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Good afternoon. Good morning. Good day, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I am a retired cardiac surgeon in Yorkshire in the United Kingdom. The immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College, London. I'd like to extend my profound thanks to med all for hosting these sessions as we have 135 registrants from 37 countries this evening. That is only possible with companies like med all who want to make education free to all interested in medicine. I'd also like to thank the 4233 followers on Facebook and the 680 on Instagram. This evening is a very special evening. The reason is this book. My fellow John Taylor is 1/5 down karate who goes to Okinawa once a year to train. He can't join us this evening as he is teaching in a Kudu. He met up with a co-author of this book Wendall at a karate seminar in Chicago and sent me a copy it was published at the end of last year. And Malvin Macklin and Wendell goins have written the way of the surgeon, the intersection of martial arts and surgery. I immediately reached out to Melvin and Wendell and said, you've put into writing what I've been saying for a number of years in trying to teach. Are you interested? And I'm very grateful that Melvin has joined us this evening. He's a native of Chicago and received his undergraduate degree with the highest honors from Howard University of Washington. He graduated top of his class from medical school and completed his training in general surgery at Howard University Hospital with two years of research at the National Institute in Bethesda Maryland. He finished his surgical training at Washington University School of Medicine at Barnes Jewish Hospital in plastics and reconstructive surgery. And during his tenure was twice named teacher of the year. This also struck me cos as you know, I run the silver scalpel award to identify the best surgical train of the UK. He has a private practice at Saint Louis and is recognized as Saint Louis prestigious top doctors in plastic and reconstructive surgery since 2008. He is currently an assistant professor of surgery at Saint Louis University and a head of the plastic surgery division at S AM the Poor Hospital in Saint Louis. Now, in addition to his surgical expertise, Malvin is the father of two sons and I chatted to him yesterday. He is at lacrosse training, but he's also a former international competitor as the second degree black belt in Taekwondo and is currently training in a kiddo with a rank of second Q. He is a member of the Association of ringside physicians and certified ringside physicians and works with local promotions for M MA kickboxing, boxing and UFC. And I'm delighted to introduce Melvin this evening. Welcome Melvin and thank you very much for joining the Black Belt Academy of Surgical Skills. Why the book? Well, uh the book was, the book has been in the same way with you. You've, you've had the mart arts training and the book has been in the back of your back of my head for years. And it really wasn't the book, but the kind of the approach, you know, um I started training when I was a freshman in college and from uh becau I, by the time I got to medical school, I had my black belt already. And the most instrumental thing that happened to me as a black belt was the day after the week after I got my black belt master Alpha goes all teach those white belts. And then I like, uh, you know, deer in the headlights, you realized now I have to teach everything that I thought I knew that I master you with my black belt test. And I realized that if you can't teach, you don't know it, which then flipped into, all right, everything I'm gonna learn, I'm gonna learn it as I have to teach it. And then when I got to medical school, I learned how to teach it. When I got to residency, I learned how to teach it. Um So, you know, my approach to medicine, surgery has always had a martial arts, you know, been to it and it's been in the back of my head for a long time. Uh And by the time when the pandemic happened, you know, a lot of changes happened, I had some free time on my hand and I always thought about writing a funny comparison of martial art deer, you know, wax on, wax off, you know, all the different, you know, be like water, all the different martial art saying na end up blind with surgery cause I use them all the time in the operating room, you know, like, uh, the riddle of steel. I say that all the time in the operating room, what is the riddle of steel that, you know, that people think that steel is strong but flesh, flesh is strong. So it started off as kind of a goof project. And then as I was writing, they say writing is therapy and I kept writing, I kept writing and I kept writing and then Wendell kept writing and then realized, oh my goodness, we need to actually break this down. And as we were writing, we realized that what we're saying is not u new or unique or even extremely brilliant. It's the same thing, every martial large practitioner who is in the health care or even every martial large practitioner who's in law or every martial large practitioner who is interior design, they take those things and they put them in their daily professional work. Uh We said, let's just get this out before someone else beats us to the punch the same way with Alex Gray Bell and Elijah Gray. Someone's gonna come to this and get it out there. So I'd like to go through your book and pick out some particular chapters. Uh, you talk about 47 times sweat more now, bleed less in battle. How does that relate to surgery? Oh, uh uh, let's take it down one at a time. What's the first one you wanna talk about full seven times? Uh, that, uh, chapter is particularly focused on failure, you know, it's focused on, on what do you do. Um, and not so much failure and how you, it's more so how you approach even in your training. Um You know, it's gonna get hard, it's gonna get hard and you're gonna get knocked down and then when you knock down, you don't look at it as something negative like, oh, I'm terrible. I'm an awful student. I'm, I'm a terrible, um, I'm a, I'm a terrible resident. You look at as a learning opportunity to pick yourself up and and be better cause in the ring, if you fall down in the cage, when you fall down, either you lost or you gave up. And so you gotta, you gotta stand up just one more time. And it's a saying from karate, you know, fall seven times, you'll stand up eight, fall eight times, stand up nine. It's only you, you don't quit. You don't lose when you get knocked down, you lose when you quit. And the uh there's nothing easy or natural about surgical training and you have to be indominable in the pursuit of your education. If you show up and just spectate one of my things. I hate the moment. Usually when I have students, uh I'm very selective with students. I pick to come into my practice. I asked them first, do you wanna spectate or do you want to learn if you wanna spectate? You're gonna have a wonderful time. I'm gonna make zero effort to teach you. You're just gonna spectate with your hands in your pocket and just look, if you wanna learn, it's gonna be ars process and at some point during the, during rotation, you're gonna cry because I'm gonna knock you down and I'm gonna have you pick yourself back up, knock you down, pick yourself back up. And that's gonna be throughout the entire practice so that you get to learn not only the, the technical aspects but how to be a quality healthcare professional on your own because what little time I have with you is small compared to the rest of your life. So, I've got to get you on the right path to teach you. Hey, you made a mistake. What are you gonna learn from it? Let's get back up and keep going and stand up eight times. You got, you got knocked down 10 times. Make it 11. It's not a failure unless you fail to learn from it. Indeed. And that's probably where the sweat more, bleed less in battle comes from. Yeah. Yeah, it's, that's the, the, the, the training aspect of it. You, uh it all is a lot of these things are kind of the same. It's you imagine the parable of the nine blind men and the elephant, they just look at it from different points of view. Um The sweat more battle means, you know, I'm at the gym, I'm training, I'm training, I'm training, I'm training, I'm training, I'm training to the point where I'm tired when I used to train. I used to fight, you know, we spar for a three minute round and then bring in somebody else and I spar, you know, Dan for three minutes and then end of the end of the second round, I spar Sherman for three minutes and in the second round, I bring Larry in. So I'm fighting four different people. I'm dog tired and they're bringing in somebody fresh every single time. But I'm sweating I'm tired, I'm panting and my teammates were telling me, don't give up, don't give up, don't give up. Because now when it's tournament time and I'm fighting the guy who I'm training with, he didn't fight for people when he was training, he fought only, you know, like once or twice. So by the time it's time for me to, I remember when, when I was in, in, at Howard we would show up in our Howard training uniforms and we'd see our, our, our opponents just go, oh, you, you, you're, you're from Howard because they knew we had a reputation. You know, what, what weight class do you fight? Oh, you're heavyweight. Ok. Good. They knew I was, they weren't fighting me because they knew that whoever they had to fight from Howard was gonna fight hard, harder than you ever fought in the life. And we used to train hard, like 34 hours every day, Monday through Saturday, not on Sunday doc on Friday and Sunday. But we trained hard and I took that same principle of training harder to studying harder. And I remember very in one particular lesson. And, uh, uh, it was my second year of, um, hold a second, my second year of, uh, of medical school. Uh, I was training on the transplant team with a guy named Louis Porter at the time I was first in my class, I realize, ok, this is not much competition between me and Louis. I first, Lewis is not first, it's not gonna be a big competition, but day one, day one and Lewis was a powerlifter. He used to eat a lot of, he had arms bigger than your thighs and he showed up to the first day of the rotation with a stack of milk cards, a stack of milk cards that were brown while I was home sleeping. Lewis was like, I am not gonna be outworked by that guy. He was taking his no cards and he's going over, going over, going over. There's no cards. So day one, he had been more prepared. He had been preparing himself more than I have. So you have to do that, not just in martial arts but also in surgery, you have to be ready because when you are in the operating room, you don't get a second chance, or more importantly, your patient doesn't get a second chance because when you screw up, you know, it's ok. I screwed up. But when you screw up, it's also on the patient. They are personally paying for your failure of commitment and to excellence. And that and that is it, isn't it? It's the commitment, commitment to excellence and attention to detail. Yeah, with where there is no commitment to excellence. There is no excellence indeed. So wax on, wax off. We're all familiar with this from the karate kid movie. I like that. Yeah. What do you mean? How do you translate that to surgery. Well, actually, um, the thing I liked about it didn't really appreciate it until later on. Like, I have two boys and two boys and they trained on a keto and it is hard to get someone to learn how to fight when you have fear. And Mr Miyagi, um, did a wonderful job of training Daniel how to do the basics without fear. So, instead of like blocking, like, 00, you know, he just had him doing this, I'm doing this and he got it so smooth and effortless that he was able to do this without conscious thought. So when it came time to actually block, it wasn't, oh, it's just block. It made it smooth and effortless. So the persistent and consistent repetition of the basics under low intensity. And I like how you described it having low fidelity models. So learning to fight under low intensity, under low fidelity doing the basics even when I was a white belt, putting your hands on your hips and just walking back and forth doing those basics to the point where you can get them where they're smooth with low fidelity and low risk and low intention. That way when we start start doing with more graduated responsibility, it doesn't become, you're not frightened, you're not scared, you're not, you don't, there's no hesitation, you can do it effortlessly because that's the whole point of mastery is not to do it well, but to do it well and effortlessly. Anybody can do it well, once, let's do it well and effortlessly when it counts right now. That's where it, and that, that comes from consistent, persistent practice over and over and over again. And it's just the basics and that, and that's it, isn't it? It's attending to the basics over and over again. Wax on, wax, wax off. Yeah. People, people get bored with that, don't they? They do, they do, they get so bored with it. They want to do the fancy stuff, but you can't do the fancy stuff. Like if you look at Lego brick, a Lego brick is boring. You know, it's, it's dull, it's boring. It's got six sides, it's got three bumps, it's boring. But when you put them all together with initial Lego bricks that look exactly like the same Lego brick. You can make some anxiety but you have to have a perfect Lego brick to fit together with a perfect Lego brick to fit together with a Lego brick in order to do anything consistent. So, you know, that wax on, wax off of just doing it, doing it, doing it and understanding that the basics are all right. Even though it's not exciting, it's not thrilling. I mean, if you look at the analogy of a Zen Garden, uh Zen Garden, you know, a Japanese Zen Garden, it's got the pebbles and the boulder and the, and the trees and it looks wonderful. And looks beautiful. But it takes hours of meticulous boarding work, just boring work, pulling the rake in a straight line, you can't rush it and do it overnight. You have to do just the basics consistently. And if you do the basics consistently, it adds up to something that's wonderful and fancy. So what would you say, Melvin to somebody who would say, would say, oh, this is boring, then quit if it's boring. But because you're, you're distracted, you're distracted, you're thinking the exciting thing is the important thing. The exciting thing is not the important thing. The exciting thing is doing the right thing. They're distracted looking away like what Yoda said, you know, uh never your mind on where you are, you know, always your mind in the future. You should focus on where you are right now doing the right thing right now for the purpose of doing it, right is how you get to do the fancy things later on. If you're just looking at the horizon, you're not gonna be paying attention to where your foot are going. I mean, you know, like I said, eating of an elephant starts with one bite, the climbing of a mountain, uh is done one step at a time. If you're looking for something exciting, go do something else because ideally in surgery, we do not want surgery to be exciting. We want it to be very boring. We start and then we finish. We want warfare to be very boring. We start and then we finish and all the enemies are down below us because our plan was executed smoothly. If you're looking for excitement, find something else. Excitement is the concept of, oh, it's something new coming out. I don't mind. And now we got, oh, no, this is the basics. This should look like you are doing this effortlessly. If you've seen someone who's masterful fight, they look bored and, and that's it, isn't it? Slow? Is smooth and smooth, is fast. Yeah. Yeah. It, it, it very much so and it's, it's by going slowly, it allows you because anybody can do anything quickly. You can do it quickly and it looks like you've done it well and it can mimic uh proficiency. Like say for a front snack kick could do it looks like you did a nice fun snack kick. You did a front snack kick not selling did not so nice. Your precision may have been off, your accuracy may have been off. Your power may have been off. But by going slowly, you are able to, to, to synchronize, you know, your body motion and your thought process and you're able to isolate all the individual things that go into it. Even I know you trained in NYO. If you do any to Tommy cutting, you're just not whacking with, you know, with 333 ft of, of steel. It's, it's a, it's a extend out, you project your force past it, you pull back and then you flick your wrist and drop your weight to make a nice cut. It looks like you're doing it in one smooth motion. But by going slowly able to break down and see all the individual parts that make it happen so they can all cascade as in one motion. Like if you look at piano piano players is the same thing. You'll start off with du du du, du du du du du du and then you'll get faster. And then my wife plays my wife Gabriella, not Gabrielle Gabriella, uh played uh with sotto and it's just the fastest thing I've ever seen in my life. And, but she started off going slowly and by going slowly, she was able to make certain all 10 of her fingers were moving and her both feet were moving well, and as she got proficient, she removed the excess space and you said like, oh, you talk about the dios. So by, by going slowly, it allows you to understand all those processes. So they occur in one smooth motion. That's true. Whether it's a CAA whether it's a punch block or even a cervical procedure. Because if you're doing it haphazardly and you skip a step or you or you exclude a step, it's just gonna take you even more to go backwards and include it and then it just looks, it looks haphazard. Indeed. It does. You can see it, can't you? Yeah. Yeah, we are. And, and, and, and as, as we have described in the black belt Academy, it's the set up and understanding the, the transition of movement to another. And, and certainly when doing cars, only once I got my black belt did I start thinking about the transition from one posture to another to make it smooth. Yeah. And that's the one thing about half. Uh, but people think the black belt is the ultimate, but the black belt is only the first step in learning how to learn. It's not, you can't see until you've seen. So once you start to see ha this is how I can make it better. When I step, I should step with my foot, turned my heel pointed towards my opponent to set me up for the next best thing I should, I should crouch my knees. The same thing in surgery. The, it's funny in my operating room they say, well, doctor M your sur go so smooth and with the team doesn't have to leave and go get this equipment or that equipment. It's like, well, how are you doing that? That's cause I'm here 15 minutes, half an hour before the case get everything I need. He said, well, how do you know what you need it? I don't know what I need. It's on the consent form. The surgery I'm gonna do is on the consent form. So if I know I'm gonna be doing a breast reconstruction. I know what I'm gonna need. I know I'm gonna need five A B DBS at the conclusion of surgery. II need four drain spon. I need for the littlest things they all add up. So it's, if you follow it through then you know exactly what you need. And I think there's a problem that a lot of people have and even some novice martial artist, it's the visualization And until you know how to visualize it, you know, you, you really can't, can't, you know, process it. And um II used to give the example of the uh uh the I know we have, we have, we have uh uh people listening for all over the country but the national anthem, United States national anthem, you know, everybody kind of knows, at least everybody from the United States. So that, oh say can you see and then you get to the part you don't know. Uh they hum the part they don't know. But when I make you teach it, then you have to go look at it. Oh well. So probably we have and then you go to the next part and because you, it makes you go through the whole process and what you're doing is actually visualizing the entire thing and you could take it from the beginning to end and the evolution becomes clear because everybody knows what to do. They should know how to do it smoothly. All you do is just walk yourself through it and you'll figure it out and, and this is briefing, isn't it briefing in theater? So everybody's on the same page and know, knows where to go. I also also like in martial arts, it's technique before power and speed and you've got a chapter on force has no place you like to elaborate the, the uh for play. I mean, even though the concepts are kind of a little bit different, the technique before power, um power comes from good technique, you can always add power, but power comes from really good technique. Uh like my, my, my thirteen-year-old son can hit like a brick, can hit like a brick because he's, I've trained him to u to hit from the ground. But the force has no place comes from the concept that people think surgeons operate, you know, uh a, a surgeon is a scalpel. If you don't have a scalpel, what are you doing? And the force has no place means that OK, you're not operating when you operate, you're operating before you operate, you're taking a good history, you're getting good diagnostic studies. You are, you are reviewing the best literature that's available for this particular procedure so that you just don't go rush in thinking that you're operating and all you're doing is causing more problems the same thing. Whereas, um whereas, you know, if you have a, if you have a hammer, all the world's a nail and you're just trying to kill a, kill a fly with a hammer, you know, you'll kill the fly, but you also break up all your furniture at the same time. So the, the skillful application of force is the most important, not just force, but the skillful application of force. You know, it's like a fencer. You know, we have, we uh watching one fight and this is one great fighter. His name was TJ. And he went in with a hatchet and fought another guy who uh was a fencer and the guy was just swinging his hatchet, he was throwing heavy bombs and, and um what was the guy's name? Uh Lewis, not Lewis. Um uh J Jamee, we just going in and just hit and just hitting him, just tagging him, you know, tagging in his shoulder, tagging in his chest, tagging him in his legs. And by the end of the fight TJ was doing great was limping and he never laid a hand on, on Jamee because he was going in with a lot of force. And sometimes you think that that's all that's required. Overwhelming force when all you need is just the right amount of force in the right place at the right time and jam just, just pieced him up, just get and not even hard punches like one of those pop and just, you know, one of the eyes pop it, it, that little bit of minimum force at the right time is what you need. And sometimes for some people it, it's just taking good history. It's getting as, as we, we say in the Black Belt Academy, it's decisions before incisions. So, once you, once you made the incision there's no going back. Oh, I'm, I'm stealing that one. Well, you talk about a bloody nose. What do you mean by the bloody nose in martial arts? I know what you mean. But, and it pertinent to surgery, uh, uh, the bloody nose is, is, is, uh, everyone is allergic to pain, everyone allergic to pain. But, but there is, there's no more sincere teacher than, than pain. The, the, the hard part is how to, you know, pain is like medicine. And my mom use that medicine very, it's very, very liberally to, uh, to get me to where I am today. And so I think she required, I required occasional spanking when I was younger to, you know, to, to pick up my toys or to, to do the dishes or to not leave a mess. And because that I'm not in jail and I have a good career, but it was the, the precise amount of, of, of discomfort to encourage me to go in one direction. And it is hard to, to teach someone unless you personally experience some discomfort from not learning it. So when you're sparring and you know, your spring get used to, you get tired, your hands down it's to keep your hands up. Hands, go up for a second and then you get tired, your hands go down. Yeah. Keep your hands up and they keep telling you that. But as soon as I jab you right in your face, oh, then you know your hands are up and then you forget that lesson and then hit you a second time and then your hands up and I get you after that, your hands are up the whole time because you do not like getting hit in the face and that, that pain of, uh, of getting of, of that is personally delivered to, to will, will, will crystallize the information that you need very firmly in your brain. So when you forget to check someone's H and H before surgery and man, I should have gotten the person type and cross that pain will tell you not to make that mistake again when you, um, forget to read or you or you or you, um, uh, or you, you know those personal failures that add up. You know, you have to be honest with yourself about how you participated in receiving that discomfort. So if I don't keep my hands up, I'm gonna get, I'm gonna get stole on my face. If I don't prepare for surgery ahead of time, I'm gonna get caught by my attending. He's gonna ask a question. I'm not gonna know the answer. If I, uh, if I fail, it makes it personal and it's the, the whole bloody nose goes back to the parable of the chicken and the pig. And I don't know if, you know, have you heard of the parable before? I have not. No. So when it comes to, to breakfast, we have the chicken and the pig and the chicken contributes to breakfast, the pig is committed to it. So, are you, you know, when it comes to surgery, are you contributing or are you participating? Um, when you're in the ring, you're 100% participating in all of the pain that you feel will be directly on you. Did I not train hard enough? Did I not have my mind focused well enough? Was I distracted? All those things will come directly on you and in surgery, unfortunately, the pain that the patient perceives is not gonna be on you. You have to really be aware that when I screw up, I have caused the patient significant comfort and morbidity because I was not as good as I could have been. So take that lesson and be better, be better than you were yesterday. Learn to be better. And you know, be honest with your, your mistakes, be honest with your failings. If we did everything perfectly, look at what you could have done better. That's a solitary lesson. And I like the way you started the chapter off. Everybody has a plan until they get punched in the face. Mike Tyson. Yeah. The hardest hitter. But that is true. So, what would you recommend a, apart from this goes down to the seven piece of surgery proper prior preparation prevents pee poor performance. Yeah. And that, and that's your bloody nose then. Yeah, it is, it is, it is, um, it is, it is consistent training and you can prevent, you don't have to get a bloody nose. You know, that's, uh, I'm not recommending everybody gets a bloody nose. I mean, this conversation in the operating room, you can always tell someone who hasn't been punched in their face and they probably should have been, but you can avoid the bloody nose by being prepared by putting in the work ahead of time. Yes, I'm tired but I'm going to put in that work and I was fortunate that I had Taekwondo at my school and Taekwondo was the same time every day. It was from 630 till 8, 39 o'clock, if you're on the team, sorry, from six to it was 6 to 8 and nine o'clock if you're on the team. So I knew that at six o'clock get ready to be, I had to be in the gym and ready for, you know, for that time when, uh, when you're training, you don't have th that same kind of rigid. I'm sorry, when you're in your medical school training or your surgery training, you don't have that same kind of rigid thing. So you have to make a time schedule for yourself. So that, you know what I'm done, I'm done with work and from nine o'clock to 930 I'm gonna practice my not time, uh, from, you know, 930 to 10 o'clock, I'm gonna practice my suturing, uh, my suturing and just pass the needle, pass the needle, pass, needle, pass the needle. And by, you know, by that repetition you're going to get more proficient, you may not do it perfectly, but you're gonna be a lot better than the person who never has. And this is my biggest gripe about inconsistent training is that if you train inconsistently and then you go in the ring to fight and now you have to learn how to block kick or punch, you're gonna lose because you're focusing on how to block kick or punch when you should be focusing on fighting. And if you train surgically how to ligate anastomose, use your scissors, use your forceps, well, then you can focus on actually how to do the surgery, not how to do the tech, the individual technique portions. You know, it's, it's, it's, uh, it's the same thing as playing a musical instrument if I had to figure out how to, how to like my son was, uh, was taking Trump. And so I had to figure out how to form a Bu Sure and make a uh ad note, then I can't play ad note because I'm focus on doing that. So you have to work on the basics. So when it's time to fight, when it's time to operate, you can execute it smoothly. But that requires work outside of the operating room. It requires work outside the dojo, it requires work outside the ring cage. A and, and this comes down to the 10,000 kicks then. Yeah. Yeah, it does. It, it, it uh one of my favorite films is the 30th Chamber of Ching. Um And this is like a seventies classic Kung Fu movie where the uh where the young hero and I forget the hero's name. Um You know, it's always, you know, his, he gets, he gets hurt and he runs off to the shallow tip when he wants to train, he and he says it with his mouth out of sync and he trains in each technique, but he's doing it consistently persistently. And one thing I like about it is that he showed there's an element of diversity in each of the chambers. So like, for instance, he's carrying buckets of water, but he has knives on his arms to make sure that he keeps his arms straight and, you know, keeps it, you know, keeps him up when he's practicing with the bow staff. There are little spikes in the circle that he's doing so that he's, he's focusing on doing well. So it's, you're doing consistent practice, persistent practice, but a little bit of uh discomfort makes certain that you do it. Well, you just don't do it sloppily. You don't do it Lasi you're doing it well with focus cause if you're not focused then you have a little bit of pain or, or bloody nose but you have to do it over and over and over and over again. Not so that you can do it right. But so you can't do it wrong. Agreed. And, and this is the mindset of martial arts that really applies to surgery that and preparing for theater visit it. Yeah. Absolutely. A a absolutely. And, and it is, it, there's more to mar when you asked me about what was about the book, uh this, there's a martial arts life, there's a boole way of doing things. That's a mindset that you can't, I can't sum it up into one thing. And unfortunately, it takes being in the dojo, being in the gym and sweating and bleeding and crying. If you haven't cried in the dojo, you're not training hard enough to understand that, that mindset. And once you actually in the whole book, like the whole book was written, describing values. You know, this, my book is even though I hate to say it because it sounds heretical. My book is like the Bible describing values. I like the Black Belt Surg Academy because it's actually the Ministry of, of uh you actually have AAA Natural Program, but you have to have a, a uh uh the mindset. So you can apply the structure. So then you can apply it not just for yourself. And then one of the hardest chapter I had to write was an ego chapter. Um because you start, you think you're doing it for yourself. And after a while you realize, wow, I'm a selfish jerk. I'm not doing this for myself. I'm actually need to do this for my, I need to be better for my patient. I mean, the same way we learn martial arts. It's fun to learn martial arts until barbarians are at your gate. And you realize that you need your martial arts skill to protect your family from the uh the barbarians. And then it's not about you being the greatest warrior. It's about you protecting your kids, you know, from the Vikings or whoever is or or whoever is at the uh at at the gate. So and, and as a surgeon, you're there protecting your patient, you are there protecting it is not about. And that's the bad thing about surgery is everything is focused with surgeon doctor. What do you wanna do this? It's you, you, you, you, you, you, you and it becomes so focused on you that the average person tends to believe, mistakenly believe this is about me, me, me, me, me, me, me, me, me, me and you get so focused on being me. You forget that that priority is not on your ego or your personality, it's on the patient. And when you work in the health care, the people who are helping you, the nurses, the nurse practitioners, they can tell when the focus is on the patient and not on you. They can, they can tell. And all of a sudden if you have that focus on the best outcome for the patient, guess what, your, your, your team is gonna do, they're going to meet you at your level. But if you're focused on you, you, you, you, you then guess what they're gonna do, they're gonna focus on that level. And then when you fall, when you fail, they're gonna laugh at you because they were, they were, you were, you were self self-centered and that's what you say. There's no, I in team. No. And, and the, and the surgeon without a anesthetist, a scrub nurse, the A DPS. Everybody else in theater is like a fish out of water. You can't do it by yourself. Absolutely. I tell every single one of my team, you have two jobs. You have two jobs in this operating room. Number one is to protect the patient from the surgery. And number two, protect the surgeon from the surgeon. I like that. I do like that. Yeah, I II often and Bruce Lee is famous for saying B like water. Yeah. What do you mean by b like water? Uh be like water because we, I talk about ma C mine like water. Yeah. We tend to think square peg square hole, it, it's just a human nature to think II have a problem and II need a solution. Um And when you think square peg, square hole, all you can see is a square hole. And then instead of looking for anything else, you're looking for a square peg, you know, you're not looking for uh a, a peg that may be round, that you can turn in a particular way. I mean, sorry, this triangular you turn a particular way you could fit in. But when you have a very rigid mindset, it stops you from appreciating other other things. And uh the hard part about being like water is that it is hard to be like water cause I'm not water, even though I'm 80% water, I'm not water. I'm more of a amorphous semisolid. But I need to learn, like say for instance, water could be hard like ice. So I need to learn to be hard like ice and I need to learn to be, you know, fluid like a liquid like water itself. I need to be um gasses like steam or I think gasses like a cloud or hot like steam. I need to be forceful when applied under force. I need to learn all of those things and then I need to let it go and water can be all of those things. But it's only the thing it needs to be when it needs to be that way. So if you are a surgeon and you're thinking cut, cut, cut, cut, cut, cut, cut, cut, then every single problem is gonna be solved by a knife. Oh Hold up. This person has a surgical indication but they may not have a surgical need. You know. So you have to have a flexibility in your mindset. But in order to have flexibility in your mindset, you have to learn everything you have to. You know, when Bruce Lee says, be like water, if you take water and you pour it into a pot, it becomes a pot. If you pour it into a vase, it becomes a vase. But you gotta learn how to be a, a vase first, you gotta learn how to be a pot first and then you can kinda let it go. You know, my, my martial arts instructor, he, he uh go uh since like Gordon Green, he fights like a musician, you know, and he's like, you know, little a note b note and a little syncopated mode. But he and I, I'm not a musician, so I have to learn it rigidly. And then eventually I can start to free uh to free to freestyle and, and to move on. But you don't, you really have to avoid a rigid way of thinking because a rigid way of thinking. A perfect example is a rigid way of thinking. It can, can give me an 85% success rate, which sounds phenomenal in 85% and on scores. That's a, that's AAA B or A B plus depending on how, how you graded an 85% success rate is great. However, an 85% success rate also is Russian roulette one bullet. Um um 11 bullet with, with five empty chambers is, is a 15% failure rate. And are you willing to accept that? 85% success rate knowing that it's a 50% failure. And if your mindset is on ego and on me, me, me, me, me, well, guess what happens if I'm wrong? Nothing. But if it's, if, if, if it's you in Russia roulette, are you willing to take that 15% chance? So you have to get rid of that rigid mindset in order to think of what is the, just, just the best outcome. So sometimes it means doing something that's nontraditional. Sometimes it means doing something that's innovative. Um, uh, because ultimately the patient has to have the best outcome. And if the square peg works in the square hole, great. Well, I think the other important thing is to remember time, any decision is not finite in five minutes time, it could be different because the context is different. Never assume when you go back and reassess. Yes. Yes. And the important thing in surgery is, mm, admit, you don't know, walk away, go back and look again. You might have a better clue. Absolutely. My, my, uh, my, uh, my, uh, the only acceptable answers in my operating room are, yes. No. And I don't know, uh, people you love to use the word should. Yes. Yeah. Which I, II detest the word should. I mean, whenever someone comes to my, or r and they go, oh, it should be ok. You can see my team just shrink because they know a lecture is coming. You know, that should give you the, when someone says should, they're giving you an answer that makes them not look bad. That makes me happy, but they have no data as to whether it is correct or not. And it's like saying is my parachute packed, ok? It should be, it should be, it should be, you know, maybe do you love me? I should. Huh? You know. Yes. No, I don't know. But if you say, I don't know, you have to follow it up with. I don't know, but give me a moment, let me look into it and I'll get back to you. That's correct. Fine and saying, I don't know, let's go up ego saying yes means not only do I know I could point to the data and the facts that back up to what I don't know. Saying no means he just definitely know. And I could point to the data facts that say no and I don't know what it means. I have enough confidence in myself to be able to say, I don't know. But let me go back and look at it and you'll have an opportunity to learn. Indeed. I'd, I'd, I'd add to that and say, ok, is a dirty two letter word and fine is a filthy four letter word. I should be taking notes. So what's funny is in the back of the, uh, the book, there's a thing called surgical aphorisms where II, II give you quotes and, and then I II save them because they, they're wonderful. Sometimes they just sum up everything in the right, you know, OK. Is a, is a two, is how do you say it again? OK. Is a dirty two lettered word and fine is a filthy four letter word. Yeah, that made up in the uh uh in the back of uh the way I can see this. II II love them that you get father with nice words and a gun, the nice words to learn how Capone. I'm not quite sure about that one. Yes, that's very American. So the other chapter is your body is your temple and to be sharp, you have to stay sharp. Yeah. Yeah. That chapter was written by Wendell who is, you know, uh Doctor Wendell Goins was uh my uh senior instructor when I was training and uh he is, he's a couple of years ahead of me. And so he knows very well that uh what happens if you neglect your body. Uh I, unfortunately, uh and I have to add it's not only just your body, but it's your body, your mind and your spirit. All these things need, need preparing uh from poor posture in the operating room to causing back and neck issues to, to overworking yourself and becoming emotionally drained uh to neglect in your family to even just being burned out. I can't do this anymore. You know, I II can't do this anymore. In fact, one of the, one of the reasons I went from cardiothoracic surgery into plastics cause I've spent seven, no, four years of medical school, seven years of general surgery going 100% nonstop. And it wasn't until my six year general surgery. I say, oh, I II can't do this anymore. I ha I have to take, I have to slow it down and, um, your body has, you cannot serve your patients. Well, I gue I guess the best way of saying you can't c for an, an empty cup. So you have to maintain yourself with good, uh, you know, diet, normal diet and exercise, good rest. Um, good posturing, operating, wearing comfortable shoes, wearing elastic, um, um, uh, compression socks. Um, you know, not, not over imbibing in coffee or, or, or alcohol. Uh At least not until after class, not after after surgery. Uh, all these things make a difference cause a machine that is well maintained will perform longer. And the sad part about surgery. Well, the sad part about martial arts is that as I get better, my body gets a little less good and I can't. So my experience is if I could put, take what I know now and put it back in my 20 year old body, I'd be a monster. Be an absolute monster. But I got a, I've got, I've got a 55 year old body so I can't do things I need to know. But as a surgeon, I can extend that a little bit longer. So if I, so my surgical skills when I was 30 are, are not as prodigious as they are now like at a 55 year old, my power levels are just well over 9000. Um But as I get more and more uh experienced, my body will fail me with time like, you know, hell, I'm, I'm wearing cheaters now. I used to be able to operate and not use loose. Um But you, the, the experience that you have is invaluable and unless you maintain the machine that is you, then that experience will be lost. So you have to, you know, do the basics, eat right? Exercise, sleep well, you know, hug your loved ones. Um and actually get hugs because your mental health is, is very, very fleeting and you will not be of good service to your patients if you are not well maintained. I totally agree. What do you mean by will you walk with me? Grasshopper? Uh cause what we're saying is to our trainees out there globally. Will you work with us in the black Belt Academy of Surgical Skills? Yeah. Yeah. This one of the, you I remember I talked with doctor um the uh I got my black belt that Friday. And then Monday, he asked me to teach which was just mindblowing II. You know, I used to used to tutor which is not the same thing as teaching, it was mindblowing that uh having to teach. And as you spend more of your life teaching, you gain a greater insight, you gain such, it's more much more than you see a lot of old martial arts become kind of philosophers. Uh Mori Mori Ua and the founder of Akito was a devastating fight. But as the years went on, he realized that I don't have to destroy every opponent to be a successful fighter. So as you spend more and more years teaching, you spend more and more years learning and uh the ego part of martial arts is I wanna be a great fighter and then you get to be a great fighter. And then what? And then you have all this wealth of knowledge and experience and you wanna share it, you wanna water the flowers around you. You want to watch other people grow and the greatest joy is teaching and watching other people grow. And sometimes you can share those experiences and but to see it's one thing to do something great. But then to watch your student do a great, oh, it, it's a drug. Ok. OK. So we've got some interference at the present. Uh uh Briefly. Here we go. You're back. Good. So you're 10 tenants of Surgical Bushido. Yes. We said commitment to training. And that was at the top of everybody's report. The second was attention to detail, thoroughness with tenacity. That was also at the top. Your third one is perseverance with humor in dominant spirit. Only nine people commented on that and only 41 mentioned Tumor. What, what would be your observation? This is third in your 10 tenets. Uh you know, they're listed, but they're not listed in importance. I think if I had to put anything in importance. The first one is just sho which is just the hard work. You know, it's the main, the main thing, the maintenance of your, of your skill level. But I think the responses are a reflection of who's being asked if you ask the novice of what do you think is important about surgery? They're going to say attention to detail. If you're gonna ask someone who is more mature, they're gonna say compassion. It is the most thing. And it's, and it's one of those things that when you're learning, you don't see until you see, you don't realize how important compassion is until you watch someone suffer. And then, wow, that part, I didn't do that. Anastomosis. Great. Now, this person has had septic shock and, oh God, you will, you will lose a night's sleep because you've made someone suffer. And so, you know, your answers will, will vary depending upon where you are in, uh, in your experience of, of the surgical field. And none of them are, are, are unimportant. Uh, none of them are more important. But if I were to say to someone who's starting out out, I'll say start off with a shoe heel, just hard work consistently. Learn the basics and be persistent. But then eventually you will go to, um, eventually you'll go to, uh, other, um, you know, once you learn how to do one thing, you'll have to learn how to do something else and you'll learn that, um, um, that, that commitment to excellence is more important. And then as you master that one, you'll go to the next one. So all these are important, but they still form a global thing of where you wanna be and sometimes you'll be better at, uh, at, uh, like, say, for instance, I, whenever I do things with fighters, I tell them have fun, you know, whenever they're going into the ring, they're getting to an ass kicking contest and somebody's gonna win. Don't worry about that. Have fun. And the way you have fun is that you're so prepared, you're so well prepared for the fight. By the time the fight the bell goes ding, not do but have fun. I'm not worried about losing because I've already won the fight already in my head. I'm gonna go out there and if you're having fun, but that humor doesn't come unless you're prepared. If you're just going there completely unprepared. And I'm putting your ring with Francis, uh, Ganu, you're not gonna be doing having fun. You can be terrified. Indeed. Indeed. And I think at the end of all of this, as you say, your book is insightful and it extols the virtues and values of surgery. But we are all here for our patient. And the other thing is you're only good as yesterday and today brings more challenges and as in martial arts, we should never stop learning. And when I'm training and I'm sure with you Melvin going into the dojo and going back to the basic, you're learning something new about your K but also about yourself each and every time and you take that forward. Yeah. The, the actually the one thing, the one thing that's selfish about teaching is that the student is getting something out of it, but I don't think the student realizes how much more the instructor is getting out of it, especially when you have that one student, that one student is great and you're just bouncing ideas off of them and you're getting more out of the interaction than he's ever getting. You know, you're learning what works well, what works well for this individual works well, works well for that individual and it becomes, even though it seemed like it is a selfless endeavor, it really is a selfish ivi of, of, you know, when I grow flowers, I love watching flowers grow. I love large and a beautiful flower. So it's, it's, it's um it's, you know, when I say learning never stops, you know, you're by teaching someone else, you're learning new things just even about yourself. I think that also sums up why you got Teacher of the Year award because it's a philosophy and the way you do things and teaching is a bidirectional thing. And like you, I find I learn more from the student. Yeah. Yeah, I must thank you very much. Indeed, for your time. I am so pleased you have joined the Black Belt Academy and I look forward to growing this initiative in taking this philosophy forward and we must have another conversation with Wendell, with Chris, with John all the Black Belt senses or the Black Belt Academy to further explore the values. I'd like to thank our audience for joining us wherever you are in the world. And thank you Gabrielle and med all for making this happen. It's amazing that internet connect us all on a single point in time across the globe. I look forward to seeing you next week. Thank you, Gabrielle. Thank you, Melvin. Thank you, everyone.