12 x 12

Speaker 1OK, more people will join. I'm gonna start it up first. Um, I'll introduce our two authors in a 2nd. 1st, a little bit of housekeeping. I am Doctor Ira Hershenbaum. I am the editor of the Journal of Orthopedic Experience and Innovation. Um,

Speaker 1We, um, I also am the chairman of Orthopedics at Bronx Care Health System in the South Bronx. Um, CME is available for this article. Uh, you just go to Joey.pub, click on the article that you want to get CME. CME has a nominal $50 charge from the Current Concepts Institute.

Speaker 1Additionally, you'll find future Journal Club dates on the events navigation tab on Joey.pub.

Speaker 1Uh, finally, we're doing a very large two-year project on Tribute to Titans, uh, which all of us have had mentors in Orthopedics, and we developed an Artificial intelligence survey system that allows you to record and automatically transcribe your memories and vignettes of people who were mentors to you. And that is also online on the, on the system. You just go to the events tab.

Speaker 1And finally, if you have a question, just place it in the chat, and I'll ask you to unmute, and we'll do that. Um, I am going to, um, introduce now, um, 22 authors of what is really one of the most popular articles.

Speaker 1In the last 5 years in any journal, um, the article being 12 by 12 obtainingru OR Efficiency with radical time, transparency, and Operational excellence. I'm gonna introduce Charles De Cook and Jeremy Stanton. I'd like you guys please to say a couple of things about yourself and take it from there.

Speaker 1Jeremy, you wanna start?

Speaker 2Sure. So, um, yeah, my name is Jeremy Stanton. I've been in practice for about 12 years, uh, trained at the University of Louisville, um, originally practiced in Kentucky, but then moved to the Atlanta area and I've been here for 7 years, and, um, you know, it's funny, I had no idea what Total Joints was going to become when I was a resident. Uh, I feel like we're at this place and

Speaker 2The history of Total Joints where it's absolutely fascinating. Uh, it's, it's been a lot of fun and I look forward to see where else it goes to.

Speaker 3Awesome. I'm Charlie De Cook. I'm uh 12 years here in Atlanta. We have an Arthritis and total joint program, uh, which consists of 10 total joint surgeons. We have a joint-only practice, so all we do is total joints. Um, we do them all in the Surgery center, so to give you an idea, we do about 98% of all our primaries are done in a Surgery center or in an Outpatient setting. So, that's a little bit of our background.

Speaker 1That's great, that's great. So, um, the article, uh, talked about

Speaker 1Extreme OR Efficiency, radical time transparency. How did you guys first get interested in this concept of Efficiency and time management? Because you really took a lot of Business principles that are in Toyota and elsewhere and just ripped them into the OR. Yeah,

Speaker 3that's a great question. You know, well, first of all, you know, everyone has to understand that this is a Business, right? So,

Speaker 3You know, we all want to be more efficient. Uh, you know, I don't think Jeremy and I are any any bit unique from that perspective. We all want to be able to do more cases in a day, make ourselves more productive. So, it started that way, and it started in the hospital and we said, well, how, how well can we do in the OR and how efficient can we become? And we had done pretty darn good. We became pretty efficient. We had surgeons coming to watch.

Speaker 3And say, gosh, you know, they didn't care about Jeremy and I, they, they, you know, we're average surgeons, you know. They're like, my gosh, you have the most unbelievable teams, you have assembled such a thing here, and, you know, that kind of got our wheels spinning of, OK, how do we kind of reproduce this for everybody that comes and

Speaker 3You know, can we kind of reproduce what we're doing here in Other places. So, that kind of got noodled around, um, really about 6 or 7 years ago. And, uh, it just morphed over time. And as we've uh kind of, kind of reconceptualized Efficiency in the OR we've, you know, tried to capture most of that, at least in this, in this entry article to kind of give people a flavor of, of where we think things can go.

Speaker 1Jeremy, how about you? When did you start realizing this was critical?

Speaker 2Yeah, I would, you know, it, it, some of it was just a, just a personal.

Speaker 2Effort where you're, you're, you're, you're doing a case and then you sit there and you ask yourself, why did I just do that stuff? Like, it didn't add anything to what I'm doing and you, you can sit there and start to piece apart, you know, criticize yourself a little bit, but also start pulling out the things that aren't necessarily adding anything to your procedure and it's just, just kinda fascinating to get better from a just an individual perspective. And then I would reiterate what Charlie said about teams and then you

Speaker 2You, you realize, well, hey, you know, I'm, my OR times are decreasing just from what I'm doing, and then I can add another case and then you start to develop teams that also get fascinated by what you're doing, you know, they realize that if you're doing a Hip and it takes this long and somebody else is in the Other room and it takes 2 hours, that, that there's something a little bit different there and then the teams start to develop, and it's a lot of fun, and then you can create an environment where people wanna be there, they enjoy it.

Speaker 2Um, they feel like they're doing something even a little bit bigger than she's getting a Hip or Knee done, and it, it's, it just starts turning into fun.

Speaker 1You,

Speaker 3you know, I think Jeremy kind of prompted a, a, a thought I had, which was, you know, we as surgeons are so isolated in our operating rooms, you know, when we, we do our fellowships and then we come out and practice, and we basically operate by ourselves the rest of our careers, and we kind of self-reflect on how good a surgeon we are, how good are we doing. And there's very little metrics we can use to really assess how good we are. We've got patient report outcomes, we got satisfaction scores, we got complication rates.

Speaker 3But beyond that, you know, how do you really assess yourself? So we start to think, well, you know, is time a fair metric? Um, you know, a very famous, uh, efficient surgeon once said, there's no such thing as a good slow surgeon, right? And I started, man, I started to think about that more and more, and I tried to think about all my mentors and all the people that I know as surgeons.

Speaker 3I thought, my gosh, that may be absolutely true. So, we started to think, well, maybe we can use time metrics to help assess ourselves and how well we're doing. So, you know, Jeremy talked about each step in your Surgery. You know, it's funny when you ask any surgeon, how long does it take to do a total Knee.

Speaker 3You know, they're gonna give you a general idea of what they think it is, and it's guaranteed to be a little bit shorter than, you know, what it actually is, because they're probably out of the room when their assistants closing the wound, and they have no idea it takes an hour and I don't know, 20 minutes or whatever, whatever it happens to be. So we start to think, man, oh man, we need to be a little bit more transparent.

Speaker 3About what we're doing and how we can actually improve. So we have fellows, and it has been absolutely phenomenal for us, because a fellow can, you know, start his fellowship and say, boy, it took me, you know, 50 minutes to do a total Hip. At the end, it takes him 35 or 30 or whatever the case may be, and say, how am I improved? And time is interestingly one of those metrics.

Speaker 3It is important to quality and is important to how well you can really master what we do as total joint surgeons.

Speaker 1Amazing, amazing. I mean, how did, what was, what's the first step? I think a lot of people are probably on here, and by the way, if people have questions, you can go to the chat, put them on, I'll leave a call on you or ask a question for you. What was, what was the first step? I mean, I don't say in my OR or our OR at the hospital, we'd like to get going.

Speaker 1What, like, we'd like to, I, I know we, we can go and visit you and that's great. We'll talk about that at the end. How do we get to visit you? But what's kind of the first steps, if there is such a, if even if that's a question.

Speaker 3I think the

Speaker 3first step has to be Pain.

Speaker 3It has to be painful to you, the process you're going through, right? And I think so many surgeons, frankly, Other staff can relate with this idea, and that is, gosh, I am so frustrated with what I currently am doing, right? I know I can do so much more. I know that it's such a waste of my time when I come to the hospital, and half the time I'm sitting around waiting for the next case. So, I think frustration is the

Speaker 3First key, right? If you're happy with what you're doing, if you're happy doing 3 cases a day, perfect, you know, I don't wanna change a thing that you wanna do, right? If you wanna do 2 cases a day, and you're a great surgeon, perfect, you know. Uh, but if you're frustrated, I think that's the first step, right?

Speaker 3And for us, it was frustration. And then we started to look at, OK, what are all the root causes of where can this thing go wrong? And we came up with this list of like 50 different things. We're like, oh my gosh, we can get screwed on every single step in this process, right? If you think about the patient journey from when you tell someone to

Speaker 3Come in to when they actually come in to when they get, you know, get ready in pre-op to brought back to the OR, back to the PACCU, back to recovery, back out the door. I mean, there's so many ways we can screw this up, right? Right. And, and the most frustrating thing about it is, it's often different. Like if it was.

Speaker 3One thing, right? If we told our patients, well, I need to tell them to come in 3 hours before the Surgery, and that would fix everything fine, or if it was just anesthesia that was the issue, or just this particular nurse or just a particular process, but it never is, right? So, you know, you just can't pin it down to one particular thing.

Speaker 3And uh that becomes super frustrating cause then you don't know who to blame in the process, right? It's like, gosh, you know, well, I can yell at anesthesia today, but it's really not their fault, or I can yell at somebody who didn't, who forgot to tell the next patient to come in earlier, right? So, if you don't keep track of time, just as we know, data is so important, if you're not keeping track of how you can change with time,

Speaker 3Then you're gonna have problems. So that was our concept of this radical time transparency. So, the first thing you have to do after you're frustrated is you have to measure time, right?

Speaker 3And, you know, it starts in your OR, right? You often think, well, anesthesia is slowing me down. Well, it's probably actually you because you have no idea as a surgeon how long you're taking, right? When we start to show surgeons, hey, listen, you're doing great. The Surgery will take you 40 minutes, but you've got an assistant that closes for another 40 minutes. That's where you're losing all your time, right? So you have to take it first to yourself and say,

Speaker 3How can I do better as, you know, myself, you know, what do I struggle with? You know, is it on a Knee? Am I struggling with the bad vagus knees? Is it hardware? Is it, uh, you know, exposure and Anterior approach? Whatever the case may be, you have to start really tracking individual steps in your procedure to really know how good you are, and then you start to look outward into, OK, my core team, how long does it take for my scrub tech to open up?

Speaker 3You know, and if you ask any surgeon that, they have no clue how long it takes to open up for a total Knee with 12 pans and all the rest, right? They just have no idea, right? No wonder your your turnover took 45 minutes because you only have a scrub tech, and one poor person helping out, and it's taking forever to open everything. So, you know, for us, it's, gosh, you gotta be aware of each step in time during that patient journey.

Speaker 1Jeremy, a couple of comments. Yeah, I would,

Speaker 2I, I, I, I would second what Charlie said about frustration and Pain, but sometimes when we're frustrated, we're hurting, we, we turn that into despair or, or just anger or, you know, we, we, we unleash on people. I think it's important to turn that energy into, uh, energy that then helps you solve problems. So, you've gotta be so frustrated, not that you give up, but that you then turn around and have the energy to, to, to wanna fix problems and start questioning.

Speaker 2What, why, why does this happen this way or why does that happen that way without, without blame, but just with constructive criticism for yourself and for others. Just looking at your whole system and evaluating all these little steps. Um, it, it requires some degree of vulnerability. So you have to be willing to just, just lay it wide open and go, uh, be willing to ask your assistant. What, you know, our, our first assist sometimes operate with multiple different surgeons and they see people do things better than what we do. You gotta be willing to say, what could I, what can I improve?

Speaker 2Um, and, and, and then, of course, if you're going, if you're in a hospital and you're trying to improve Efficiency, it's gonna take a lot of energy and a lot of time, a lot of persistence, and you're gonna, you're gonna feel like people get excited and things are gonna happen and you've gotta just keep, keep it going and keep re-energizing the conversation and not give up.

Speaker 1We have a question, um, from, from Mike Redler. Um, how are the messages of inefficiency received by people? Yeah,

Speaker 3yeah. Well, the great thing is if you make time transparent, you're not the one delivering that message, right? Oftentimes, you know, you confront the staff or something like that and say, boy, the circulator went and took a break there, you know, turnover times, you know, 110 minutes, and then, as Jeremy said, you get frustrated.

Speaker 3and say, hey, what's going on here? You know, I think if, if you stay independent of that, and you let data speak for itself, I think then it's received well. So, you know, in our Surgery center, in our hospital, it's been received tremendously well because everyone wants to do better.

Speaker 3Right? So, we never use it as a confrontational tool, or, boy, you know, this scrub tech takes an hour to open up a case or something like that. It's just never been that. I don't think it ever should be that. It's just a matter of fact thing, and everyone, you know, is motivated to do better, you know, that's what we're all motivated. We're not ultimately motivated by money. We're ultimately motivated to be part of something great, to take good care of patients. I mean, that's our true motivation.

Speaker 3And the scrub techs, the circulators, I mean, everyone just seems to, man, they, they love it. They look up on our screen and see the time, and they know exactly, you know, how they're contributing to the overall process, and they feel like part of the team. So, yeah, we don't want to make this a confrontational thing that never works out.

Speaker 4I think that one of the things I would question, Jos, is, is.

Speaker 4How, um, who, who's recording the data, and, you know, are they accepted as a, uh, you know, a, an independent evaluator, so they're not biased in

Speaker 1any direction.

Speaker 3Yeah, well, I mean, the first thing you have to note, every hospital system is tracking a lot of this data, right?

Speaker 3So, you know, the circular has to know when they're in the room, and, you know, when the incision, when the timeout, all these things. But the funny thing is nobody, it's locked away in some EMR for some meeting 3 months from now, so nobody can actually act on it. So, in our OR anyone can advance the time and the steps. So, we have little uh clickers that I wear stare.

Speaker 3inside. I've got my scrub tech does, my circulator does. So, as soon as someone hits the room, boom, clocked in the room, one timer goes up, you know, clocked in when incision, you know, and every step along this process is visualized for everyone to see. So everyone's kind of part of the game to make sure we're all, you know, keeping on track of this is the current step we're on.

Speaker 1You know, it's interesting, I'm gonna um show a video that uh uh Charles and Jeremy sent me. Um, first of all, I, I always want to say that one of my favorite quotes is from Anna Karenina, the first line, all happy families are the same, are happy the same way, and all unhappy families are not happy in their own special way. All good Business systems are good in the same way, and all bad ones screw it up in their own special way.

Speaker 1You know, so you're following some good Business systems. Let me show this video that was sent, um.

Speaker 1Um,

Speaker 1This one is, um, here it is.

Speaker 1Efficiency case. Do you guys see this?

Speaker 1Yeah, we got it.

Speaker 5OK. The second case is a 72-year-old female with left Hip LA. We're gonna highlight the Efficiency in the operating room for this Total hip arthroplasty. It's important to note that every team member is contributing to that Efficiency. Absolutely critical to Efficiency is making time transparent in the operating room. As you can see, this is the screen that we show during every case.

Speaker 5This screen is visible to everyone in the operating room and allows us to have radical time transparency. We know when the patient walks in the room, we know how long the Surgery took, and how long each step in the procedure takes.

Speaker 5It's important to do these tasks parallel and that series. We have a scrub tech getting ready for this case, we have others getting ready, prepped and draped, and the important time is from wheels in to incision. So in this case, the wheels are in at 7:25.

Speaker 5Noting that time from wheels end to incision is critical to a time Efficiency.

Speaker 5So I make my incision at 7:33 in the morning, and that's when the timer begins.

Speaker 5Each step in the procedure is time stamped so we can make time visible to all and improve our individual components of Efficiency. We subsequently rein the acid Tablet at 3 minutes in the procedure, and at 4 minutes we're placing the acid table or cup with a surgical impactor.

Speaker 5I'll bring you a fluoroscopy for cup position.

Speaker 57 minutes into the procedure, we're now runching the femur with the surgical impactor and because we track time during the procedure, we are able to tell how efficient our surgical impactor is.

Speaker 5Evaluating any new enabling tech Technology is simple when you're tracking time.

Speaker 5Note the time there at 8 minutes and 18 seconds. Now, I'm placing the trial components, placing the femoral head, and getting ready to reduce the Hip. The femur now took me 2 minutes and 21 seconds to perform that. Subsequent to this, I'm now reducing the Hip and bringing an X-ray to get an idea of both my leg length and offsets. Those are the images that I've obtained there in 8 minutes and 40 seconds into the procedure. I'm using uh enabling technologies to overlay those on top of each Other.

Speaker 510 minutes in the procedure, now you can see that I've placed my stem. I'm getting my final one trial analysis. I'm placing my final femoral head, and reducing the Hip for final fluoroscopic images. All implants are now in at 10 minutes and 39 seconds into the procedure.

Speaker 5And final fluoroscopic images are displayed in the upper left hand corner of the screen.

Speaker 5That should be noted, this closing of this total Hip bronthroplasty took us a total of 9 minutes and 59 seconds, almost as long as the total Hip bronchoroplasty did. It's important to note that as soon as that wound is closed, it's critical how long it takes you to get that patient out of the room, subsequently for that next patient. That's where time is lost, is when we're not.

Speaker 5Operating. So here are the final metrics. Wheels on the 757. That means it took me a total of 20 minutes to do this case. I'm comparing now my surgical Efficiency in this case to those of previous cases and my average times. We are routinely doing 12 cases by 12 o'clock in two operating rooms starting at 6:30 in the morning.

Speaker 5And we do this all with using enabling Technology to our advantage to improve our surgical Efficiency.

Speaker 5Thank you very much.

Speaker 1Yeah, so that is, uh, that is a remarkable view. There was a couple of questions, uh, that, that came up, um.

Speaker 1Um,

Speaker 1Do your scrub techs have a standardized setup from, from uh Liz Masceli? Your scrub techs have a standardized setup for the case. I'm sure you have an answer for that. Jeremy, you wanna

Speaker 2answer? Yeah, they do. They, uh, so we, uh, one, we have, we, we got together, all the, the surgeons operate our Surgery center.

Speaker 2and said, what, what's necessary in our pants? Uh, what, what, what do people need, what's not necessary? And we all came to an agreement that this, this is what I need to do, a Hip and this is what I need to do a Knee, and, and they, there's only one tray they have to find. They don't have to find this guy's or, or that person's tray and

Speaker 2Uh, and then the, the, the Mayo is, is standardized, yeah, so it's, it, it's a little different for each surgeon, but they, they know, uh, they've learned it. Uh, they've taken pictures and they've got them put away somewhere, so if they forget, they can always reference it, but, uh, it's, it's, it's gonna be the same every time, and I think that's, that's an important part. It's, it's a great question.

Speaker 2because it's an important part of Efficiency. You, you can't, can't be changing it up like, well, we're gonna do something different, totally different today, you know, we're gonna, we're gonna do the femur first and that's time on second or, or whatever, cause you, if you do that, then you'll, you'll, no one knows what, what step is next. No one knows what instrument to hand you or what to do next. So,

Speaker 1yeah.

Speaker 1It's a great question. Sorry, guys.

Speaker 3It's also so much easier to operate when you do it the same way every time, right?

Speaker 3So, one step has to become the next step. So, if I always grab a run juror, even if I don't need that run juror, I'm gonna take it from my scrub tech and screw around with it for two seconds before I hand it off, right? Just because that consistency teaches that scrub tech to do it over and over, you know, on our, on our wall, on our monitor, we have each step in the process laid out for those that need it. Now, our Surgery center, you know, we are fortunate.

Speaker 3Now to have all scrub techs that, you know, frankly, don't have to look up anywhere, they know what our next step is, but I think everybody can relate when you go to the hospital and you're dealing with, you know, a GYN, uh, scrub tech, you know, I just feel so sorry for them because, you know, I think patients and family members would just be horrified if they knew that, you know, here you're dealing with two people that never met each Other before, and here we are trying to operate together in the OR.

Speaker 3Um, so, yeah, having those consistent teams, I, I think is a super important part of this process.

Speaker 1What is the, uh, Lucas Nichol had a great question. Um, what are the actual systems we use to track time? I mean, there was a screen there, someone programmed that. I mean, what?

Speaker 3Yeah, that's something we designed. It's, it's a program we designed to help out our OR, um, I think it's, you know, it's not quite commercial, well, it is commercially available, um, but

Speaker 3Um, we, we designed it for surgeons, so when they came and saw this, you know, it kind of introduced this idea of time transparency, so that they could carry it back to their ORs. Um, so yeah, we developed that, that process.

Speaker 1It's great. It it it really it's great. I, I also wanna share another video now which was um seeing a bunch of patients, um.

Speaker 3Yeah, just just preparation for that, I, uh, you know, the bottom line is, it's obviously not just the operating room. If you have a very efficient operating room and you, you have nowhere to put your patients afterwards, you're in trouble. So this is showing, this is gonna show you both our pre-op and PACU in our Surgery center and what stage each patient is in the process at 9:10 in

Speaker 1the morning.

Speaker 1All right, here we go. OK,

Speaker 6it's 9:10. Let's say hello to our patients this morning. Here's patient number 1 Hip. How are you doing?

Speaker 6discomfort.

Speaker 6Can you list

Speaker 6Very good.

Speaker 6Here's our, our Hip. Here's our first Knee. How are you doing?

Speaker 6discomfort?

Speaker 6Very little. Good job. We'll move on. Here's number 3. Tip number 2. How are you doing, sir? Any discomfort?

Speaker 6How much?

Speaker 6Good, very good. You keep doing well. You're out walking. You're, you're up first.

Speaker 6Good job. How you doing?

Speaker 62.

Speaker 6Waiting for your legs to wake up a little bit. It's been feeling pretty good.

Speaker 6That's page number 4. Here's number 5.

Speaker 6This patient's gotten Robaxin and then we're gonna give 25 mics of fentanyl. This is our fentanyl patient. How you doing?

Speaker 6You wiggle your legs and lift your knees up. Very good.

Speaker 6And this is patient 6. He just got back from the OR. This patient's in the OR. This patient here is next.

Speaker 6And spinals placed and blocks placed, that's going back to the OR and this patient over here in the 9.

Speaker 6I just pre-op and you'll be our 9th. Say hello.

Speaker 6OK, patient number 9, say hello. How are you doing? And you repeat.

Speaker 1I think, I, I think, I

Speaker 3think one of the take-home messages there, it looks like the video is playing again. One of the take-home messages, that was our anesthesiologist that took that video. So, you know, having buy-in from anesthesia is critical in this process, right? I, I, I couldn't stress that enough, you know, it's, they are such an important part of this team. They take pride in the fact that we're doing these many cases in that period of time.

Speaker 3So they're, they're very keenly aware of how good a progress each patient is in this process. And we keep track of time as soon as they hit the recovery room. So, we know that last year, our recovery time was 2 hours and 9 minutes. That's 2 minutes shorter than it was the year before. So, we know exactly how long it takes. We know exactly why people stay in the recovery room.

Speaker 3What are those barriers or what are the reasons why people stay more than 3 hours in the recovery room? So we know every one of those and we track that data to see, boy, how can we improve our Efficiency? How can we improve postoperative urinary retention or hypotension, or all the things that keep everyone in a recovery room for longer than they should.

Speaker 1So we have a great question from Sarah Elbogan, who is the total joint coordinator at Presidio Surgery Center.

Speaker 1Do you think a center

Speaker 1can achieve similar times if they're not dedicated joint centers, and also cater to ENT, plastic, general Surgery, etc.

Speaker 3Yeah, yeah, that's a great point. It is super hard when you have multiple disciplines, multiple different specialties, right? So it is harder to attain that, but you absolutely can, but you have to silo it into each surgeon, right?

Speaker 3So you have to know exactly what that surgeon, that specialty needs, how long it takes them on average. You have to know that stuff going in. Um, so it's possible. We've seen it around the country where people are effectively doing that, but it's obviously harder. If you've got one ENT case and the next case is a total Knee and you're having to, you know, change out pants, you lose some of that effectiveness, for sure. Um, it depends also how many ORs you have. Sarah, how many ORs do you guys have there?

Speaker 3Looks like she's on. 5. Yeah, 5. Cool. And how many cases do you guys do a day?

Speaker 7Uh, it really depends on if we've got a dedicated day for Orthopedics or not.

Speaker 3Yeah, yeah. I, I think that makes so much sense to keep him somewhat dedicated, right? Whether it's in the morning or afternoon or all day.

Speaker 3I think that just helps everyone. You know, the reason why we're able to do it so efficiently is because, frankly, these guys can do this with their eyes closed, right? Another total Knee or another total Hip. If I had them do 15 different procedures, there's no way they could be that efficient and that good, right? So really trying to keep them locked in per team or at least per day, you know, that way you get the repetition doing the same thing every single case, I think is critical.

Speaker 3And you see that eye doctors, ENT docs, they can just turn a lot of cases because they can do the same thing over and over. You know, it's also, yeah, you also have to look at how you're managing, you know, your schedule, right? Are you, are you scheduling complex cases at the beginning or at the end? You know, we look at all those things, you know, when we, when we decide our order of cases, in order to, you know, kind of keep that Efficiency going.

Speaker 1I'm gonna say that helps them.

Speaker 2Sarah, I think, I think part of the answer to your question too goes into this, the, the part of the article called Operational Excellence, and so there are principles is that

Speaker 2Uh, apply to any specialty and it should. And so while, while Doctor De Cook can do a Hip in less than 20 minutes, and that's pretty cool, it's doing that 12 times by noon, that's, that's really amazing, right? So it, it becomes these steps of, well, how do we, how do we clean the room and how do we get the, uh, you know, what point do we start cleaning the room and at what point

Speaker 2Um, do we, do we start the spinal? At what point does the room start to get open? And how do you, how do you turn over a room quickly enough? And I, I think you can do that with, with, probably with any specialty. I, I would think turnover actually might be harder in Orthopedics than, than some of these Other uh surgeries.

Speaker 2There are more soft tissue. So one of, one of the principles with this is, you know, we, we, we tend to operate, there's er operating in series in parallel. We tend to do things in series in the operating room, that's just tradition where one step has to be completed before we begin the next one. And the more you can layer things where multiple things are going on at the same time, the quicker you'll, you'll get, you'll get back in the room. There's this um

Speaker 2Uh, term that, that called a knot, which is non-operative time, and our goal is to reduce that. So, so if the Hip took 40 minutes, and that's what one surgeon does, that's fine. It's that non-operative time that we really want to reduce.

Speaker 3I, I'll add to that. That's a great point, Jeremy. I'll add to that. If you think about the hospital, right? You have one dedicated person that's gonna come in the room and help clean, right, after a case, right? And then,

Speaker 3Somehow that gets communicated to the scrub tech to start opening the next case, and then somehow some communication happens to the nurse to help come help, right? And then maybe you notify anesthesia, and it's all happening in series, and you're relying on all these communications, and everyone doing that effectively. So, our philosophy at our Surgery center is, anybody can do anything, right? So I am opening trays, I am mopping, I can do any step.

Speaker 3That any Other scrub, you know, scrub tech circulator can do, right? My radiology tech, my rep, we all feel like we can each contribute, right? My assistants can interchange, right? If I've got an assistant closing in one room, they can take a different part of that procedure. Just because you can interchange those tasks. If you have one person that does one thing, it's just not effective. It just, you lose too much time doing

Speaker 1it that way.

Speaker 1There was a question. I, I, I'm not, Ahmed Siddiki, do you want to ask your question yourself, or you want me to ask it for you? What do you, you know, Ahmed?

Speaker 1And they see it on mute.

Speaker 1Um, hey,

Speaker 8yeah, Doctor, uh, Krishna, I'm here. So, so my question was, uh, two things. So in terms of spinal, what kind of spinal are you using? Obviously, there's been a lot of talks about mipivoccaine recently. Um, and, and, and how much time do you usually have from the time that the spinal goes in, in the pre-op area to time to incision and by the time you're done with the operation.

Speaker 8Obviously, you guys are, you are super, super efficient. One of the, you know, so I've really tried to push the, you know, the anesthesiologist and the team to try to do spinals and pre-op and one of their biggest concern is like, well, you know, we don't mind doing that, but then the time to get in the room and, and, and by the time you're cutting, it's just gonna be extended period of time. So, so how did, you know, how did you guys really fine tune that side of things and then

Speaker 8And I guess on a separate question is how do you really incentivize hospital staff to keep up with the efficiencies, you know, like the Surgery center is one thing, you know, where, you know, I have great experience there and obviously there's room for improvement, but the hospital has been the biggest struggle, uh, to really incentivize staff to, you know, keep, you know, building on what you're trying to build and, you know, where everyone's there.

Speaker 8You're working different shifts and lunch breaks and after like, you know, 12 o'clock, it's just like a standstill, you know. So, so what are some of your, you know, insight and advice with, with that?

Speaker 3Man, those are, those are great questions. First of all, let me deal with anesthesia. Anesthesia should not be doing things in your OR. You should be doing things in your OR. It's for operating, it's not for anesthesia. By that, I mean,

Speaker 3They should do pre-op in the pre-op, they should do all the blocks, all the spinals, that should be done there, right? For contamination, for infection reasons, and for time reasons, that should all be done in pre-op, right? Now, what they're telling you is absolutely true. The anesthesiologist brings up a good point, and that is, listen, we can give you a spinal.

Speaker 3But if you don't consistently do a case in 60 minutes, I have no idea when to start the spinal. I have no idea how much dose to give you on the mepivacaine or chloroprocane or lidocaine or whatever one you decide, right? Each of our surgeons has an average surgical time, right?

Speaker 3So, our doses of our spinals are related to that individual surgeon. It's not based on the patient height, right? So that's typically how anesthesia has done it for a long time. That's bogus, that's done, right? It has to be based on the surgical time. And you have to know when to tell him to start that or her that particular

Speaker 3spinal, right? If you don't know how much longer it's gonna take, then you're gonna randomly say, well, go ahead, go ahead and put the next spinal in. I'm closing, or I'm putting the cup in, or I think it's about time, right? The problem is if you have one room or two rooms, oftentimes, you don't know when to tell the anesthesiologist to start, and that's your fault, right? Because you have to give them granular data so they know exactly how long.

Speaker 3So to give you an idea how we've transitioned, we've done the pivocaine. As our surgeons have become more efficient, the dosing has changed. It became necessary for us to change to shorter acting, so we're currently doing chlorprocaine. A lot of centers do lidocaine. But to that anesthesiologist's point, he brings up a good thing. If you tell them to start that spinal and pre-op, and that spinal wears out, then we're in trouble, right? So you have to be granular with your OR time.

Speaker 3And that has to be transparent to the anesthesiologist, then you can hold them accountable for that.

Speaker 3I hope that answers it. I think there's another question. Jeremy, you want to answer the second part?

Speaker 2Uh, right, so in the in the hospital, uh, so one thing I think is important is dedicated staff. So you, you can't in Charlie.

Speaker 2Referenced that earlier, you can't have the, the, you know, general Surgery, OBGYN tech come into your room and expect to do a halfway decent, efficient procedure. Uh, and so in the Surgery center, that's a natural setup. It's, it's gonna be dedicated staff, but in a, uh, but even, even maybe to some degree dedicated to you, but in the hospital, that's where it's a little more challenging. What's, what's interesting, you know, staffing is a big deal right now and all the hospitals are struggling with it.

Speaker 2Um, I, a couple of the articles we referenced in the paper and I was actually trying to kind of pull it up, but they, they talk about how, uh, they, they're, they're reducing their overtime. They're in the hos in a hospital setting by becoming more efficient. They're, uh, people are not staying late. Um, they're actually hiring more personnel to be able to be more efficient, but their personnel costs are going down. So,

Speaker 2What, I think what you do is you go to your administration or your Surgery director and you show them these types of numbers and you, and you get buy-in where I need dedicated staff. I need the same people every week, uh, and, and then you, you also find the people who can naturally do this well and people who don't. There are people who will never get this, they'll never, staff will never go, hey, I, I wanna, I wanna work this way, but you won't, there are people out there who love it, and when they love it, it's so much fun cause then they

Speaker 2I mean, they, they, they, they, you create an environment that they wanna be in, they love being efficient, they love getting stuff done, and when you find those people, you hang on to them.

Speaker 1There's no special incentive programs, like if we finish by 12, everyone gets uh a Chuck E. Cheese uh coupon or something. You know,

Speaker 3you know, we randomly do those things, you know, we randomly take our staff out and do those kind of things.

Speaker 3But there's not a, hey, if I can do my 12 by 12, then, uh, you know, everybody gets lunch. There's not that. And frankly, that's motivation is fleeting. It doesn't work effectively, right? It's, are they proud to be part of your team? Do they want to be part of it? Now, they'll self select out, right? So we all know, I mean, there's people in hospitals that have been there for a long time, and frankly, nobody is going to push them to do anything, right? That's never gonna, you're never going to change a lot of people, right?

Speaker 3But, you know, that self selects out. I mean, they would last about a half day in our Surgery center or hospital before they realize they're in the wrong place, right? So, I think it's more about that than, you know, motivating, motivating them financially, for sure. The Other thing I'll say is we are adequately staffed. By that, I mean, when you see what our turnover looks like.

Speaker 3Man, it's impressive because we have 4 or 5 people that go in the room, they're taking all the trays out, they're cleaning, they're getting everything ready. If you think you can do that with one scrub tech and a circulator, it's never gonna happen, right? Think about just moving a patient from the bed to the stretcher or vice versa, right? That's a 3-man process in and of itself. You know, no wonder they have to wait 15 minutes in your hospitals because they got no help, right?

Speaker 3So, I think you really have to look and be very critical during the turnover time of who's actually in the room to help, right? A lot of times you go in a hospital, it's like, there's nobody there, right? There's nobody there to help, and it's, it's not a one-man show, so you have to have the adequate staff. And if you're collecting.

Speaker 3This data, not only time, but if you're collecting the value and money you're making, it will be abundantly obvious to hospital administrators, oh my gosh, maybe I do need another 4 orderlies to help me with turnovers. You know, those kind of processes become uh, you know, very transparent and very obvious once you show them

Speaker 3that.

Speaker 1It's amazing to me is that by using time as your metric.

Speaker 1You could actually prove in a hospital setting, I'm talking about now. You can actually

Speaker 1Make a case for the, to the administration or to whoever it is, or to me who is the chairman, and say, OK, we did this as best we could with Bob and Susan, who's all we have. We seem to be maxed out. Give us this, and now let's see what all the times look like. And if all of a sudden you were doing 4 cases by 12.

Speaker 1I'm just saying, um, which is considered very good in a hospital, OK, um, and now you're doing the same 4 cases by 11.

Speaker 1Or by 10:45, all of a sudden, time is your metric.

Speaker 1Has now become a religion in the administrator's head. I mean, I think, I think I love the idea that you're doing time because no one could argue it. A second is a second. That's right, you know, it's, it's universal. It's universal, even in Atlanta, even though you guys talk a lot slower than us New Yorkers, it's time is the same.

Speaker 1Absolutely. Yeah, yeah, that,

Speaker 3that brings up a great point. So to give you an idea just to understand, you know, our staffing, we have just 2 rooms in our Surgery center. We did that on purpose, right? But I had 4 scrub techs today. I had 3 circulators, and I had 1 Other assistant, and I had 1 person, the SPD, right? We did 15 cases. The last case went out of the room at 1:30.

Speaker 3Right? 15 cases. So if I go to someone and say, hey, listen, this is working. I'm spending extra, I don't know, 1 scrub tech, an extra circular, an extra person, let's say 3 people, right? If I can do that kind of volume and Efficiency, it's a no-brainer to hire those people. It's no brainer to get more people involved in turnover times and help,

Speaker 1right? I've spoken to my CEO many times, and he has said the following line.

Speaker 1Every time people say I want more people because, and I'm gonna bring you more money, be more efficient, I throw more people and I don't get the Efficiency. And he may be right, unless you have the metric, the right metric.

Speaker 3Exactly. Well, you know, there's Parkinson's law, and that is, you know, you're gonna get everything, you're gonna do something in a specific period of time that you're given to do it.

Speaker 3Right? So if the expectation is a 30-minute turnover time, it don't, it doesn't matter if you have one person or 4 people, they're gonna lollygag around and get it done in 30 minutes. Or if it's 1 or 4 people, right? It's just, it's Parkinson's law at its finest, right? So, you have to change those kind of expectations, right? In our Surgery center, we have never had a late start. Never.

Speaker 1Right, so we have Doctor Siddiki has another question. Ahmed.

Speaker 8Hey, yeah, sorry. So one last question. So, so you touched on it before about efficiencies and, and, and time and all that, and you kind of mentioned, you know, about one of the inefficiencies are, you know, it takes you 40 minutes to do a case and it takes, you know, the system 40 minutes to close. So that's kind of where I'm stuck right now, you know, I'm, I'm about, you know, 16 months in and I'm around the 30, 35 minute mark until, you know, incision to when I'm done and all they have to close is subcu and put the dressing.

Speaker 8And that's it, and it takes them just as long as to do it. Uh, so, so, and I've, and I have two PAs and, you know, I have two rooms and, and they work well, but, you know, what do you recommend to try to get these PAs who do a good job to like get further efficient at closing without telling them, you gotta hurry up, you know, like it's hard to find good PAs also. So just some thoughts, you know, that you would recommend.

Speaker 3Well, to give you an idea on a total Knee, right? I mean, we use a bi-directional, right? So one

Speaker 3Operating going up, I'm going down. I actually stay in until near the very end of closing just because of that very thing that you say, and that is, I want to stay in that room as long as I can to ensure that we're gonna efficiently close, right? You also have to have the right type of closers, right? I mean, if you've got a closer who's taking 40 minutes to close, there's a problem, right? Especially if it's a Hip or a Knee, I mean, it should not take that long. Um.

Speaker 3So that, that's my, you know, you gotta look at their experience, and you should stay in there until you absolutely have to go to the next room. So if you're bouncing back between rooms, I stay in there to close until I know that next patient's ready to cut on, right? Or in, in, in case I look over and say, boy, it looks like they need help prepping and draping, right? So, I just kind of go wherever I think I'm needed the most. I've got cameras, you know, in both rooms, so I can keep an eye on things and where things are going.

Speaker 2I, I think the key to your question is you, you've identified a problem, right? So that's the first step and so often we don't. Now, I think when we talk about radical time transparency, and one of the key issues is that we're not just going, we feel like this is the problem, but, but we're putting numbers to it. We're actually sitting down and going, how long does this actually take? And does it take this PA this long or this PA this long?

Speaker 2If you can, you can gather that information and then they can see it, our, our natural tendency is to go, hmm, I could do better. Uh, if you can compare that time to someone else's, you know, whether someone else in your group or your hospital or even somewhere else in the country, how long it takes to close.

Speaker 2They can, they can go, oh, I, I'm not as good as Other people. Uh, and then sometimes they naturally work on speeding that up. It may be beneficial to go visit someone else with your PA to let them and, and figure out, well, what are we doing differently? Is it our suture? Is it our, and, and so you, once you know the problem and you quantify it, then you, and then you can also watch your progress. So you, if you're keeping track of the times, if they, if they go from 30 minutes to 20 minutes,

Speaker 2That's incredible. And so they also need to see that and celebrate that and know that we, we've got a 33% improvement in our closing time and that's pretty awesome. And then when they see that, I think that also motivate them more to keep it going.

Speaker 1We got a couple of great questions, uh, that I'd like to, but of course, someone from, I don't know who's who has this cause the name got obliterated, but having cross-department buy-in.

Speaker 1Uh, what happens when unforeseen circumstances come up? Uh, whoever said that question, do you want to, uh, say it yourself, or I'll finish it up.

Speaker 1You can go ahead and ask it, uh, Doctor Ira. Yeah, OK, sure. So what happens when unforeseen circumstances come up out of your control, such as the patient arrives late, the patient doesn't clear pre-op well, something happens in the OR, you know, does your system give

Speaker 1You the flexibility to be proactive in mitigating the waste associated with unforeseen delays. And you know, I didn't ask this question because that is very erudite and quite good, and it, it's just not someone from the Bronx, but I, I get it, yeah.

Speaker 3Well, if you look at drum buffer rope theory, which basically means we need a continuous product into the OR, that means that if you have a patient that doesn't show up or if they show up late, you need the next patient ready to go.

Speaker 3So to give you an idea, I have 3 or 4 patients ready to go if that happens. Let's say one of them has AFib on the monitor, one of them doesn't show up. I always have another patient ready to go in that process. So, getting those patients ready in the queue, knowing when to get those patients to the OR, right? So we make, we make incisions that generally between 6:15 and 6:30 every morning.

Speaker 3So we generally get patients there, the first two patients show up at 5:00 a.m., the next one at 5:30, next at 6:00, and so on and so forth. But that is the basic philosophy of, if one of those patients screws up, you know, we have more to go. Now, if all three of them didn't show up, well, uh, yeah, uh, then it would be a problem. Let's say, you know, another concern people have is, OK, I'm about done with the procedure. What if I, you know, fractured the calcar on the way out or something like that or something unforeseen.

Speaker 3Happens, rupture an MCL or something, you know, something tragic happens, right? So, you do have to have a little bit of filler there and you have to know how long it takes you to screw up, you know, fix something you screwed up, right? So for me, if I happen to get a calcar Fracture, I know it takes me to cable, it takes me about a minute and a half to cable a femur, right? So that's not gonna make a difference one way or another. So you have to have some room, uh, for unforeseen circumstances.

Speaker 3You know, like, let's say, you know, gosh, I really need to cement this femur. It's a terrible femur, you know, that kind of thing. You have to have a little bit of leeway there, but that's based on what you know about your average

Speaker 3times.

Speaker 1So, uh, we have a couple of what I think rapid-fire questions here. Are you cementing any knees or using mostly cement? Yeah,

Speaker 3I happen

Speaker 3to cement all my knees in the Surgery center right now just because, you know, we're all about value and our press fit knees right now are very expensive, so we cement all our, our total knees.

Speaker 1All right, and from uh uh Fred Buntner, um, Fred, you want to ask your question yourself, or do you want me to hit this one?

Speaker 1Oh, make Fritz ask it. Fritz, go ahead.

Speaker 9OK. Hey, how are you doing? Nice talks. Um, I have one issue, like in a big hospital, I guess, I, I know my people are going to be there for 10 hours. So I sometimes run into the issue that if I finish faster, they're going to start slowing down because they don't want to have the next case flipped into the room and do a Spine washout or whatever. So they kind of like, everything works really well until 12:30. And then suddenly, for whatever reason, things like turnover, suddenly I have a 2-hour turnover in between, just to make it that they can leave at 5 o'clock.

Speaker 3Yeah, yeah. Oh my gosh, that is so funny. That happens in Atlanta all the time, especially at our hospital. Yeah, that has to be at an administrative level, right? You have to go in and plead your case and say, listen.

Speaker 3We want to be more efficient, but these guys, I'm gonna run them to death, they're gonna do 6 or 7 cases, then they have to go and do another room. So, early on, we said, listen, you can't do this to our staff. If we're that super efficient, you can't make them go over there. Let them go eat, let them relax after they're done, let them stay on the clock, uh, and that has to be something that you're fighting with administration, with nursing, or wherever it needs to be, whatever level.

Speaker 3We made that, we made that plea long ago, and it, it, it's effective, right? Same with our Surgery center, right? They know, like, even though we worked them to the bone until 1:30 today, we, they knew they could relax for a few hours before they're off the clock, you know, they can do some mindless, easy stuff where they're cleaning rooms or, you know, getting the next cases ready for the next day. So, you do have to do that, otherwise they'll have no motivation to finish. Great point, Fritz.

Speaker 1So Jeremy Smith asked, so what Knee positioner do you use? Knee position.

Speaker 3Yeah, so, you know, everything we do, obviously, any new Technology, a Knee positioner, uh, it's all with obviously taking good care of the patient and Efficiency, right? So,

Speaker 3You know, we use uh something called a velocity, which moves up and down very fast. It allows you to, you know, flex, hyperflex the Knee, extend it quite quickly. A lot of people are enamored with that when they come to the OR cause, you know, it, it moves the Knee quite quickly, which is, you know, in our world, it's pretty nice.

Speaker 1Who makes that?

Speaker 1I have no idea. Good deal. Uh, I honestly don't know either. Awesome, awesome. Great. Yeah, I'm glad the company had great name, great unaided name recognition on that one. It,

Speaker 2it's called Velocity bump. Uh, it's simple. Uh, it'd be hard to get it wrong. Uh, I mean, and, and it doesn't have to be perfect, you know, it doesn't, it's not a position or that, so, so, so it could be put anywhere and it still works. So

Speaker 1it's easy. So how do people were, were sort of talking in.

Speaker 1How do people get to visit you guys?

Speaker 1Yeah, I mean, what we

Speaker 3can provide our contact info. We love talking to whole groups, you know, obviously the surgeon is just one part of it, so it's rare that it's just the surgeon comes by himself. They can, but herself or himself can come anytime they want. So we have people come all the time.

Speaker 3Text us, email us, we'll get it all set up for you. It's always best to bring your team, right? A lot of times it's the surgeon bringing their team to say, look what's possible, you know. You know, I was watching this F1 race, and I was like, oh my gosh, they just did a pit stop in like 3 seconds. I was like, this is freaking unbelievable. They changed the tires, they gassed up, they did everything in 3 seconds. It's like almost unfathomable.

Speaker 3Right? I think we hold ourselves to this mediocre visibility of Efficiency, and like, no, there's no way, like everyone calls me out like there's no way you do 12 cases by 12 o'clock. It's so bullshit, you know, I don't believe you, and they bring their team, they see it, they're like, oh my gosh. Again, this has nothing to do with, oh, he's a great surgeon. It's they never say that, it's what a what a fantastic team you have, you know.

Speaker 3So if you gotta see it to believe it, you gotta bring the right people, anesthesia, the administrators to really be able to kind of wrap their head around the ideas, we really do suck, there really is a better way to do it.

Speaker 1Last question, and then I'm gonna, uh, wrap up up. At what point during your procedures are you calling for the next patient? Was there a trial and error process, or, uh,

Speaker 3yeah, yeah, there's about a 10-year trial and error process, right? Once.

Speaker 3Yeah, once you get really good, right? Obviously, first in practice, you know, your, your surgical times go from, I did a great case. It took me 30 minutes to, it took me 2.5 hours, right? I mean, that's the first, you know, first year or two in practice. And then it comes down and down and down, right? And then it doesn't.

Speaker 3No matter if it's a crow 3 displays or a nasty 20-degree vagus Knee, you get it zipped down to where you're gonna end up being, right? Once you get it zipped down to, OK, this is where it is, if you know you're within 10 minutes either way, regardless of how terrible or easy the joint is.

Speaker 3If you've got that kind of consistency, then you can go to your anesthesiologist and say, no, exactly. OK, when I ream, that's when you do the next spinal, or when I ream, or when I put this point in, or whatever starting part of the procedure. Now, it used to be, I would call that out. I don't even do that anymore, right? So they know, cause they have visibility into what's happening in the OR. There's no calls up, hey, is he ready to do the spinal? Are you sure you're ready kind of deal. It's none of that anymore. It's just the transparency.

Speaker 1Interesting, interesting stuff. So, I want to let everyone know we're recording this. The recording of the whole uh session as well as the videos that you saw are gonna be available on dotsocial. I'm gonna be pushing that on LinkedIn, so you'll see it there, and everyone who is here tonight and everyone who signed up will get an email with the link. You don't have to sign up to anything. You can see the videos and see tonight's uh, recordings. Um.

Speaker 1Um, just some final comments from both of you guys. Let's start with Jeremy. Jeremy, some final comments and advice to the crew who is listening.

Speaker 2Yeah, I mean, I, I think one of the, I, I, I, I think, first of all, you, you, you've got to decide do you want this or not. If you want it bad enough, then you just, you just keep going. Um, the, uh for those who, at the Surgery center, it's, it's easy, right? The, the whole environment set up for Patient experience and quite honestly, surgeon experience, and it's, it's easier to make these changes, but I think you can do it anywhere. Uh, I think you, you, you develop a plan if, if, you know, you go to your administ.

Speaker 2and you, you can show them how we improve our Efficiency, we can, we can reduce your personnel costs, we can reduce overtime costs, uh, we can increase revenue for the hospital, and there's, there's studies out there, they're in the paper, uh, that, that show this. And it's not, not just an idea, it's, it's, it's real. And, um, yeah, so you, you, you, you create, you, you sell it, you have to sell it. You sell it to the administration, you have to sell it to your anesthesiologist, you sell it to your staff, and, um,

Speaker 2I think a big part of this too is, is, as you make these improvements, be very, show gratitude to your staff. Uh, you know, we, we don't say thank you enough, uh, create an environment that they enjoy being in. Uh, you want, you want the staff fighting to be in your room because you want, you wanna get those right people. You want, you want 6 or 7 people going, I wanna be in that room and they want it, not that, yes, they're gonna work harder, but they also know they're gonna have a good time. Uh, so create that kind of environment. Uh, and then,

Speaker 2Uh, just, just keep going with it, and, and it's something you get to play with, and when you really get into it, it's, it, it's fun, it just turns into fun.

Speaker 1Charlie?

Speaker 3Yeah, I think, I think the uh first and last thing has always been and always will be taking great care of our patients, right? Our surgical outcomes, how we do for our patients is by far the most important thing, right? If you start with that premise, Efficiency just comes along for the ride once you throw in radical time transparency, right?

Speaker 3You improve your own techniques. Everyone else improves around you, and you do a better Surgery, right? So, don't think of this as we rush Surgery or we decrease the quality of a total Knee or total Hip. That's not it at all. It's, we care about our patients, we're trying to do the very best we can, and by doing that, we are doing everything consistently the same every time, those same steps in the procedure, and we have that visibility in our ORs to do that.

Speaker 3I think I'll end at that.

Speaker 1It's absolutely awesome. Uh, I really wanna thank you guys, not only for

Speaker 1A remarkable article, which I was going to pass on to some of my Business school professors, see if they want to read.

Speaker 1Republished that in the Business school, uh, review, but I also, uh, wanna thank you for tonight and for the, uh, great work you do. I mean, it's just, uh, it's great to be an orthopedic surgeon, you know, like Joe DiMaggio said, I thank God every day he made me a Yankee, and we thank God every day he made us orthopedic surgeons, so it worked out. Sara,

Speaker 3thanks, thanks for the invitation. Thanks for giving us this, uh, this voice and for this incredible journal.

Speaker 1Thank you.

Speaker 1Appreciate it. All right, I'm gonna end for everybody. Um, thank you, thank you all for coming and keep your eyes open for the for the video.

Speaker 1Yes,

Speaker 2like.