It's time. It's 5 o'clock. We're going to get started. Thank you, guys, for coming. We're excited about this session. We're basically representing the Young Member Steering Committee, and we wanted to put forth some kind of content for the younger members, trainees, and people early in practice to help in those first few years that can be kind of anxiety-ridden about how to build a practice, how to be successful. And so we hope that you'll definitely get something good out of this. So I'm going to kick it off. And this talk is entitled Defining Success in Practice, and it's something that we don't necessarily spend time thinking about, especially when we go through our training, you want to get the best spot in residency. You want to get a good fellowship. And then when you're out in practice, it's kind of like, well, what now? How do I? There's no test. There's no grade. No one's grading you. So how do you define how well you're doing? So it's difficult. It's definitely not an easy thing. And the other thing that's difficult is that it changes, because at one point in your career, you could define success one way, and that could change completely, which is definitely my experience, and I'm sure similar to the people up here on the panel. And what I see as being successful is very different than what you may think of as success. And the ability to be mindful about it and to be able to put that into words is a skill, just like any other, that you have to practice. And so one of the things that I'm going to leave you with is basically doing this regularly in your life, yearly, every five years, whatever it is, and being able to define what it means and how it looks for you to be successful. And it may be something similar to this Venn diagram, but you need to come up with one for yourself. So you have to be intentional about it. This takes work. It takes practice, just like any other skill, and you have to actually be introspective and think about what's important to you, and with great power comes great responsibility. It may be a combination of these factors. Time with your family. Obviously, health should be in there. Financial security and prosperity, I think, is important. Happiness is something that you define for yourself. It can be defined externally, but more importantly, it should be defined internally, because I think we oftentimes get caught up with getting your name on the number of papers, but what does that actually do for your happiness or for your ease of life day to day? And then, obviously, freedom of choice, I think, is another thing that's very important. And back to my earlier point about the change, the shift in mentality from when you're a trainee to when you're an attending is that you kind of need to realize that you're actually holding much more power than you used to as a trainee, and being able to kind of own that and leverage that for your happiness and success, however you define it. And then also thinking about the time aspect of it is that there's goals that you want to achieve or a certain lifestyle you want to achieve now versus how that's going to look later on, and having an eye towards that shift. And so something that's really important that I do is keeping track of your progress. And so that may be clinical volume, it may be a financial aspect of revenue sources from your practice or passive streams of income, as well as remembering why we got into this, which is to help people, and helping not just patients but trainees, if you're involved in education, teaching, giving lectures, you should track it, because the only way to know that if you're improving or if you're reaching your goals is to be able to track it. And so this is just an example, and you can kind of track and see your progress over time. So in summary, you should define the things that are important to you now, you need to be intentional about it, and you need to follow yourself as you go, and you'll see how you kind of change and grow with time. And now we're going to go to the next one, which I think is a little bit more... Actually, nope, he's not here right now. So we'll go to Jill McLaughlin. All righty. So I have no financial disclosures, but I do want to disclose that I'm not a coding expert. And I did actually prepare this talk with Dr. Tom Kaplan, and I want to thank him. He's one of the members of the ASH Coding Committee, and he was a huge help with all of my coding questions. So coding's really important. Essentially, it's essentially... But nobody really cares about your money as much as you do. There's many codes for the same procedure, which makes it kind of confusing, and not all codes are created equal, and additionally, codes are often updated frequently. But in the words of Ann Miller, as surgeons, we aren't paid by the surgeries we do, but instead how we code them. One thing that's a little bit confusing is codes can be bundled and unbundled, and how do you find this data out? Well, the CMS.gov has an updated quarterly NCCI database that basically has a list of zeros and ones. If you look at the zeros, it means that those codes can never be coded together, while ones mean that they have to be justifiably combined with the modifier number 59. Now, as I just said, it's updated quite frequently at this website here, but do you have a lot of time for that? That is a little challenge. How do you get these kind of resources, and how do you learn about coding? You can learn from your partners, your mentors, coding courses, and coders in your practice. I recommend all of you getting audits of your coded procedures and coded notes early on. But also, if you're looking for a really good way to have a coding resource, I highly recommend the AOS Codex app, both available online and also via the telephone. I also thought that you had to be an AOS member to obtain access, but you don't. I actually was able to obtain access really recently. And I would say that one of the reasons why I think it's really important is because it actually will interpret and update NCCI edits for you, describe the code, also describe the global services package and what's bundled or not bundled, and use specific language to describe what's in your operative report, but also is RVU value listed, as well as whether or not an assistant surgeon can be present, and also modifiers and is more specially specific. I'm actually not a member of AOS, but I still am able to access it, so I'm pretty happy about that. So just to kind of go over what our talk will be about is an outline of what you would want to include in your operative reports, outpatient clinic visits, and also medical decision making. I'd recommend you all looking at the handout to kind of follow along, because I'm just going to quickly go through a few examples. And so also hospital notes and modifiers, and also just to review in depth on more topics at the HANP website, or go to additional coding courses, which ASSH provides. So in the operative report, we all kind of know its general structure, but things that are really important, the coders are going to be looking closely for your comorbid conditions. It really helps to explain the difficulty of the procedure. But also you want to identify all the surgeons within the surgery, including their name and name, and justify if you have an assistant surgeon or an assistant in the OR, otherwise that person may not get paid. You have to confirm that all procedures are listed, and in fact, many people recommend that going paragraph by paragraph with each procedure is helpful in helping your coders to interpret your operative reports and get you the money that you deserve. Also symmetric procedures, they have to have a separate dictation. It's not sufficient to say, I did the same thing on this side. You want to make templates. That helps you to have a stratified way to have your thoughts organized, but also be anatomically specific. I mean, if you look at the codes here, without listing the number of pieces of a disarray fracture, whether it's extra-articular, you can see there's a large variation in the RVU value. And they're always going to down code, depending on what you list. So if you also look at the location of an extensor tendon in the hand versus the wrist and forearm, you can see that the location of that tendon repair is strikingly different in terms of your RVU output. And actually, I think it's Marker Kant told me in an ultrasound course previously, he was asking me, where does the hand end and the wrist begin? And I think it's an interesting thought to really think about as you're coding your procedures. So we're just going to quickly go on to the next topic. So this is on medical decision making and outpatient clinic visits. So it's new in 2021. It's currently outpatient only, but likely will expand to inpatient in 2023. And the important thing is that it's easier to obtain a level four encounter. If you see there that there's a 40% difference between a level four and a level three encounter. And so what does medical decision making involve? It's first problems and the number and complexity of those, as well as data and the amount and complexity, and then risk of complications. And two out of three elements have to be met for that level to be qualified for that level. So we're going to go through some examples. So first we look at the diagnosis. So that's the problem. So this patient has a chronic illness with progression. So that's a problem element number four. If we look at the Nexus data, we're going to see that the patient had a note that was reviewed by a primary care physician, as well as an order for an MRI. That gives us one, two problem elements, which makes this a level three. Now we look at the risk. This patient has following up with splinting insets and following up after a MRI study. So I would consider that to be a relatively low risk. And if you think two out of three, we got a 99203. Let's go to the next one. So moderate is really the most confusing part, I think, of most of the review for people. People get really tripped up on multiple things, including the fact that any time you're reviewing a prior external note, you can actually count each individual provider as one of those elements. So if you have a provider note from PCP that you reviewed, as well as rheumatology and cardiology, that would be three of the notes that you met, and met all the requirements for category one, which means three out of three for a level four. So let's go on to the next example. So here we have a patient who had an acute uncomplicated illness, a bursitis at the elbow. That would be a problem element number three. I like to identify exactly, after the diagnosis, exactly what I think it is in terms of acute uncomplicated illness, because I think it helps the coders to actually identify that more easily. Now, you go into the data elements, we look at the review of the test, and we have a lab value that's reviewed, as well as additional labs that were ordered. Those are multiple problem elements we got a level four encounter. And then we look at the risk, and the patient had a prescription medication that was prescribed for their bursitis, Celebrex. That's considered to be a drug management, so that's a level four, so the total CBT code would be a 9.92244. So again, let's look at the moderate, again, more detail. It's important that if you're going to review a test, that you cannot review a test that doesn't have an identifiable CTT code. So if you're going to look at a CBC, you can't differentiate a hemoglobin and a white blood cell count, and actually try to count those both. That doesn't work like that. So you have to have something that's TSH, or something completely separate from what you're actually reviewing. And you can't review studies that you've ordered. So next example here is an open fracture with an acute complicated injury. I would consider that to be a problem element number four. If you look at the independent interpretation of a test, now this only requires you to interpret one study. I think this is actually the easiest thing to obtain for hand surgeons who are seeing patients for the first time. The reason being that most of your patients, if they're referred from the outside hospital or DD, or even for a nurse study after a primary care is ordered, you can actually review these. And if you independently review and interpret these studies, these then count as your category two, which automatically gives you a level four. Which then we go on to the next part, which is risk. And we can see here, the patient's going to follow up in one month. That's a low risk. So I would consider this to be a level four encounter. So again, a little more detail about independent interpretation of the test. You really want to make sure that these are tests that you did not order. So if you have an x-ray machine within your clinic, you cannot count this for your test. So you would, again, start to state your findings within the boundaries of what you would think would be a standard reporting of this type of study. And so I would recommend listing the types of views that you had an x-ray or CT. And then also from electrodiagnostic studies, having your interpretation of your motor and sensory neuroconduction studies, EMG, and interpretation. So let's look at the next example. So we have two diagnoses, and that's chronic illness with regression. So that would consider, and I would actually want to emphasize the fact that you have to address the management of the conditions within each encounter. So on this particular patient, she has diabetes. And in the, here, I highlight the patient's elevated hemoglobin A and C. So this would be problem element number four. And then we go on to the review of the test here, the data. And this is minimal, because I had actually ordered these tests previous to the patient's encounter. So I cannot count these as a problem, as a data review. Finally, we look at the risk. And as you can see, the patient is undergoing a trigger finger release, trigger thumb release for the elevated hemoglobin A and C. I consider this to be a level four risk encounter. And I give her 99214. And the reason being that she has a minor surgery with identified risk factors. But also, when we think about risk for surgery, we really have to, it's really within our sole and specialty guidelines. So it can be really debated which procedures we consider minor versus major. I mean, I think if we took a poll in this audience, I think we would have a discrepant amount of views about which ones we would think would be minor or major. I mean, I would consider that carpal tunnel release would even be major, given that it has a high risk of nerve injury. And it's one of the most common procedures for peripheral nerve release that we have that happen. So just to quickly go over modifiers. So when we use modifiers, well, essentially, modifiers have to be listed for patients who are undergoing surgery within the following day, or if you see them in the hospital that day prior. Because otherwise, your E&M code will not be paid for. So basically, use a 25 modifier for patients that are having in-office procedure, and 57 for operating room procedures. So again, if you do not do this, the coders will not, and the people who you're billing for will not actually list this as a separate E&M billable event, which means that you won't get paid for that E&M code. And so it's really important to know that, as well as the fact that there's also E&M codes that are generally not billable during the global period. But if you do see a patient who has a separate diagnosis within that global period that needs to be treated, you have to then identify that by with a modifier number 24. So hospital codes, I'm just going to quickly mention that these patients, that we don't have the historic element. We still have the historic elements. This may be updated in 2023. But I would avoid using any consult codes. They essentially don't get paid. And use, for ER codes, these different types of code values. So finally, I know this is a quick whirlwind of information, which was trying to be as brief as possible. But these are some resources that you have available to you. I would encourage all of you to check out the ASSH Hanpy website, in fact. And also, I would like to thank everybody for this opportunity to speak today. And also thank my mentors for the people who initially fueled my interest in coding. Thanks. Jason? Introduce Jason Streslow. I was just saying that I don't remember who was next. There you go. All right. We're going to change gears a little bit. Sorry, I'm going to redirect that. And talk about building a referral network. And it's not something that we concentrate on coming out of our fellowships and residencies. And sometimes it can be really hard to kind of navigate how to do it successfully. You know, this is the advice you typically get. Be good. Be nice. Right? Has everyone heard that? That's what I got, which was super helpful. But it's true. But it doesn't actually help you build a referral network. That kind of actually helps you keep a referral network, right? So if you do good work and you're nice to the people that are referring to you, they're going to continue to refer to you. But how do you start that process? And I think that's the more important question. So what's the goals? Really the goals here are how do you bring in new business? How do you start a practice? How do you get people to send you their patients? You know, if your practice is entirely ED-based, i.e., you're getting consults for trauma and patients from the emergency department, then really it's sort of a self-fulfilling prophecy as long as you're associated with a hospital. But if you're not or you're trying to build your elective practice, there are many other ways to do it. I think the sort of three simple ways are obviously patient referrals. And I'm going to point to why this one in particular is so important. Patients refer patients, right? And so as soon as you have a patient that's happy, this goes back to being good and being nice. As soon as you have patients that are happy when they need or their friends need or their family needs something, you're going to be the first person that they recommend. Even if it's not inside of your scope, they're going to be sent to you. Number two is employee referrals. This speaks to just being a nice and easily approachable person inside your own practice, inside your own hospital, and in the community. And really, employee referrals can be a really powerful way, particularly across things like the primary care offices that are in your building. Because if you're seen as someone that can have patients sent to, they can talk to you, they can easily communicate with you, then as soon as there's someone who comes in with a problem that you'd like to see them for, they're going to refer to you. Last but not least is partner referrals. This one seems self-evident. You'd be surprised. And depending on the practice you're in, your partners may have a referral practice that doesn't include you, particularly if they haven't previously had a hand surgeon and now you're joining a practice that you're new to. So, you know, who are people looking to refer people to? Really, likable people and competent people. This goes back to that be nice, be good motto, but it is really true. And the more quote-unquote likable and the more competent you appear, the more likely you are to get a referral. But that's kind of challenged a little bit. You know, the old AAA theory of affable, available, and able really isn't enough. Okay? And so, like I said and started out with, you know, be nice and be good, that's great. But what else do you have to do to keep and get those referrals? And this is actually a really nice paper in JAMA. Looking at patient communication is probably the single biggest thing that brings patients to your clinic. Okay? And what does that mean? Well, it means actually describing what you're going to do, what you're treating them for, and what their follow-up and their other options are. I recommend reading it. It's a pretty brief read, but it really talks about how prioritizing that patient-surgeon interaction, sitting down, taking two seconds out of your busy clinic, because your clinic will be busy, and connecting with that patient will go way farther than any of the other tools that you have in your toolbox for referrals. What doesn't work? Well, some behaviors, and this is another paper kind of showing you the same thing. Really, to get people to refer to you, you have to establish that one-on-one communication skill with the patient. And if you do that, they will automatically send you referrals. The same thing goes for those referrals from your partners, the referrals from the employees, the people that you work with. And really, it's communicating with them. So, do you loop back once you've got the referral and say, hey, thanks for sending the referral. Here's what we talked about about this patient. Here's what I'm planning as a treatment plan. That goes a long way. It also goes a long way to letting the person who's going to send you the referral know what you want to see and how you manage patients. So, you're actually kind of educating them about what you're looking for and you're providing them some education about how you manage these problems and they can be an excellent ally to help you. Particularly if the patient, let's say, isn't having a great post-op course or they're struggling through their non-operative management, if you've got that ally who's a PCP or the rheumatologist or whoever it is, they'll be able to provide some calming force for that patient and then that patient will be happy with your overall care. The business world talks a lot about referrals and the whole handshake policy inside the business world, but we could probably take a lot out of it. That article from the Harvard Business Review talks about some really, really good, strong strategies. So, we'll go through each one of them really briefly. Make sure your business is worth sharing, right? Again, be competent. That's a no-brainer. I'm sure you all will be, so that's one you can kind of put in the back pocket. Manage your referrals. Something that we don't think about, but actually identifying who's sending you the referrals. So early on in my practice, I'd write down the names of people who sent me patients. I'd usually send them a letter and say, hey, thanks for the referral. It's really easy to do. You can have your nurse, your MA, or whoever's working with you just jot that down at the end of the day and you can send a nice, simple thank you. It goes a long way. Request the referral, and we're going to get to this in a moment, but you actually have to ask, right? You have to ask people, hey, send me patients. Sometimes it's awkward. It actually works. Prepare for the referral, so make sure that if you know that someone's going to send you a referral, you let your team know so they can make sure that that process for the patient is smooth, right? So anytime I have a new referral from someone who hasn't referred to me in the past, I get an email or I get a phone call, I immediately send that to my nurse and say, hey, we need to make sure this patient has a great experience as they come into your practice. And then show appreciation, so that's the thank you aspect. Dale Carnegie of the business world fame, you'll get them if you ask for them, but you've got to ask, and no one does. So going out there, asking, making sure you're connecting with the people who will be sending you or who you think will be sending you referrals goes a long way. I already talked about tracking who they are. Motivate them, show them why it's worthwhile. I'm going to get the patients in quickly. I'm going to take good care of them, and I'm going to let you know what I did. And if you do motivate them, that can go a long way, and it's simple stuff, really simple stuff that helps motivate, right? Feedback, thank yous, and making sure you take good care of those patients. So these are the top kind of highlights. I think one of the ones that when we ask for a referral, make sure you are telling them what you're looking for in your practice, right? That'll help. This is the stuff I see. Give them a list, give them a card, let them know, hey, I'm going to see all these carpal tunnel, I'll see all the revisions, I'll see whatever you want, right? Be available, that affable, available, and able, right? You have to have those things. Those go without saying, because the person who's beside you looking for that same referral is probably going to have those as well. But to go in above and beyond really opens the door for you. We talked a little bit already about word of mouth. As soon as people know that you're available, as soon as they know that you're going to take good care of their patients, word gets around. Word spreads word, which spreads word. Social media, we were going to have a talk on that. Social media certainly can help you. I personally don't find it very helpful. I don't have people say, hey, I found you on social media, that's why I'm here. But I think what can be helpful there is if people know that you're in the world, right? You exist. You're publishing or you're out at the sports games or whatever it is that you do to generate your referral practice. It can be helpful because people at least recognize the name, and that can certainly go a long way. I am always interested because I'm not a huge social media person, but I'm always interested to see how people use it. So just some rules to live by. Really talk doctor to doctor, surgeon to surgeon, referee to referral to make sure that people know what you're looking for, what you're offering, and make sure you take good care of your patients. Tailor to your audience, right? If it's a PCP, that letter's going to say something different than if you're going to send it to a rheumatologist or another hand surgeon. And then last but not least, just make it easy, right? The simplest things, make it easy. Letting your team know they're coming, making sure that when they get there, they have a good experience. And if you do those things, you'll have the referrals. Hopefully that was helpful. Thanks, Jason. I'm going to talk next about how to build. Yeah, so this is definitely a skill that we don't really get taught in our training, but I think it's, you know, when you're out in practice, even, you know, whatever setting you're in, you kind of need to learn these managing skills because you have a staff that's working for you and you're responsible for them, you know, in a big way. So you got to know who you're, who are the players on your team. You know, there's the office staff, including front desk, call center. Sometimes you can outsource some of these services and we can talk about that later in the question and answer session. You have some kind of billing staff. You have a surgical coordinator who's booking your surgery. You may have someone who does some marketing or community outreach for you. And then, of course, you have the clinical staff, which may be an MA or nurses and physician extenders. Okay, so how do you become efficient in a practice? So you have to understand what each person who works for you does. And the only way that comes about is by intentional interaction with them. So you should speak to your staff and understand what they do. It shows that you care. And if you understand what they're doing and you're connected to the work that they're doing, it's going to make your whole practice more productive. And so this, like I said, it takes work, but you have to know from top to bottom what each person does. And, you know, technically it'd be good to know the nuts and bolts of how people that book surgery for me. You know, I know the steps it takes to book a surgery, and when I first started, I sat down, and he said, okay, here's a booking. Take me through, start to finish what it takes for you to book a surgery. That does a few things. Number one, it helps me understand what that individual's process is like, because then I know what to expect, how long it takes. I can have realistic expectations of her. And then also, when she's out, and someone else needs to cover, I can help sort of facilitate that process. And as you know, especially in a private practice, when there's not as much redundancy, one person being. know it's like you can definitely feel it but anyway same thing with billing so like for an example with bit with billers is I really strongly suggest that you set up can understand retrospectively, and hopefully you do this quarterly and not every two years or something, you can understand that it'll give you feedback about your coding practices as it relates to your collection. So you may realize that I'm billing for the brachioradialis tenotomy with the dysradius, but it's not getting paid on Cignum. Why is that? Maybe because I didn't put in the right data in my op note, the right information. The only way for you to know that is for you to review it, and you should be getting paid for that. Yeah, we all complain about the guidelines, the coding, the this, which is true, but we need to be able to maximize the system that's actually in place right now. And so one of the ways to do that is to get this feedback. making sure that each member of the group understands what you're working for, what you're working towards. And it's very easy for, let's say, someone in your call center who kind of comes into like an area, they got their headset on, and it's very removed from interacting with patients or understanding what the mission is. And so one small thing that I did in my practice is I moved my call center staff to the front. So they're patient facing now. And so now, and that made a huge difference, and it increased everyone's mood, people need social interaction, and it sort of reminded them why they're here is to take care of patients, to help the doctors take care of patients. It increases their feeling of investment in their work, and I think that it sort of creates a common inertia towards a common goal. I put up these pictures because Steve Kerr, I'm a big basketball fan, and Steve Kerr did this experiment where he let his players coach the team in games. I don't know if you guys heard about this, like last year or the year before. And it was fascinating. It had like a really positive impact because it sort of empowered the players to have their opinions heard and felt. And it's the same thing with your staff. And then, you know, this is uncomfortable. We don't learn how to hire and fire people. You don't learn that in med school. But I think it's really important because if you're not actively involved in who's on your team, then it's on you. It's on you if it doesn't go well. And that can be direct or indirect. Meeting frequently, now this doesn't need to be onerous, but it does need to happen. It needs to be on the calendar. There needs to be some kind of beverage or food or something to make everyone kind of a little bit at ease. It's not just a, you know, sitting around like Dr. Evil. But this also prevents more problems. And then finally, you want to be able to reward success. You know, like, we all like making money. It's not a bad thing to do, to want to make money and be successful while taking care of patients. And your staff is the same way. And so that may mean incentivizing their pay or changing the reimbursement structure of your staff. It can be tied to the amount of surgeries you're doing, to the amount of patients you guys are seeing. But being creative, because humans respond, you know, we're all people, we respond to incentives. So I think giving your staff that opportunity is a good option. So I mean, in summary, no matter what practice model you're in, you know, the more active role you have in managing it, the better it's going to be. It's like any investment. The more you put in, the more you're going to get out. And another sort of thing is that I've learned the hard way is making sure that your whole staff, your team, is closely tied and aware. Thank you. All right, good afternoon, everyone. Friday afternoon. I'm sure everyone's dying to get out of here and go celebrate Hand Fellowships. Let me start here. So my name's Kyle Eberlin. I'm a hand surgeon here in Boston. I'm going to be sharing some thoughts about developing an academic practice. So just show of hands, who is either in an academic practice or potentially interested in an academic practice in the future. So quite a few people. Okay, good. Most of these thoughts are just kind of my two cents, things I've learned. I'm starting my ninth year of practice. I'm very involved in education. I run a residency program and helped run our hand surgery fellowship and have thought a lot about this stuff. So here are my disclosures, not really relevant here. And the first thing I would say is that every academic setup and practice is very unique. You are not going to find a one-size-fits-all practice. Whether you are in a large academic center or a small one or a private-demic, everyone's going to be a little different, and so it's not one-size-fits-all. And when you're starting your practice or getting ready to start your practice, there are a number of things that I think that you should think about academically. So I'm going to go through these sort of one by one, but these are my sort of five things that I think I wanted to say. The first is to set your goals. So it was already mentioned, but I think it's really critical. Define your academic niche, so think about what you want to do in your practice. Determine the available resources and the research infrastructure, because presumably if you want to go into academics or you are going into academics, that will be part of it, whether it's clinical research or basic science. You need buy-in from your boss. I have a lot of thoughts about that. It's very important. And then you have to, to some degree, prioritize your personal and family life, no matter how busy you are. So setting your goals. What is it that you want to do? It's not what your parents told you that you want to do. It's not what your residency program director told you you want to do. What do you want to do? And you've got to think, you've got to be an adult and you've got to think strategically about your future. What are you interested in clinically? What surgeries do you like to do? What makes you wake up in the morning and say, gosh, I want to solve that particular problem? That's what you should do. And then you've got to consider the balance between your clinical responsibilities and your research and administrative time. And I think that's, you know, I think a lot of us, that's our existential struggle, which is, you know, there's only 24 hours in a day. And how do you balance all of those things? And I think in academics in particular, it becomes very germane to all of these things because you have, there's often a lot going on. And then you have to think about how to get involved in societies. And if so, which ones, right? Everyone's here at the ASSH. This is a great meeting. But many of you are orthopedic surgeons or plastic surgeons, or maybe even general surgeons. And, you know, maybe you'll get involved in the AOS or the ASPS. And then there's subspecialty societies. There's ASPN for peripheral nerve. There's all these things. And you can't do everything. You got to pick and choose to some degree. And there may be one reason to do one versus another. So in an academic practice, when you start out, a huge part is going to be your clinical productivity. And that's what honestly you should focus on initially, because you got to get busy clinically. You got to be a good surgeon. But you may, you're going to have research interests in academics, right? You may, like I said, you may have basic science or outcomes research. And so you have to balance those two things. But your administrative responsibilities, the more into it you get, are going to grow. And figuring out how to, this triangle here is challenging. And everyone will be different. But you have to think about those things strategically. So is anyone familiar with the Eisenhower matrix? This is a behavioral psychology thing. It's worthwhile thinking about it as you kind of start your practice. But this is like business school type thing. So there are four quadrants here. There are things that are urgent and important. You should do those. Things that are not urgent and important, you should do those to some degree. And on the bottom right, of course, not urgent, not important, that takes the back burner. And prioritizing your life with your practice and everything else, your research, like think about it to some degree in this way. So this is called the Eisenhower matrix. So for instance, get involved with ASSH. And the best thing, Amrish is here at the top of the list, I recommend is being involved with the Young Leaders Program. This is something to which you can apply. I did it in, I forget what year, maybe 2018 or something. But it's a great way to get involved with the society. And most societies have things like this. You would be shocked at how easy it is to get involved in committees. Like literally all you have to do is volunteer and show up and do anything. Literally anything. If you don't just sit there in the room and you actually do something, you will be way more involved than you think. I'm not kidding. So this is a great way with ASSH. So point number two, find your academic niche. So you should have thought about this as a resident, as a fellow, in your early practice. And as I said, you've got to figure out what your own interests are. And also that of your institution. As a plastic trained hand surgeon, if I say I'm going to do all my research on olecranon fractures, that's a bad idea. It's not my strength. It's also not something I'm going to be doing a lot of. But I do a lot of nerve surgery, take care of a lot of trauma. So you have to fit that into your goals. And then figure out if you want to do basic science or outcomes research. So you really have to have good collaborators. We're all busy surgeons. I operate more than five days a week, usually. And you cannot do it all yourself. It's not possible. And if you really want to make an impact, you have to have good collaborators. So for me, I got interested in aroma management and nerve injuries. And so you've got to find your earthworm, so to speak. Whatever it is that you like to do, find it and stick with it. Point number three, determine the available resources in your institution. So again, starting in academic practice, are you going to have a research coordinator, research fellows? As you get busier, you may have more of them. As you publish and people want to work with you, who's going to help you with the grant? Who's going to write the IRB? Who's going to help with data collection for your studies? You may have all the energy in the world, but you cannot do all this yourself. So one of the things that you can do is to harness the power of your residents and fellows. Get engaged. If you're interested in something, one of your trainees will be interested in that. You just got to find the right person and someone who is motivated and that you can help shape their career also. And you have to build a team. This is so imperative for success. You cannot do this by yourself. And so there's tons of great ideas that will come about. But I'll say in my practice, this is our group of residents from last year, actually. And all of them are amazing people and are interested in different things. And many of them will come to me with an idea. I'm like, great, let's do it. Actually, from yesterday, this is our research team, our clinical and research team for hand surgery at MGH and another group of very brilliant people. Welcome, Eric. And you just have to have this team. And the bigger your team is, the more involved and engaged you are, the better off you're going to be. So point number four, you need buy-in from your boss. And I really think, in an academic setting, this is really critical. And you think there's going to be support for what you want to do. But whoever hires you, if they do not share your vision, and they do not share the desire to help your individual success, not like, hey, we need someone who's going to do dysarthritis fractures and elbow trauma. No, they need to want you individually to succeed. And they have to share that, make it part of their mission for you to succeed. And the shared goal model is just so important. And I think just one sort of brief anecdote. My practice is entirely extremity surgery. I'm a plastic surgeon. I do no cosmetic surgery, no breast surgery, no craniofacial surgery. And when I started, and you're sitting there, you're twiddling your thumbs, and you're like, gosh, I have no patience. Like, when are the patients going to come in? And you're doing all the things that was already discussed by Jason and others. You know, when people would call me and say, can you help with this breast reconstruction? I'd say, no, I cannot. I'm not doing anything not related to my own interests. And you have to have a boss, whoever that is, that shares that vision. Because otherwise, it's just not going to work. So I really think that's important. And finally, prioritize your personal and family life. There are always competing interests, always, no matter how busy you are. But you have to determine how you want to be productive. And for me, it's very early in the morning, before my family is awake. It does take hard work and commitment. And I will say that one of my really trusted mentors, Jesse Jupiter, who's an amazing person, he said to me, he said, Kyle, if you want to be productive, do it early in the morning. You know, I have two kids. I want to come home at the end of the day, whatever time it is. Usually it's after 9 p.m., but if I want to see, you know, I want to see my family, I want to do whatever, but early in the morning is the time. And so, you know, we go away as a family a couple times a year, and that is relatively sort of dedicated family time. You know, yes, I'll do work in the morning, and I'm usually up at 4 o'clock in the morning, even on vacation. That's my academic time. I'll do that. I'm there before all our residents are there every single day of the week, and that's when I do it. And so that doesn't have to be how you do it, but you do have to think about it, because as your life expands and as you get more involved in things, like, there's only so many hours in the day. So however that works for you, you have to do it. And so my wife and daughters are amazing. You know, before the ASSH meeting, my wife is like, are you going to be home a single night this week? I'm like, nope. She's like, oh, all right, you don't need dinner. So that makes it easy. So, but you have to have a support structure that allows you to do it. So I'm going to end there. I appreciate everyone's time. I'm happy to discuss this after the fact. Thanks. Thank you. Thanks, Kyle. And then I think, should we do Chris? Why don't you go? Okay. All right, Chris Grandizio, I'm from Geisinger Commonwealth School of Medicine, this is Maximizing Educational Research and Mentorship Opportunities. Out of curiosity, how many people in here are trainees, residents or fellows? Okay, a lot. All right, objective, understand how to maximize mentorship, research, and educational experiences in early practice. I was an Irish literature major, and unfortunately I didn't make it through this entire book, but you can take my word that the origins of mentorship were often traced to Homer's The Odyssey, mentor-guided telemachus during Odysseus' time away. I reached out to a few trainees within our program and asked them to define mentorship and list some positive traits in some of their past mentors, and the responses were all variable, but they all captured, I think, some very important components of mentorship. I think at the start of these relationships, it's important that both the mentor and the mentee really understand the components of the relationship. This is a dynamic and active process, and I think that's critical to remember, that this is not a passive process for either party. The mentor embraces opportunities to promote both the personal and professional growth of the mentee. The goal is to develop talent and teach a skill set, and that can be clinical skills, that can be research, that can be teaching, and it's existed for centuries in medicine, but it's far less formal than it is in other fields. The process has to have balance. The mentor and the mentee have to be equally invested, and there's equal benefits for both. Another critical feature is that this is a mentee-driven process. You have to be engaged and invested as the mentee in order to really make this work, and on the other side, the mentor has to have a personal interest in the success of the mentee and wants them to be a better version of themselves. Mentorship can be organic and informal, or it can be inorganic, which is a much more formal process. If you look at orthopedic residents, only 44% are satisfied with their current mentoring environment, and we know that satisfaction with these type of programs are higher when it's a formal mentorship program. While there are overlaps, apprenticeships are not the same as mentorships, and being a good role model, while important, is not the same as being a mentor. It has a life cycle. It has a beginning and an end, and it starts with building rapport and developing trust. You work to define and set expectations, progress towards a goal. You refine skills and overcome barriers, and this is often a very challenging component of this, and then once the goals are met, it's completed. I think another element to consider is that as the mentee, you want to pay this forward. You want to increase the pool of available mentors. Why does this matter? In upper extremity surgery, we need a robust pipeline, and medical student interest in orthopedics is lower than we assume, and this is particularly true for female medical students. You need to engage mentees before residency, ideally in medical school or even an undergraduate, in order to improve gender demographics and hand surgery. It's not enough to have available fellowship mentors. Again, why does this matter? The benefits for the mentee are things like increased professional growth, increased chance of academic promotion, research and grant production, mentor benefits, professional productivity, pay it forward, and it can decrease burnout. I think remembering these relationships and remembering what it was like and why you got into this, I think, can help you through some of the challenging aspects, particularly in early practice when you're stressed and your time constraints go up. So the traits of an effective mentor have been reviewed in a number of research articles, which I've listed here, I think are worth reading. I like to use a trained analogy for this, and we're all on the same track, we're all on the same pathway. As a mentee, there are just a few stops or a few stations behind, and I think keeping that perspective is important when they're going through challenges or struggles, remembering what that was like in order to be an effective mentor. So I'm five years into practice, and I think of mentorship for me as a mosaic, because I'm still a mentee, I still rely heavily on really strong mentors, and you may need multiple mentors for multiple goals. As a mentor, you have the advantage of combining these positive attributes to make yourself more effective. Some pros and pitfalls. This is something I really wish I recognized early in practice. There's nothing that you can give that's more valuable than your time. Make time for it, be present when you're doing it, be engaged, remember what it was like, and constructive criticism. You really need to become effective at giving constructive criticism. It's very easy to mentor strong trainees. It's very challenging to mentor people that are struggling or having difficulties, and I think this is an important component. We'll transition quickly to research. I like to look at this through the lens of mentorship. If you're going to establish research as a component of your clinical practice, and Kyle went through a lot of this, there's three challenges. Time, money, resources. There's time constraints. There's a lot of ways to approach this. I schedule research that I schedule my clinic in the OR. It's on a calendar. You would never think of not showing up to your clinic day. It's on your calendar. So you schedule time for meetings, manuscripts. I find it's really helpful at a minimum to have a weekly collaborative meeting with your team that's on the calendar. And as Dr. Greenberg really eloquently stated in the presidential address, periodic reassessments of priorities and commitments. You have to balance work with what you love and value in life and these two Looney Tunes. There's financial barriers, and my anecdote for this, I was two years into practice. I finally felt like I was getting busy. I wanted to start an upper extremity research fellowship. I went to my chairman in my medical school with a plan of what I wanted to do, how I wanted to do it, and it really helped to highlight the benefits to the system, not just to me. And I asked, and I was fully expecting a hard no, and they were super supportive. And at the time, it was like the coyote that caught the roadrunner. You didn't really know what to do with it. I was surprised they said yes, but you have to ask, and it helps to have protected time. Sometimes research stipends are difficult to obtain, but depending on your practice structure, FTE or RVU compensation may be more reachable. Not every surgeon is going to have the ability to get NIH grants or R01 grants, but there are available sources, things like hospital and university grants, tremendous resources to the ASSH and industry funding. Finally, you have to build a team, and this is one benefit of the mentor-mentee relationship, and Amrit covered a lot of this. One point from this, I think it's really important to recognize unique skill sets and be willing to learn from others, and I think that's regardless of their specialty or level of training. I've learned a tremendous amount from trainees that I've worked with that have expertise in certain areas. And finally, maximizing educational opportunities in early practice. I think there's a lot of millennials in the room, and I think we've all read the articles on how difficult we are to train and how the pendulum has swung too far for work-life balance. I think we're almost out of the woods because they're now starting to publish articles for Gen Z, so any of you who are here, best of luck. But newer learners are always going to continue to utilize newer resources, and so we often look at the classic textbooks and articles as standing in opposition to some of these newer educational sources, but there's fantastic educational content in things like podcasts, social media, and videos. So I think instead of viewing these as opposing forces, see how they can complement each other. And finally, a plug for some content on the ASSH, which again, I think is fantastic. I think no talk on mentorship would be complete without thanking the people that helped get you here. And with that, if there's any questions, I'm happy to answer them afterwards. Thank you. All right, that's great to hear so many of you are here and especially on this Friday before you get to go enjoy this amazing city. So my name is Eric Wagner and I'm at Emory and I'm going to sort of talk a little bit about leveraging the internet and social media strategies and considerations at least that I have had and I have kind of morphed during my first years. None of my disclosures are relevant. It's pretty amazing when you look at the evolution of education, particularly online education. You know, this is a 1983 picture. It's amazing how far the world has come since that point with the advent of the internet. I know, crazy, right? 1983. Sorry, it's blurry, but it just shows you like when things were introduced, I mean, it's amazing the evolution to where we are now and where we're going with regards to the web and with regards to the availability of online education. I mean, you heard over and over again about Handy and Hanpy and all this other great stuff that the Hand Society is driving. Patients do want education in this study in 2016, which is outdated at this point because the internet moves so fast and this generation has moved so fast, you would argue even at this point, 43% read about it before coming in and seeing a physician. And when they decided on who to actually come, and this is a 2022 study, the most important factor was what they read on Google and what they heard from word of mouth. And Google was actually more important for everybody except for the demographic above the age of 75 than what they heard from word of mouth. So I think there is some use in identifying, utilizing, and in trying to control that story a little bit. There's many ways to market from the internet or just in general. And I'm not necessarily here to give you an in-detail lecture on how to actually market. And without question, myself and anybody else is not going to be an expert in marketing. It's not something that we do very well. But it's something that you can learn to do better, I think. Traditionally, marketing was TV commercials. This is an Emory. This is actually how bad our marketing division is at Emory. This looks like it was made in the 1980s, right? This was a 2022 commercial. That's how bad we are at this. And billboards, there's still billboards all over Atlanta about this. But a lot of the more recent generations don't pay as much attention to those and pay a lot more attention to some of the online options that you have. So online marketing is nice. It also is, depending on what you use and depending on how you use it and how much effort you put into it versus paying somebody to do it, it is relatively affordable and accessible. But it takes time if you're going to do it yourself. And that's a big disadvantage. There's some other ones I'm going to talk about a little bit later with regards specifically to social media. You can create websites, maybe generic websites for your division or personal websites. Emory and many academic institutions don't let you do personal websites. But most private academics and private practices obviously don't care. And these can be very powerful marketing tools to direct patients to in their referrals. I found YouTube is a very helpful way. I put a lot of the technique articles that I publish or that we write up for like Handy or ViewMedi onto YouTube. This is a way that patients can be educated in addition to trainees, but it's also a way that patients can identify, hey, like you know how to do these surgeries, look, you talked about it on YouTube. I've had multiple patients be like, oh, yeah, I watched you do that on YouTube. I don't really have any questions, like where do I sign? So I mean, I think there is some value in controlling this online thing, even if it's not personally, even if you're doing it through your university like I'm doing. Physician rating sites in general, physicians hate these. This study suggests that the SSHH membership, 65% of them did not like these physician rated sites. Some surgeons actually even admitted to making patients sign consents to not post unfavorable reviews. I would not necessarily recommend that. I don't even think that would hold up in the court of law, so I don't think that's legal, but I would not recommend doing that, but it shows you how much patients hate these websites. This shows how highly unfavorable or unfavorable their view of these websites are in general. This is a recent survey. But as Samir and others have pointed out, they do matter, and I would argue you should pay attention to them even if you don't like them. This is a really nice review that Samir and Aaron wrote on this. The way I do it is I take happy patients, and this is not just me. This is something that we do at Emory. We take happy patients and we give them a card that has a QR scan that takes them to the Google review site for me, and then a website address that takes them to Health Grade. This is, I guess, a way to control the dialogue a bit by giving the happy patients, the ones that theoretically are going to, if they do write reviews, are going to write positive reviews, help you to direct the message, because in general, although you'd think everybody's going to write you positive reviews, that's not always the case, unfortunately, and I'll just kind of show you a brief breakdown of mine. This was taken a couple days ago. You can see we've, using that card, have controlled the message a bit, but there still are some negative reviews. Some of these negative reviews are ones that you don't have a lot of control of. So this is a lady that I treated a disarray fracture, non-operatively, she was reduced by a resident, came back to clinic, very reasonable reduction, but got some stiffness, as sometimes they do after they break their wrists. She was furious that she had stiffness, furious she could not get back to yoga, and decided to tell the whole world how furious she was about it. I mean, there's not a whole lot I think I could have done. If I had operated on her, I'm pretty sure I wouldn't have made her happy, and unfortunately, this is one of the reviews. You also unfortunately have patients who don't understand the whole one-to-five rating system, despite very much liking what you did for them, and not having any issues with what you did for them, still mistake that whole one-to-five system. But nonetheless, it's still nice to kind of control the dialogue, I think, in some respects. So social media is an interesting one, and I think this is something we are going to learn more and more about as time kind of goes, and I can't help but think that there are going to be some issues, unfortunately, from a HIPAA standpoint, and from a government regulation standpoint with us, but that's a whole other sort of discussion. In 2010, not a ton of people used, not a ton of patients used social sites, but that was 2010. If you look at what happened from 2010 just in the U.S. population, compared to 2021, you have double the amount of population using social media sites. So you can imagine upper extremity patients are now using them at very, very high volumes at this point. And in general, across sort of all surgery, people are using social media sites, sorry, they are using social media sites, they are using other sites as well, but these are not just young patients, these are also patients over the age of 56. Ortho-residents even, residencies have changed with COVID. More and more have used it since COVID, and I don't exactly know how they did tiers, but they rated it in tiers, and it seemed like some of the more reputable ones had more accounts and more followers with this. Academic versus private surgeons, it doesn't really matter, they both do it. Academics have a little bit more YouTube, but in general, social media usage, both types of surgeons, both types of hand surgeons do it. You can see here the different options here, but social media is present in this case. And this is a macro view, unfortunately, across all specialties, all surgical specialties, shows there's no practical recommendations in the professional standards for social media, which means we have not learned how to regulate ourselves. At some point, I think we're probably gonna be regulated, and unfortunately, I hope everybody's getting consent for posting these patients on social media, and I hope patients aren't having a problem, but there's a lot of HIPAA data going out on social media that you probably are seeing on your friends or colleagues or other surgeons, and so I can't help but think at some point, there's gonna be some issues, but so far, there hasn't been anything sort of super major. I actually have tried to correlate social media with citations, as you know, JHS uses social media to promote a lot of their articles. There's been a re-correlation so far, correlating tweets to citations. I do use Twitter as a professional account, I can say I doubt it has much impact at all, and not that many people follow it, but nonetheless, I do think it's fun to just interact with other people on it. It shows a very weak correlation here, and in general, this is a really massive systematic review. I don't imagine what resident or medical student went through 1,700 trials in this systematic review. I've done systematic reviews of 20 trials, and that took a long time. I can't imagine how long that took, but nonetheless, they did. You can see online mentions were associated with potentially higher degrees of citations, Black Factor VIII index, and kind of shows some of the correlation between the site, the online mentions, and the citations. So what do I do? So personally, I've made a decision to separate professional and personal life in a lot of respects, and I do do that for social media as well, in some respects. I did start the Emory Upper Sherman YouTube, that's where I post a lot of circle videos that I and others include. I also started our Instagram, Facebook, and Twitter accounts, and do drive a lot of this with the help of my younger, more tech-savvy fellows. So personally, I have a personal social media that's not linked to this, and then I have a professional one that I promote both what I'm doing as well as what my partners are doing in this profession. I personally like that better. I do have a personal Twitter that I do use to promote, so I guess it's not totally separate, but my Facebook and Instagram are separate. But I think you can do it. I would just caution you with regards to HIPAA stuff, because I do see that coming down the road at some point. So final thoughts. You kind of have to decide what's good for you. I gave you some options, at least what I do. It's not the end-all, be-all. I'm not obviously perfect, as you saw with some of those reviews. I think you have to decide your priorities, how you want to market yourself, the different resources. Hopefully, at least you understand some of the different resources. I would encourage you, no matter what you do, to take control of the message. Don't let others take control of it. Do try to take control. Do try to educate. Do try to take control of your message out there, because it does matter, unfortunately or fortunately. What people read on the Internet, they do interpret as a reflection of you. So I would encourage you to consider these things, and reach out to me if you all have any questions. So thank you. Thank you. Amir, can I? Thank you. I wanted to... Yeah. I don't know if this is on. Well, I'll just speak loudly. Yeah, I think it's good. Is it? Yeah. Is it on now? Yes? Okay. Yeah. Just one comment. That was a great talk. My high recommendation when you start your practice is to Google yourself, because you know what? Guess who else is going to Google you? Every single one of your patients is going to search for you on Google, and you don't know what you're going to find unless you do it. And there may be good things, and there may be things that you're like, oh, I wish that wasn't kind of number one on the list. But it allows you, to Eric's point, to control the narrative. For instance, I can't tell you the number of patients who come in, and they have searched for me, and I know that, because they'll say, oh, I saw that you put some kid's arm back on, so if you did that, you must be able to do whatever problem it is they're presenting with. So that is actually strategically very useful for me, because if that's what they find, then they're like, oh, that's complicated, so this simpler problem must be okay. So controlling the narrative is really important. So Google yourself, and figure out a way to modify it if you need to. I think we'd open up for questions, and feel free to ask any questions. We can take a few minutes before we adjourn to our alumni sessions tonight. Does anyone have any questions? Both. So the QR code goes to Google, the website's to Health Grids. Obviously people pay attention, as you can see the differences in reviews, I have four times the amount of reviews on Health Grids than Google, so I don't think people are so savvy enough to use the QR code as they are using a website, but nonetheless, it goes to both. So we try to control that. We actually did this, Emory Orthopaedics did a study on that, looking at the number of, they kind of studied how, when patients first came, the number of clicks, the number of times they accessed different websites prior to coming, and they kind of really went into detail about that, and they actually found that Google, without question, is the most common one, and if you're gonna ever try to control a narrative, you should do it on Google. The nice thing about Health Grids, though, is if you have a lot of reviews on Health Grids, that's the first thing that comes up when you search, you know, so-and-so, Kyle Everton, MD, he has a bunch of reviews on Health Grids, that Health Grids is gonna be the first thing that pops up on the Google search. So you are kind of controlling both narratives, but yeah, it's- You can, you can make your, in fact, you should make yourself a professional Google entry. Yeah, absolutely. And that's free. Good point. I mean, so then it comes up as your name, MD, as like a, as an entity. One other comment. It's very hard to expunge negative reviews, it's like really hard to do that, so you're better off drowning any of those out with positive reviews. So just, if a patient is not particularly happy, don't give them the QR code or the website. You all know who those patients are. Give it to the happy ones. You had a question in the back. It's kind of a common thread, I think, across most of the talks, is that no one is going to be as invested in your practice as you. If it's a coding thing, if it's research, if it's financial, the more you put in, the more you're going to get out. I mean, that's, I think, the thread from today. What do you guys think, and the audience, about the third-party sites or services that can help you, like PatientPop, and that sort of thing, there are these companies that will say, and you probably already get emails from them, we'll manage your website and your online presence, and what do you guys think about those services? So do you guys have an opinion, and I'll give you mine? My opinion is that you don't really need that, it's a waste of money. I agree. I think your time is better spent being a good doctor, taking good care of patients, and you can curate your narrative online yourself. It's really not that hard. I would 100% agree. I mean, I think you get into some ethical issues with some of the services they offer, but I, in general, think you can control your own message well enough that you don't need to pay for that. Maybe the exception, if you have a very extensive website that you don't know how to edit, paying somebody to help manage that, sure, maybe that makes sense. Like I said, unfortunately at Emory, they don't let us have our own websites, hence why we use Emory stuff to sort of really push the narrative, but I personally created all of our social media websites and post on it, it's not that much work, so I would say control your own narrative. I don't think you need to pay for it. I'm glad you guys said that. I feel the same way, and I think that it's kind of another example of an industry that may be preying on doctors a little bit, and it's kind of like an analogy would be like a financial advisor, and maybe you guys are learning about finances and having an advisor that's taking a percentage, a constant percentage of what you're making as opposed to fee-for-service type of industry, which I think is much more, if you need a website, get someone to design your website, and then that's it, and then manage your narrative yourself. I want to make one other point about social media. Eric has two, you mentioned he has a personal and a professional one. I only have one. I can barely manage one of them. You all will find that patients not only will search for you, but will try to add you as friends or whatever it is, or like follow you and things, and it gets a little tricky. This past week, I saw a patient in the office with a pretty complicated problem, and like two minutes later, they added me on social media, and I was like, that is, because it popped up on my phone. I'm like, whoa, that's really weird. So you got to figure out how you're going to handle that, because it's going to happen, and you just, everything must be professional. I don't think there's an exact code of ethics per se, but everything must be professional. I think this is the updated version of physicians or surgeons giving their cell phone numbers to patients, which some people do routinely, right, and that's a personal decision that they made in their practice, and adding a patient on social media is the kind of modern equivalent of this. It has to be above board. Any other questions? I'll probably be the outlier here. I don't do it at all. So everything goes through my nurse or the team. I personally, like the telephone thing, I don't want anyone to have my phone number. I don't give my email address out. No patient gets anything from me. That's just a personal decision I've made. I've never had someone say, oh, I can't reach you, right? But I think the corollary of that is you have to make sure whoever you delegate that to, number one, is 100% trustworthy, and number two, will call and forward everything to you if they need to. So I'll tell you, my patients are always like, your nurse Barb is the best. She responds to everything. And I feel comfortable with that, so I never worry about it. But I can see both sides of the table there, but I don't. Chris, what do you think? We have a direct messaging system where patients can send us a message that goes right into my inbox within our EMR, and my nurse and PA will answer probably 90% of those, and they know at this point to forward me patients having an issue or a problem. And I choose to respond to those directly myself, but the majority of those messages, I agree, are fielded by my team, who I think do a fantastic job of it. So we have Epic, so a lot of the in-basket messages go to our APPs, but I give every single patient my email address, every single one. And almost, very few patients will abuse it. And it's not my cell phone number, it's my email. And patients I find like having the ability to reach out to you, they know you use email. And if people start to abuse it, my responses get shorter and shorter and shorter and shorter, to the point where I'll respond 48 hours later, I'll say, please come to the office or something like that. So I think you can control it a little bit. Eric, what about you? So I guess I'm on the opposite end of my colleagues. So I call every patient I operate on for the week on Sunday afternoon, when I'm, like, if there's a lull in the day, doing laundry or whatever else. They all have my cell phone then, if they have caller ID. And that phone call takes 30 seconds per patient, because they're not expecting the call. And I can say, if you go through the health grades on MyHealthGrid, you'll see probably more mentions of that phone call than actually the surgeries that I did on them. And somehow that translates to me caring a little bit more. And so they all have my cell phone. I have very few that abuse it. And the ones that do, I simply, we have a patient portal message, or a patient portal that they can easily access, and I simply reply saying, please go through the patient portal. And that's it. And then that's it. And I've yet to have somebody, after I said that, ever message me again in some inappropriate context. So I've yet to have anybody abuse it. And I have some patients that are over the top. But nonetheless, they seem to respect that boundary for the most part. And there's certain times when they've actually reached out in true emergencies that I've actually appreciated being able to get them in a little bit quicker. So. Jill, how about you? And maybe the opposite. I just want to add on to that. For anybody who's not really comfortable with giving your personal cell phone, you can actually make a Google phone number that actually is separate from your own personal number. And I think that's actually a really good way to kind of differentiate what your own personal calls would be versus, you know, those from patients. I personally have given my cell phone number out to multiple patients, and I find most of the time that they don't abuse it. I think during board collection, it becomes very apparent if you have to have follow-up that you have very close communication with the patients that you're having come back. And I think that the relationship that you're able to build is much stronger if they feel like there's a personal connection. And so I think, I know that certainly some of my patients would not have come back had I not reached out to them personally and given my cell phone number. So at least during board collection, it might be a good idea. When you get more busy and you have a good nurse, then maybe tell her back. I think what you can see is that there's a huge spectrum of how you can handle it. There's lots of different ways to do it. But you need to have a plan, and you need to have a plan that works for you. I'm actually somewhere in the middle of the spectrum. My routine is when I consent someone before surgery, I ask for their cell phone. And I call them the day after surgery to check on them, which usually decreases the amount of the questions that come, and my arm's numb, what happened, are my nerves cut or something like that, because of the block or whatever. And then I have given out my cell phone sparingly when there's a concern, when there's a problem. If there's a complication, not that I've ever had a complication, but that sort of shows them that you're available, that you're concerned, that you're responsive, because that's very important to patients. Yeah, the only thing I was going to say is, I think the one thing that you'll hear across the board is you have to be responsive. Whatever technique you decide to use, I still phone the patients, I still call them. I just use Doximity, so I have a hospital line that looks like they call, that I'm calling them from. But when you, one four-second phone call with a family member or with the patient saying everything went well, I'm really excited, I think everything is going to go great, we'll see you in a couple weeks, they love it. And they do really, really appreciate that phone call. So whatever technique you use, just make sure it's ironclad so the patients who have to see you or have to communicate with you get the service they need, because it'll make a big difference. I think we're going to adjourn there.

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