of knee tissue that we get them doing a knee replacement. And they have ways to get rid of kind of all the tissue in it, but leave it as a three dimensional piece and then they can immunostain for the nerves. This was kind of stuff that I was doing 20 years ago. And my phd, they would also, then at the same time, they could put micropipette into the nerve and now they can get DNA from that. So they can tell you what an individual nerve fiber is doing. And so the goal of these is to really find out um what, what the nerves are doing in the bones. And they, they can make these incredible 3d pictures without all the tissue, but of the bone with all the nerves. And it's, it's just pretty amazing stuff. So I got to meet him when I interviewed it was like, whoa, this is really full circle. Now, this was what I was doing a million years ago as a phd student. And maybe this really does have some value in what we do and hopefully we can, uh I can help the, that team with their goals on the clinical side and give some clinical acumen to the scientific side and uh we can come up with some really cool stuff. So that, that's an exciting part of coming to Florida. Um, hi. Um, I had a question on terms of research that you were talking about. Um, would you say that quality of research stands out more to you or quantity? And also how is a, an applicant that has non orthopedic, uh, research you in terms of, um, when they're being reviewed for application? Um, I think your question was, is quality or quantity more important. The last part, uh, it's a little hard to hear, uh, with the speaker, what was the last part of the question? All right. Yeah. The last question was, um, how are applicants with non orthopedic, uh, research you? Oh, ok. Got you. Yeah. Yeah. Um, well, I think, uh, yeah, quality and quantity. It's, it's hard, I mean, I think as a student it'd be really hard to have a really high quality paper that you're the number one author and you've designed, I mean, that just isn't really gonna happen. I don't think. Uh, so more than likely you're, you're participating in things and moving things along. Hopefully you're getting to where you can start to write papers and you'll see some of, you know, you'll probably have colleagues that have maybe they can get to being first author and they've written a bunch of papers. I mean, there are some students who are just utterly prolific and can get all kinds of stuff done, you know. Uh, it also helps you in your interviews to have a few papers because it gives you something to talk about on your, during your, uh, interviews. Well, uh, you know, hopefully get to that stage. You, some of the interview are short and other are longer, but anything on your CV is a good thing to talk about. And if it's a longer interview, you having more things to talk about is good and you will be surprise that, you know, you'll have written some paper that you thought it was, you know, whatever and then somebody else you'll be interviewing and they'll be like the world expert on that topic. So you better really know your stuff about everything you've written. Um, so, I don't know, I think you want some balance with that but, uh, it's nice to have more than one, more than one paper that you're a part of in terms of, uh, or does it matter if it's orthopedics, you know, II think it's good to have other stuff that's not a negative. But the part about having them orthopedics is that you then know the people better to write you letters and their topics that you can talk about in interviews and, you know, maybe that's repetitive. But those are important things. So if it's on, uh you know, your papers are all on uh viruses and I don't know, neck cancer or, you know, Drosophila or something like this. Most orthopedic surgeons aren't going to be able to talk, they, they aren't gonna know anything about that to, to talk about. So it's not just the scientific kind of merit of what you've done, but how it relates to getting you to the next step. If this is what you wanna do, did you talk about work-life balance? Um as somebody who's building a patient panel now versus having an established uh like patient panel, like let's say back at Parkins or at Johns Hopkins and how that differs. Um Yeah, it uh I mean worklife Balance for orthopedic surgeons is often a difficult, it's a difficult topic for everybody these days in medicine, but especially surgeons because you, you know, you have to be in the clinic to see patients and get them to do surgery and then you have to do surgery. So you're in multiple areas of the health system, not just kind of one. And so you need those to all to work efficiently to uh maximize your time so that you're hopefully not there too long so that you can, you can be home. So that's, that's really important. I think um you know, vacations are really important. Uh It, it, it's really important to think about those things and to talk to others about it as you go on. Um, because the people b, burnouts are a very real thing and it's, it's, it's higher in surgeons and orthopedic surgeons perhaps than other fields. Although I think it's high in medicine period. So it's important to recognize that from an early stage and to think about that as you design your life, how you're organizing that around your loved ones and your family and how you can exercise enough and do your hobbies and these things. Because if you don't do those things, you, you're gonna run into a problem. So, it, but on the other hand, you're building a practice, you also have to be available. I mean, that's the, the three A's right. Availability, affability and there's another one that I've forgotten, but, um, availability is pretty important. So, if you're me right now I'm going out trying to talk to all the UF health physicians and with the loss of surgeons over the past six months, they haven't been able to get people in to get their joints replaced where they've had to send them out, which I certainly don't want. So, um, I have to work to try and be available and if somebody, you know, Epic chats me about Joe, do you know? Ok. Yeah, I can see Joe tomorrow. No problem. So, you know, that, that's a, that's an important thing to build a successful practice if you don't do that. Yeah, some people are still successful. Who kind of have a practice given to them. Maybe I, yeah, I have a three month backlog. I'm so busy that I can't see anybody else. It doesn't matter to me because I'm busy so I can't do them anyway. That's not most people, most people, it's a dog eat dog, scrappy type of thing where you're trying to get people in and, uh, get them taken care of so that, uh, you can, uh, do your thing and be successful and build. I mean, that's what I need to do so that we can start getting all these people in, hire a couple more people and get them just as busy. You know, most people in orthopedics wanna be busy. Kinda stemming from that question. I know you said your practice is comprised of around 40% revisions. Um, from my limited experience, it seems that sometimes the revisions take an unpredictable amount of time depending on how complicated it is as well as having a propensity for postoperative complications. Has that really affected your practice and kinda intervened on the free time that you would have liked to have. Um, well, I think uh part of that gets to be what kind of a surgeon you are. If you're slow, then, yeah, it'd be a real problem. So don't be a slow surgeon. II think slow surgeons are bad from a number of perspectives. Their complication rates are higher, their infection rates are higher. Uh you know, if you're, that, it kinda gets around that you're not as fast as somebody else, you'll get more patients if you're, you, you, you don't be fat too fast and be sloppy and bad, that's not what I'm talking about. But, yeah, the revision surgeries, somebody who doesn't do many, they're gonna take a lot longer than me to do revisions and there's different types of revisions. So there are some that are pretty straightforward. Uh There's others that, you know, whoever did it, it's gonna take a long time. There's no way around it. I mean, uh there, there aren't as many of those. So, and you, you try to only get one super hard one per day and you put that at the end so that you're not, you're not kind of slowing things down has been my general strategy, but you're right. It's, uh it's why a lot of people don't wanna do them. Yeah, takes longer. You know, you could do, uh you had two rooms, you could do eight or nine primaries. Uh I, you know, if I'm doing a two or three revisions, II get six done at the same time or something, you might be able to do three or four, I've seen some pretty slow revisions. That's all I asked. Yeah. Any questions for some, there's nothing you can do. They're gonna be slow. Uh And others can be made to move faster if you have a totally cemented thing. In there and you have to chip out all that cement. It's pretty hard to get that to be really fast. I had a question as well. Um Thanks again for coming to speak to us. I know you said that the, the hand guys really kind of weren't, uh, at your speed but the trauma. Excuse me, the joint guys were. I was just curious what sort of dissuaded you from trauma or what really pulled you towards joints and, and sort of making that uh that decision. Well, I've done a lot of trauma uh at my last position, I was uh on the level one trauma call. So I had to do trauma call every fourth night and I'm just getting too old to do that, but I like drama. There's no, it, it's fun, s one. Um can you talk about what it's been like trying to build um kind of a division cause I know Doctor Hagan had the, was tasked with building the trauma division and it's been a great energy, like found a lot of great people. Can you talk about what you are kind of looking for and what that's been like for you? Um Well, that, that's a good, interesting question. I'm, I'm just starting. So I think first is for me to kind of get the lay of the land and um get things kind of stabilized and I wanna recruit the right people. So I want people who are interested in research and really can make a big difference and are good surgeons and are good people. Mm. That's not everybody. So, uh, you know, this isn't private practice. Get paid a little less here than you, you would or could potentially. Right. If you're in a private practice job, you know, you make money off of the outpatient surgery center. So, every surgery that's done there you get a little cut out of, that's, that doesn't happen in academic practice. Um, but we have a lot of benefits from being in academic practice. A lot of access to really cool stuff and teaching. And, um, so you, you wanna recruit the right people, you don't want unhappy people who are doing things that they don't wanna do. You want people who can do revisions, uh, well and quickly and who are interested to do them and who wanna be team players and doing that so that when we get, you know, we get transfers in all that kind of stuff so that somebody can take care of them. Hopefully, it doesn't matter which one of you it is so that it's done well and efficiently. And, uh, so that'll be, uh, kind of the challenge and we'll be getting started more on that, uh, in the month years to come and the worst is to hire the wrong person. So I'd rather hire, hire nobody and do the work myself than hire the wrong person. Maybe it's one of you guys? Ok. I didn't hear you, I guess. Does it look like we have any more questions? I know you gave us a lot of advice for medical students. Did you have any anyone, like, if you want one thing for us to take home from this, uh, talk today? Is there anything that you would tell us? Yeah. I mean, I think, I think, you know, kind of those three things that II harped on a little bit, keep your grades and stuff up. You don't, you don't want any bad grades. That's a, you don't want any red flags, you know? So you want good grades, you wanna try and get some projects done and then you really wanna get in to know people so that you have good letters and so that, you know what to do when you're a sub high, that's one of the hardest things to teach is how to, to be that good subby. And so that you can only do that at your place, then you can go to another whole crazy place that you don't know of. You, you know, you, you, and you gotta do that several times and you can do a really good job at that. It's not the easiest thing, you know, and everybody is different. Some people talk too much. Some people don't talk enough and some people were perfect, of course. But usually you're kind of on one side or the other and that self feedback as to how to do that isn't always obvious to people, you know. So you, you wanna kind of seek out those cues and um when you see if you work with a resident who's just fantastic, you, you kinda wanna pick up what they're doing, really pay attention and figure out how you can move yourself to that level because if you can do that earlier, it'll be noticed and then you'll be more successful, I think in it. So those are kind of hard things to do, figuring out that's not what's taught to you in, in classrooms, right? So the social awareness and interactions are really, really important. Well, great, well, fun talking to you and um you know, let me know if you have any further questions. Happy to answer. OK, thank you. Thank you. All right, have a great day. Bye now. See you and