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a whole kind of session dedicated to it before in the Dina or not. But it's obviously something that is very important for us all to be learning about, not just from our own personal experiences, but actually because of the people and the teams that were also responsible for. So I've got a pretty awesome faculty actually today, so we're not quite yet signed in, but I'll introduce as we go along. So we're going to kick off with Anna, who I met recently on the British Society Traveling Fellowship. She's an assistant professor at Louisiana State. She is another female hip surgeon, So, uh, we're a rare breed. But you've got two of us today, so that's amazing as well. Uh, is going to talk to us about Ivor ship bias, if that's all right. All right. Thank you. You're right. It's so weird to do it without seeing the people. But that's okay. Um, I want to start with the caveat. As I learned on my fellowship, being any kind of professor is much less meaningful in the United States than it is over there. So does anybody, just anybody off the street working at a university can be a professor of various ranks. So just bear that in mind as I do this talk. Um, So this is what we're going to talk about? Just an introduction, sort of of myself in the US, uh, medical training system to give you some context context, Uh, we'll talk about survivorship bias. And I would love to have, uh, you know, candid discussion, if possible. I I plan on, uh, you may remember, I don't have much of a filter, so I plan on being sort of very honest about things. Um, so if we can Yeah. And then we'll conclude. Um, So, uh, first of all, thank you again for having me. I'm really honored to be a part of this. And thanks for giving me the first lot. So I can, uh, do it, perform a clinic. So I work in academics. Uh, so at a teaching hospital, uh, an adult reconstruction. So, uh, in the US, uh, it's not so much divided into hip and knee. It's more, um, joint replacement versus, like, more soft tissue surgery. So I do both hips and knees. Primary and revisions. I'm in New Orleans, Louisiana, where in the middle of our carnival season, and I started practice fairly recently about in the fall of 2018 training. I was at University of Chicago and the University of Virginia, where I did my fellowship. Um, I did get a master's in skeletal and dental archaeology at UCL back in the day, So I I do have a connection, uh, to you guys. That way, Uh, I'm of the generation of elder millennial. I have two little girls, and as I was mentioned, I was the 2022 British Ship Society American Society traveling fellow, which was an amazing experience. And I encourage all of you, um, doing well, whether it's hip surgery or any kind of, uh, you know, uh, specialty that to do a traveling fellowship, especially international one. It was a really amazing experience. I mean, a lot of, uh, you know, lifelong friendships and connections and learned a ton because it's very easy to get sort of wrapped up in the way you do things that your institution or in your own sort of country. And it's very, very cool to see. Um, the different ways of approaching the same problem so I think, is a context. I'd like to tell you a little bit more about the US medical training system. This is a picture of me 7000 weeks pregnant in 2016, hanging out at work. So, uh, first we do our undergraduate degree, which is four years, um, starting after high school. So, at age 18, some people will take a gap between undergraduate medical school to either do other things. Like what I did my masters or to sort of prepare their application, um, to be sort of more prepared to get in cause it's it is quite competitive to get into medical school in the United States. Then we have four years of medical schools as postgraduate, uh, then residency, which is five years from most surgical subspecialties, including orthopedics, uh, and then residency hours. So you really you start around four or five in the morning until probably later in the evening. Um, or you have 24 hour call with a post call day. Some places kind of get around even having a post call day by having what's called home call. Where, um, technically you're on call, but you could go home. But even But even If you don't go home, you're you. Technically, don't need to take that post call day, which can be rough. Um, you often have weekend responsibilities for rounding. And the term Golden weekend refers to having two days off in a row, which happens fairly round. Meaning not having to go to the hospital. No rounding? No nothing. Um, we have an 80 hour weekly work. Our limit that was introduced. Um, probably about 10 years ago. This is averaged over four weeks at the resident is responsible for reporting the hours. So, you know, in the in the interest of being candid, uh, it's crazy how I managed to work from 6 a.m. to six. PM for five years. Exactly. So isn't that funny how that works? Um, fellowship happens after that. That's in a subspecialty, for example. Hand peed sports or Rican like I did. That's one year long. Um, and then after that, you're ready to rock and roll, so we'll move on to now. What is survivorship bias. So, uh, it's essentially an error that arises. Uh, I'm coding here an article, but that we look at the data we have but ignore the selection process that led us to have those data. Uh, what does that mean? So one example is commonly uses out of entrepreneurs. So, for example, like, uh, if you look at Steve Jobs Mark Zuckerberg, they are these billionaire entrepreneurs who started to start up after dropping out of college. If you look at these few examples of sexual successful people, you maybe led to believe that the way to become a successful entrepreneurs to drop out of college. But that is not the case. It just so happens that those few people, uh, that we're seeing had that path. And so that's we're sort of skewed by the data that we're evaluating to think that that's the way to success, whereas more likely, you should probably finish your college. If you want to be successful, there's I don't know why I put this on there because it just makes me look stupid. But there's an example that I really spend a lot of trying trying to figure out in the corporate world about mutual funds, but I cannot explain it. So if you're interested in figuring out how survivorship bias is relevant in, uh the in finance, go ahead and Google that I tried. Uh, but one that I can explain is this picture of a plate. It's a pretty, very common example used to describe survivor surprise. So the idea is that, um in one or two there was this mathematician that was again who? This is probably not true. Based on the research, I did. But it's a good story that he was asked by the, uh, the US military to help redesign where to put armor on planes to reinforce them better so that they're less likely to be shot down. And they provided him with all these planes that had returned from combat. And this is an example of where all the little, um, the red marks are like a bullet bullet holes from planes that were at return from combat. And the idea was that, you know, they they had asked him where should we put this? This arm er And they had assumed he was going to recommend putting putting the reinforcements where there was the most damage to these planes that have returned from combat. But the point was, this was an example of survivorship bias in that the planes that didn't return from combat, I either ones that have been shot down, those are probably the ones that, uh, were shot in places that needed to have more reinforcement, if that makes sense, Um, so the the idea was by only examining the planes that actually returned, you were getting a skewed sample, and it was actually a misleading, um into where this arm or so would be, uh, put. So that that's been sort of tout is the classic example of survivorship eyes. And again, this is very detailed article because he was a mathematician about how they had examined his writings and said the story probably wasn't true, But I still think it's a good thing to, uh, to quote because it helped at least helped me, Um, when I first learned about it to understand the concept. So then, um, that brings us to how does survivorship bias apply to medical education? This is a great, um, opinion piece, uh, co written by one of the speakers you're going to see later today. But, um, essentially, the idea is that you made it through your training and so you believe you know, we believe ourselves to be good doctors. Thus, the training must have been good to produce me, whereas that's not necessarily the case. So what about, you know, is me coming in at four. Am everyday or working until I deliver? Right? Is that good training? Because I happen to make it through. And I'm now, you know, a practicing surgeon. Uh, you know, survivorship bias would lead me to believe that Yes, because I had to do it that way. Then that's that's the best way to train doctors. But I think the whole point of having this talk and having this discussion is that that that's not necessarily the case and what I want. You know, the point of these discussions of survivorship bias is what about the perspective of those who leave training and do not go on to become practicing surgeons? Uh, we should probably hear those perspectives two in the same way. Thinking about where to reinforce the planes, uh, that we don't see that we're, uh that did not make it back. So that brought me to to look into So who is most likely to leave training. So, in the United States, uh, there's a literature show that black residents are dismissed from residency at a disproportionately higher rate. Um, and who is not represented in medical leadership to provide the perspective and again in the US, women are underrepresented medical leadership. And then this is not a type of 0.5% of, uh, tenured faculty in US medical scores are black women. So it's very low rate of these people in leadership so we can get their perspectives, um, moving on more specifically to orthopedic surgery. So there was a review of department chairs in the US find that, uh, 2.8% were female, and interestingly, 20/20 percent had done their fellowship at two specific institutions. Uh, which again shows? Uh, we're not getting a full perspective, both from, um, from a gender perspective and also from where even where people train this particular side did not look at race or ethnicity, and then a review even get even more granular. Review of adult reconstruction. So, like hip and knee replacement fellowship directors in the United States. Um, all right, male. Uh, and, uh, you know, you see the sort of various ethnic break, uh, break down there as well. So just going to say as you go through leadership, um, and training. You may not be getting the perspective of of everyone involved in order to sort of make assessments of how our training is working. So how can we hear from those who have been dismissed from training or not? Representative leadership to sort of address are survivorship bias. One relatively new, uh uh, program is Speak up. Ortho, which is a social media venue for anonymous accounts to discuss bullying, harassment that happened during training or may have caused it to leave training. And then, you know, uh, just anecdotally. And, um, I know there's been increased interest in survey studies that have targeted trainees who have left, but this is a very difficult thing to study for sure. Um, but I think it's very important in order to, um, make sure we really understand, um, how we can improve our training and avoid survivorship bias when thinking about it. So and this is this is the get real part of the talk. I guess I wanted to talk about some personal examples of my own. You know, I just kind of looked deeply as in my own training experience and how I you know, examples of when I think I exhibit in my own survivorship bias. So one would be a lunch break. It sounds so simple. But, you know, I was when I trained you just you either eight. Never. Or you just sort of eight while working, Um, and I found myself I'll be honest with you. You couldn't think it's terrible being kind of resentful when I would have residents working with me who would just leave for lunch. You know, it sounds so terrible, I know, but it's just again because I trained just never taking breaks, right? You think that that's how you have to do it? So I've been sort of trying to, uh, be more more accepting and change my perspective. Just because I did it that way doesn't mean that's the way it has to be, um, again. And then I have I've had trainees request to to leave, working with me to go to a partners O. P. Appointment, and again, I was totally fine with it. But my first instinct was to be like, Well, I had to go to all my appointments alone on post call days and never took any time off and, you know, never even tried to take extra call. So I wouldn't inconvenience anybody when I was pregnant as a trainee. Um, so again, this is this is reframe trying to reframe to say that just because I did something a certain way and I trained that way, it doesn't mean it has to be that way. Uh, in the future 24 hour call as a concept, right? Something that we do in the U. S all the time. Uh, it's not necessarily the best way to do it. And, you know, in the airline industry, they don't do it. They want people to be awake when they're when they're flying a plane. So again, something we as a as a training system in the country, may have to reframe as a person of a you know, of a gender minority the idea of having just have a thick skin like that, the advice that I was given, um, and that I see sort of events during training. You know, people are attending. Maybe mail ones are going to say offensive things and you just deal with it. Don't worry about it. This part of part of the process. Don't make a big deal about it. Keep your head down again. That's the the the model that I was taught. But so survivorship bias may make us think that that's how you have to train. Um, but I'm trying to be better in the future and tell trainees I work with No, you should, um, call these things out, or at least talk to trusted mentors. Um, if you're worried about retaliation, because we do need to change the culture, parental leave again only took what I was allowed, which was probably about four weeks when I was a trainee again. That's pretty disgusting. I think so. Just because I managed to become a practicing surgeon in Phoenix training. But taking only four weeks of of parental leave doesn't mean that that has to be the way everybody does it again. Same thing working up until you deliver. And then, uh, this I put it in there so that you all would be mad at me. But I remember talking to some folks and they were like, Man, you know, why are you giving us career advice? Were older than you and I said. You know, maybe you'd be done quicker if you all got to work before 10 AM But again, it doesn't mean just because we happen to be successful after five years of physically and emotionally punishing ourselves. Does that mean it has to be that way? You know? No, not necessarily. And this traveling fellowship kind of help me see that there's many different ways to go through training and be a fantastic surgeon. So I think now I'll sort of unsure my screen and because it's really weird not seeing people's spaces, but, um, it would be.