Can I just have a show of hands, first of all, who are residents in the room? Who are fellows in the room? Who's in their first five years of practice? Okay, so that's, so we have sort of an early group of individuals, right? So how many of you went to my presidential talk yesterday? Okay, how many didn't go? Don't be afraid. So the reason I'm asking is that there really, there is some overlap with yesterday. So I'll give you one audible if you want it, and if you don't, there's no pride here. My audible was, if you wanted the opportunity just to sort of ask questions about anything, and you just can't, it's a small room, this is a really, it's a nice intimate group. You could ask questions about anything as it relates to leadership, organization, life insurance, estate planning, asset protection, private equity, you know, any, I mean, because we don't all have the opportunity to be in the same place at the same time, and one of the best things about this last three days for me has been the opportunity to have, you know, over 100 one-on-one conversations that have been really sincere and kind of soulful with people, and I'm feeling, even though I have a lot going on, I didn't feel like I have to rush everywhere. I had enough time, and that was really gratifying, and people came up to me and were asking me a lot of questions, and I thought, if that's something you guys would find useful, you know, this is, I love this talk, and I modified it a bit because I assumed some people had seen some things from yesterday, so I took some things out, so it wouldn't be totally redundant, but, you know, I'd be willing to do that. We have 15 minutes, right? Is that right? So did you want to raise your hand if that's, you'd have to have a question, and I don't want this to be a waste of time, and if you don't, that's okay. So anyone, Buehler, anyone? You like this idea? You want to start with it? So okay, so you guys know kind of what I'm, you saw the lecture yesterday, and you know the way I think about things, and obviously, you know, I've published lots of papers and textbooks and have been training residents and fellows for 23 years and have been involved with team physicians and all these things, you know, and I'll be honest, yesterday, one of the things that was really meaningful to me is that it provided an opportunity to sort of take down the barrier a bit and maybe share some things that were really sort of personal and how also imperfect I am, and everyone is, and like you said, Jackie, where'd she go? Yeah, so like you said, you know, when I started writing this talk years ago, I remember being on the plane, and Emily looked over, and she was like, you're kidding, right? And it's, I think it's a combination between contrition and confession. That's the way I look at it, you know? So anyway, let's try this, and if it's not working, we feel like we're not getting anywhere or not anything of value, I want to give you something of value if I can for the next couple of minutes. Yeah, with you. Yeah. And to please just think about something that maybe might be helpful. I guess my question is, so I'm in my seventh year of practice, and I wear a lot of hats, and I'm incredibly busy, and I guess how do you do all of the things that you've done so successfully for so long? Because, you know, especially with a young family, that's the thing that I find so challenging. Yeah. How do you make it all work and be successful at all? So, you know, that's a lot of the talk, in a way, but I would say the things that have been particularly, look, in many ways, I look at the last 25 years of my career in cycles, or in stages, I should say, and they're not all the same. And when I was first out, all I wanted to do was build a successful practice, and I had no help initially, and I was in a big group, but you come in, you've got to earn your keep here. And so the things that have been most meaningful to me are to delegate responsibly, which means knowing the people that, well, first, building a team. We always say there's no I in team, all this stuff, right? But the point is that there's no way you can do a lot of things unless you have really competent people around you, even if you have to overpay them, okay? Or even if you have to have more than you need, in the end, it's kind of your salvage. So, I learned that early on from people like Freddie Fu, Russ Warren, and others. And so that has been particularly helpful. So, identifying really high-quality people that have similar aspirations, they want to feel valued, they don't, certainly they want a good salary, but they want to feel valued and they want to feel that you have gratitude for what they do, and you match the things, I try to match the things that I do to their skill set, but then I always follow up. So, for example, when we have these research assistants who help us do a lot of these publications, I could never do all this myself, we now have weekly meetings. And because we're so robust, everyone's in the same room at the same time, it's an hour meeting, and one week is basic science shoulder, the next week is basic science knee. Are you in private practice? Okay, academic? Perfect. So, then the next week is clinical hip, and we go through it, right? And everyone has a chance to speak and update, and we keep everything updated, and we're very, very inclusive, so people stay engaged and don't feel alienated from the process, right? So, that's been very helpful. So, responsible delegation, not dumping on someone, but responsibly delegating to other individuals, that's been very helpful. Interpersonally, I said it yesterday, I try not to think about this concept of balance in terms of, I'm just going to work like hell right now, and then when it's all over, I'm just going to reconcile it, and, you know, we'll make up for lost time. That, I put that out the window a long time ago because I have a lot of passion for my kids, and my family, and Ethan, my own son, Ethan's here, he was gracious enough to join us, and his two friends, one of them is pre-med at University of Illinois. And so, that was really important to me. So, taking a legitimate vacation, we've pretty much always done two weeks over Christmas, one week over the summer, and then a lot of passion for activities like skiing and sailing and some personal things. So, that's it. The other thing is balancing it with physical activity, okay? So, for a long time, I just preserved a time in my schedule that nobody could touch. So, mine was Tuesdays and Thursday mornings with a trainer, because I found if I didn't have a trainer, I just wasn't working out, I was just, you know, I'd come home, I was just tired. And my worst time in my life was probably early when Ethan and Adam were really young, and I just was, I was overweight, I was unhealthy, I just looked like shit. And if you look at those pictures, that's what I was saying, pictures tell a story, I went back, and I was like, I was just a different human being at that time because I was so focused on getting my career up and running. So, that was my really big time, that was my mistake time. And the way I corrected, so if there's anything I can teach you, is I learned to delegate responsibly, I learned to make sure the people I'm working with understood that I truly value what they do. I bring enough people in that there's maybe even a little bit of redundancy, but making sure everyone feels like they have a responsibility and you're meeting their needs. And I pay them well, and it's not all about how much I can retain, it's keep them around you, because when you lose good people, that has an enormous cost. I've lost three people in 25 years, and I have a pretty big team right now. So, that is just, we're really, really, we're just really, really loyal to one another. And I'm not afraid to make the coffee, to mop the floors in the room, and so forth. There just really are no real boundaries in terms of how we behave with each other, but our roles are respected. And then I just really try to lead by example the best I can. So, besides delegation, besides the people around you, I think, and it's just, that's kind of the layered approach. And then the balance is, like, I've been taking Fridays off largely for about five or six years now. I still, I don't do any patient care or any surgery. I'm busy, but it gives me flexibility, so that I can unload during the week, so that not every single night I have something. So, I can push it to Friday, so that my weeks are more normalized. And blocking time for you, that nobody else can touch, is huge, I think. Because if you don't take care of your physical wellness, it's really hard, I think, to be successful in the other things. It's just, it's a biologic phenomenon. I mean, I look at JR. JR, you've always looked like the way you do, as long as I've known you, right? JR wasn't always great. Yeah, but, like, what do you do for exercise? How did you carve it out in your life? You made it really important. Look, I always did it personally. I didn't do it through a trainer. But I grew up as a college athlete in New Jersey. I rode a lightweight crew. And I just said, I'm going to take an hour every day, three to five days a week, and work out. So, I still do. Yeah. I mean, how bad would, when you don't do it, or you slip. Doesn't everything else sort of feel off? Well, yeah. So, I graduated from college at 145 pounds. I weigh 145 pounds now. At one point, I got up to 160. Very similar things that you did. Perhaps a little bit older, because I did it when I, I put on that weight when I was being a chairman and trying to do all this stuff. I just had so many things to do. And my kids are actually older at that stage. But it's, you know, you've got to take the time to exercise, take time for your mental health. Because it's the only way you can do everything safely and for your family. Your family needs you to be thinking healthy, good. Yeah. Do you, does that help? I don't know. I mean, with the question. There's no magic. I mean, it's pretty common sense. Like, what's the biggest thing you struggle with? Well, I think, I think it's, I have a tough time saying no. Okay. And then I think, sometimes when you don't have the operational control to build a team around you. Yep. That becomes really a big, a big struggle for me. Because I know what I want, and I just don't always have the resources to do it. And so, getting the commitment and buy-in from the people who make those decisions to see the same vision and invest is sometimes hard. Read this. Just take a minute. Okay. I don't know if it's helpful, but just very specific things. You're not going to make change unless you just, you know, do it and make change. The saying no thing I gave you, I gave you, and this is the other thing. When I do say yes, I focus on taking things, like there's a thing, a principle in business called vertical integration and horizontal integration. Horizontal integration is when you have a knowledge pool, and you accept a new task, and you move horizontally, and you, it's what Steve Burkhardt mentioned in his innovation lecture in a different way. So, you can take on new responsibility and do it with excellence because you're borrowing from something you're already doing. It's sort of an economy. It's an efficiency. It's an economy of scale, right? Vertical tasks are things that you don't do. Nothing in your life, you know, someone comes to you, and I want you to, you know, I had to do, this guy Willenda climbed between two buildings, and they wanted me to be the medical expert in front of 24 million people on TV to talk about a guy walking on a tightrope. I don't know shit about a guy walking on a tightrope. I don't know anything about that, okay? It took me six hours to figure out, you know, anything about it. It's something that, you know, is ego gratifying, but that's not in my knowledge set, you know? So, the point is that pick things that you have a knowledge base and say no to the things that are not going to deliver anything of benefit. They're going to take you out of balance from your family, right? They're going to take you out of balance from your friends, from your work. So, say no to the things that really don't deliver anything of value or take time that really, you really could be purposing otherwise. Look, as I say, we pay for things with time, not with money, you know? And people will circle back, okay? I told that story about Rick Ryu. He came back. You know, people, smart people know that if you're contemplating whether or not you're saying yes or no, that you're really assessing the situation and you're not going to, and if you accept the responsibility, then you're going to do it with excellence. The worst problem is that we all know this. Beachy and Lou, when someone says yes and doesn't follow through, that's a way worse problem. You cannot get out from under unreliability. That's sort of an original sin. You say yes, you have to do it. Right. And if you don't like it, you just do it. Because once your label is undeliverable, it's bad. You know, if you, especially if you have academic aspirations, people will forget that you say no, but they won't forget the fact that you were unreliable. You had a question over there. Yeah, please. So when you look back, what is one thing, you know, maybe 10 years ago or so, that you already established that you would do differently? You never told me how to work. Well, I think the one thing for me over the last 10 to 15 years is that my biggest change was focusing on my health and carving time for my family. And that felt good. So that when I was at work, I felt better at work. So I think that that really helped me. I think, you know, as I said, I think the worst I was was my two boys. I have three kids. And when Ethan and Adam were really young, and I remember being in the house on Magnolia, and we'd be in the basement. They would be fighting, but play fighting, you know, wrestling around. And I'd be on the floor with them. And I literally would like fall asleep while they're all wrestling around. You don't remember, you were too young. But I remember just being tired all the time. I just didn't feel well, you know, I didn't have a medical problem. I just wasn't getting proper sleep, whether it was enough or not. I wasn't focusing enough on my health. And I was out of balance in terms of the time being spent. I was just always working. I'd work during the day, come home at night. I've learned to multitask and not waste time. I can tell you that. I feel that I'm working smarter and smarter and smarter. And during the day, for example, in between cases, I'm always dictating. I'm always making phone calls. I'm on email. I'm never not doing something during the day so that when the nighttime comes, I don't have to be doing something all the time. So I just do not waste time during the day when I'm able to do that. That's helped an enormous amount. I have a physician assistant, Kyle, who was here yesterday, who is really social. Everybody loves him. I mean, this guy, there's everyone who knows him. He's just like this effusive, really just awesome individual. But he's always working because he wastes, not waste time, he just isn't always working because he's sort of building. He has his purpose that way, but he's also excellent and sometimes has trouble balancing getting the work done because he has a tough time sort of reining in. And I tell him this to his face. We joke around about it. I'm like, dude, just sit down and don't talk to anyone. And I'm not saying keep your head down and ignore people, but there's a time to get some work done too. You know what I mean? So it depends what your priorities are. My priorities are not to be working all the time at night and have time to exercise. The best way I'm able to do it is to not miss a window when I can be doing something else during that time. Don't confuse that with sort of that back-of-the-white code phenomenon when people are trying to talk to you, walking away and ignoring them. Do your best to make that a quality interaction. Put the computer down. Try not to look at the phone and so forth and really make the interaction quality, but then get back onto something else if that makes sense. So I think that's helped me a lot. Coming in the same pathway, what are the two or three things that you regret or you would have done differently? That's a great one. What would I have done differently I regret? I would say that I wasn't – it's not regret. I just didn't have the – I feel like I have a lot more insight now than I didn't have before. And what I shared yesterday was, you know, I think that whenever you meet someone who has had a really significant event in their life when they're very young, okay, or they had to maybe pay the way through school, they had economic challenge. Like Rick Ryu's talk today, he talked a little bit about what it was like when he grew up. Did you hear his talk for the diversity? Yeah. These individuals are far more prepared later in life to handle challenges. I was the flip side, quite frankly. I was really – even though I literally put myself through medical school and college and medical school but still grew up in a fine setting, it was just that was the economic change in my family at the time. That was never a problem. I didn't look back and say, oh my God, I wish I had more and more. I was fine. But the point is that when people have really big challenges that register early, they are often better equipped to deal with things later on in life, okay, in my opinion. That's what I was trying to get to yesterday with this humility thing. Just kind of moving along and doing my thing and a couple of things happened. I'm like, wow, I have nothing really to borrow from in early life experiences to help me with this right now. Got through it, learned sort of everything is gravitation to the mean. Something can be really bad or really great but in the end, we all sort of kind of gravitate to the mean, right? So I would say it's not that I have regrets. I just wasn't prepared, I think. I had to learn. So I think that we do differently through life based on our life experiences. Like you do different as a doctor through life experience. You become a better doctor every year of your life because of all the patients you've treated and you get to borrow from their good and their bad outcomes, right? And that's the art of medicine. That's truly the art of medicine. It's not picking up a book and reading a new paper and learning a new technique. It's how to make good decisions that are in the best interest of your patient to avoid that most common complication which is not meeting the patient's expectations. Fortunately, all the stuff we do has a low complication rate. The number one is doing something that doesn't lead to a good outcome in the patient because it was just not well thought out and it didn't meet their expectations. So I can't tell you any great lesson learned other than some of the things I've already shared with you. And the things I'm telling you about now from time balance, you know, that's had a big impact for me for sure. Bill? I thought that was a great comment you made yesterday. And maybe for the younger people, us old guys would probably be glad to learn it, is that what's good enough? I mean, you can spend, you know, two hours on a talk that's like your usual awesome. You can spend another four hours on it and it doesn't get that much better. Right, right. That was a great comment and you can share that. Yeah, I agree. I think I was the person in college who would go to a room and stand up and recite things to the point where I, in preparing for a test, I mean, I went to University of Illinois, this young lady goes to University of Illinois, and I used to go to these buildings on the quad and study. It was all by curve. Our biology class had over 100 people. I would literally go to a room, know the material so well that I could recite it and so I had a visual, I wrote it, I just worked with it. I was getting 99% and above on everything and I was finishing the test in a third of the time. I could have spent half the time doing that and probably still gotten 99%. I would have worked really hard. I was clearly an overachiever. School was not easy for me. But being overprepared for something doesn't, it's like that concept by Warren Buffett. You know, jumping over a bunch of seven-foot bars that yield the same thing as a one-foot bar, you might as well jump over a one-foot bar and get the same outcome. So balancing this concept of efficiency versus perfection, you don't want shoddy work. You don't want to be an 80-20 person where you just ignore 20% all the time. But you can selectively pick things that you can be really efficient with your time and move forward rather than getting stagnated. So that is a good concept and that's something you just learn with time based on your own personal skills. JR, we're going to have to finish up, JR. We'll get to the next talk. Go ahead. Well, Brian, the only thing I'd say, you know, and I'm a few years older than you, a decade older than you, and there are a lot of people that are my contemporaries and I think if we went through a stage where we probably didn't have enough time with our kids, we just didn't have the time to do it or maybe weren't as effective of it. So I would, one of the things I'd advise the young people in the room is make more time for your kids. You might think you have a good home life and a work-life balance, but you never have enough home life. And to that point, I knew that I'm a little bit younger than JR and I designed my life so that I could see my kids grow up. So we lived across the street from their grandmother. I lived in my own office in the surgery center which was miles from my house. Went home every day and saw the kids. I saw my kids grow up again. And that takes a chunk out of your productivity too, but you know what? It's something to consider. Yeah, I'll leave you with this one. And kids don't know how much you know until they know how much you care. And I don't think Ethan cares about how much I know I think this is a good take home because you can never buy that back. And that's something we learned over the pandemic. The greatest thing about the pandemic for a lot of us was I never thought I'd have our three. They believed me. They wanted to get the hell out of there at some point. But I will tell you that none of us expected we'd ever have our kids in the same place at the same time on top of each other making food together, doing all these things, reigning it all in. That, God willing, will never happen again, but that was a silver lining in the whole thing. Thank you for your time. And if you guys ever want to reach out, my email is bcole at rushortho.com and I'm always happy to talk about this stuff. So I like doing this I think more than some of the cartilage work and everything else because that stuff has gotten much easier, you know, although we still have more questions and answers. Anyway, thank you and thanks for your

leadership

delegating responsibilities

work-life balance

personal anecdotes

physical wellness

operational control