Were you always called Theo, or were you called Ted? My parents really liked the name Theodore, so they chose Theodore, but they didn't love Ted, and so I've always been Theo to them, and I guess most of my close friends and family. My program director in residency, because he always liked to sort of needle people a little bit and come up with his own nicknames for them, called me Ted all the time, and he still does when we are back at alumni meetings at the academy and other things like that, so I'll usually respond to that, too. My dad's name was Theodore, and one of my brothers, too. They went by Ted, so that was... Yeah, good name. Yeah, I had another good friend in med school who always called me Teddy, actually, but anyway. Yeah, my brother went by Teddy, interesting. Terrific. Well, I think they sent a list of kind of standard questions here, but I almost, with you, would love to just hear about what it was like back in the sort of world of open shoulder surgery, and this newfangled device called the arthroscope comes along. I was fortunate during the course of my faculty tenure at Baylor to overlap with Steve Burkhart and the Burkhart Research Institute, where we had a joint fellowship between Houston and San Antonio for the last two years of his career, and then I'm out at Southern California Orthopedic Institute right now, where Steve Snyder obviously left an incredible legacy, and I understand they were sort of contemporaries and close friends and colleagues of yours for many years, and so I definitely want to highlight that today. Sure. But I guess even, you know, they ask a lot about the institute, but how did you just get into arthroscopic surgery way back when? Well, in 1976, I visited Lanny Johnson. He had an exhibit at the academy, and I became enthralled with the pictures he took, and everybody else said, well, if you look at a knee, I could see more open, and I could never see more open, and I thought, well, I'm not as good as these other guys, so I bought an arthroscope in 76 and started scoping knees, and there was very few people to talk to. Lanny and Dick O'Connor and some other people early on, and then I visited Lanny in 1980, and I never opened a knee after that, so Lanny was my mentor. He showed me the 18-gauge needle operation, and from then on, it was that kind of history, and I ran into your partner, Dr. Steiner, in about 81, I think, and started the San Diego shoulder meeting, but this was always done through Anna because this was new. The traditional knee surgeons at that time had no use for the arthroscope. In fact, the academy once had a symposium, what was better, the arthroscope or the arthrogram, and early on, the people scoped knees, and then they referred them to a surgeon to say what was going on, so initially, I would look at a knee, and I would say, oh, you don't have a tear of the medial meniscus. You have a tear of the lateral meniscus, and now I can know I only have to make the incision on the lateral side of your knee, and all that then changed, but we were challenged by traditional medicine, traditional surgeons who had no use for us, so when the shoulder came along, I had already lived through that with the knee people, so I felt a little stronger that this shoulder was here to come. Yeah, I think a lot of, I'm sort of mid-career right now in my 40s, but arthroscopy, I was young enough as a medical student that I think arthroscopic rotator cuff repair had just kind of taken off and sort of become the norm, but I still saw some mini open rotator cuff repairs in my training, and that transition had just happened, and I think for younger surgeons who've trained in the era of the arthroscope, it's almost second nature, and probably a lot of them may not understand some of the sort of trials and tribulations and maybe dissenting opinions or resistance which it met when people pioneering it like you kind of brought it to the fore, but I guess could you talk a little bit about how just your involvement in the beginnings of Anna and organizing the society and meetings and the San Diego shoulder meeting and kind of how those kind of got off the ground? Well, I wasn't initially a member, I think I became a member in 1980, and at that time it was just a group of people who were the giants to me, and they didn't know me from anyone, and I went to a meeting in Chicago of this organization, and Dr. Howard Sweeney was my mentor, my first year of residency, and to my surprise, Dr. Sweeney was in the audience as an early member, so I thought there must be something to this organization, Anna, and then over time I have made lots of friends, and Anna was devoted toward treating all surgeons, and as I mentioned was not accepted by a traditional knee and shoulder orthopedic surgeons, and was not in the residency program. In fact, when I was involved with, so early on the Anna then decided to have a learning center, and I was on the initial board of directors of the learning center with Jack McGinney and Whit Ewing, and then two members of the academy, and then they bought the learning center into fruition, and then Anna, actually during my year as president, I hired or got the board to hire a real fundraiser, a company who had raised money for the cable car in San Francisco group, and we raised seven million dollars for Anna, that was Anna's contribution to the orthopedic learning center in the various stations, and we met with industry at that time. Yeah, that's great. That sort of dovetails into one of the questions I wanted to ask, which is just, what is your favorite aspect of being an Anna member? I think the fellowship, their devoted education of all surgeons, and that helped me become a better surgeon. And kind of following up on that, since you were talking about the early days of just seeing and incorporating the arthroscope into your practice, is there some advice you might give your younger self, if you could sort of time travel and share that? Yeah, Yogi Berra had a statement, when you come to a fork in the road, take it. So, I think you have to seize the opportunity. I was involved with a local orthopedic chapter of the Western Orthopedic, and fellowship with the other people in my town, or in San Diego, and then at that time, I wanted to start a shoulder meeting, or I wanted to start a study group meeting. And at that time, one of the companies that, I think it was Upjohn, the salesman came by and he said, well, I have a mailing list of all the orthopedists in San Diego County. And I said, well, I want to have a meeting. I'll just send a meeting and say, I'm having a study group with video to look at knee scopes. And I thought, well, I don't know where that'll go, but at least I don't have to type everybody's name out and mail out a list. So, basically, you seize the opportunity, because I wanted to learn more about how to do a scope. So, everybody thinks I knew a lot about the shoulder, and it was only because I have a lot of good friends who knew a lot about the shoulder, who would teach me about the shoulder. And then as you get involved, I just think you need to volunteer and put yourself out there and just see what comes your way, and you'll be surprised. No, that's terrific. Along those lines, what's the best piece of career advice that anyone gave you along the way? I think be present in your hometown. There was a famous orthopedic surgeon, I won't mention his name, who was very famous, but he was so busy chasing his accolades, his gold stars, that he practically ran out of town. So, I think you have to be present to the people in your community, whether you happen to like football, or you want to be the team doc, or you happen to like to ballet, or music, or whatever, and be involved with the people in your local community. Yeah, that's great. You've served as a past president, I believe. Is there something, a bit of advice you would give to someone assuming that role in the current era? Yeah, my advice to them would be, you're elected to keep the organization running. You're elected by the membership, so kind of take what comes your way. What's the problem at that time? And when you have a board of directors, you have to, often there's a shy person or two, often there's a shy person or two on the board of directors, and you have to say, well, it's you, hey Theo, what do you think about this? Because often everybody else is talking, and you're not getting the total input from everybody. And then be careful that, you know, a lot of every, we all have egos, so we have our agenda, but I think you have to decide what's the best agenda. Bernie Morey, when he was going out as president of the Shoulder to Elbow Society, said his job was just to keep the ship from sinking and, you know, and make small corrections on course, rather than do a 90-degree turn or a ship wheelie, something like that. Yeah, and along those lines, is there something you would say to potential new members who are on the fence about whether to join the organization, or maybe young surgeons coming out of training today? Well, I think it's a place, if you want to make an impact on an organization, I think Anna has more room for people to be involved. The problem is, to be involved, you may have to volunteer at the Learning Center, so you have to fly to Chicago, so you have to start deciding how much of your own time you're going to give up just for volunteering, and what your goal is. If you just want to volunteer and help others, you'll get a lot of reward from the people. If you want to just be an all-star, you know, without putting your time in, I think you're going to be disappointed. What sort of got you into orthopedic surgery in the first place? How did you kind of choose that path? Well, I was an intern at Cook County Hospital in Chicago back in the days they had interns, and I actually had an internal medicine residency, and then I rotated to orthopedics, and they looked like they were having a good time, and I didn't really like surgery that much, holding retractors, and so I thought the orthopedists were enjoyable. They put someone in a cast, hung them in traction, and that was kind of fun, and then lo and behold, total joints came out, you know, just as I was finishing my residency in arthroscopy. I didn't know anything about until I was in practice for seven years. So you had to do some time holding retractors, and then escaped it again as the arthroscope kind of came along. Yeah, then I thought the arthroscope, what I could see with the arthroscope, when I, with the initial needle scope, was way beyond what I could see open, and I remember Lenny had an exhibit at the academy, and for two years, I think, and I went every day to his exhibit, and I just kept looking at the pictures, saying, wow, if I could just see that. So, you know, that was it. Yeah, that has opened the door to quite a number of surgical advances, and now there are quite a number of things beyond diagnostics where we do really complicated repairing and reconstructive surgeries, visualizing through the scope. Was that something that was apparent kind of early on, all those possibilities, or when did you start to think, oh, wow, there's, we can do a lot more with this? Initially, I was just happy to see, and, you know, initially, you just saw it, and then you made an open incision, and then we came in the resection, taking out parts of the meniscus, or my first shoulder scope, I took out a huge SLAP3 lesion, you know, probably the best result I've ever had in my life was the first case, and so this was all new to me, and then it got more complex, because you had to do meniscus repairs. I remember visiting surgeons. Tom Rosenberg in Salt Lake City was the first person I knew to do meniscus repair, and then we moved into shoulder repair. Lanny Johnson introduced his staple, and there was this whole emphasis on instability, and I had an older practice with more rotator cuff, and I did my first cuff repair in 1996, you know, using one of Lanny's staples, and you put the staple in with the torn cuff into the abraded tuberosity, and then he went back six weeks later and took out the staple, and lo and behold, you know, something was going on there, so that was the amazing part of it, but I think with time, the arthroscopist has to be careful not to have too big an ego, because there is a place for open surgery, and I think the arthroscopy initially got burned with their enthusiasm for thermal capsular shrinkage and enthusiasm for repairing the labral, and we were even blind to what bone loss was, so now we have to come deal with bone loss, you know, that's a whole other different series of operations that were done open, and actually Ettore Taverna was the first person, he's in Italy, to do an arthroscopic bone block, and he took bone from the clavicle, tibial tubercle, iliac crest, everything to put in, and we eventually will probably come to some kind of allograft, and if I can go on, the other thing is, you know, we thought, we think, we still don't know how to repair massive cuff tears, and we kind of badmouth the reverse shoulder, but the reverse shoulder is an all-star, maybe now we'll do minimally invasive reverse total shoulder replaces, but I think we have to be careful not to get so carried away with our arthroscopic wizardry that we're missing doing the right operation for the patient. Yeah, that's a great comment about, yeah, two areas that I think are, continue to be really, really hot topics in shoulder surgery today, and we, I was fortunate enough to be one of the traveling fellows this year for the Association, and we had that discussion in our Mexico City site, where one of the surgeons over there had gone over to France and was, become quite facile with arthroscopic Latter-day, and I feel like I've, in my practice, I've spent quite a bit of time trying to really learn and master the open procedure and make it reproducible and good for my patients, but, and so for me, I think open surgery will be the standard of my practice, although I think there are some surgeons who look at it just like rotator cuff repairs, and well, okay, open rotator cuff repair used to be the standard, but as techniques evolve and things become more reproducible, we may be doing more and more of those kind of complex instability bone block procedures through the arthroscope as well. I think so, I think we're going to, we will evolve either to an allograft or some kind of a bone implant to fix the defect. I think we know the defect and how to fix it, but, you know, the arthroscopic Latter-day was brought with a lot of complications, including axillary artery problems that some of the early pioneers just kind of swept under the rug, and the other thing that bugs me a little bit about arthroscopy and the Avent Association is when you were in Mexico City and the people in Latin America were doing arthroscopic mini-laminectomies 10 years ago, and yet the spine is sort of ripe for that area, but the aorta has never entered the spine arena. Well, you're on record now, so maybe that'll give some impetus to it. Yeah, they moved into the hip and, you know, and I scoped hips when they had, you know, loose bodies and that, especially after a fracture, but then we got in the CAM arthritis, and actually I have a friend of mine who wanted to scope hips because they all had arthritis, and he'd get people that he could total joints on who were under the Medicare age. Got it. Yeah, and it was nice that you brought up the rotator cuff as well, because I think that this sort of massive cuff tear has been understood to be problematic for a long time now, and it remains still a challenge and sort of two of your colleagues I referenced earlier, Dr. Snyder and Dr. Burkhart, and you're good friends, and they're good friends, but kind of came at the rotator cuff in different ways, so if I were going to put you on the spot, I would say, you know, do you do a cowboy way, double row, knotless rotator cuff, or a, you know, single row, triple loaded, low tension repair with a crimson duvet, or something in between? Well, oh my gosh, so first off, I think the, oh my god, the anatomical, the single and double row people deny the anatomy of the rotator cuff, and I'm blanking on his name, the doctor in Japan that did this, no, in, yeah, Japan, that did this, you'll come to me in a minute, that did the studies on the anatomy, so first off, the supraspinatus sits right on the edge of the tuberosity, and the infraspinatus wraps around and goes laterally, so your, Dr. Snyder, I disagree with this, his single row is good, because you may not over tension a repair, but some cuffs need a, need a, an anatomical repair, so I would argue that the medial row is actually a supraspinatus repair and the lateral row is an infraspinatus repair if there's enough tissue to go that way. And then both of them got in to the patch business, whether it's a patch or, you know, it's a superior capsular reconstruction. And now there's a group of people who are advocating tendon transfers coming down to our microscopic incisions. And, you know, I grew up in a polio era where we did lots of tendon transfers and I was actually originally a hand surgeon, did a lot of upper extremity tendon transfers too. So tendon transfers make the most sense, but I don't think they can compete in the average person with a reverse total shoulder for a massive tear. And, you know, if you come across a massive tear, do your best to do a partial repair, you know, put some sort of a patch on or, you know, all the patches have what I call goo juice now. They have some kind of stuff in there that's gonna make it heal quicker which sells from somewhere. Yeah, no, that's a great perspective. Going back to kind of your career with Anna, what do you think was sort of your greatest contribution to the organization? I think Dick Casperi promoted the learning center and sort of got that off their butt. And then I was on the initial board of directors of the learning center. And I think that taking that and integrating that with AAOS in the first five years had a lot of tension between AAOS and Anna until Joe Zuckerman came along with AAOS and said, hey, we all gotta get along together. And that took it to the next impetus. And then the other thing I did was to hire, as I mentioned, a professional fundraiser because I think Anna needs trouble raising money and learning how to raise money. And then one of my fundraising buddies said, there's a care and feeding of donors. And I think Anna would do that better than I have. But I think my decision was to get those things off. And then on a personal level, I was involved with the OLC when it moved forward and with the shoulder courses and then the knee courses. And then we had courses designed specifically for residents. And then the SOMOS course came along with the militaries. I think that's where the learning was and the key thing that I contributed to. Yeah, that's quite a legacy. And I'm glad Joe Zuckerman was a part of the solution there. He was my chair. And I think I was a resident at Joint Diseases during his presidential year. So at a meeting where he was, I think, assuming the presidency of the academy, I was a fourth year resident rounding on his patients and updating him every day, just trying to hold down the fort and hope everything went smoothly. So small world. Well, Joe is a giant in getting the Anna AOS together because initially the learning center had half from Anna and half from Anna AOS. And there was tension about where the money was gonna come from and what they were gonna do. But Anna was definitely the leader in that part. And then, you know, Anna AOS, OLC is now allegedly independent. Well, yeah. Hopefully both will continue to, certainly the Anna Center will continue to offer high-level courses and kind of continue to help surgeons get better with their arthroscopic skill sets. I think so. Well, the problem is people that don't have good skill sets somehow lack awareness that they don't have good skill sets. Yeah, that's, I suppose, a challenge in orthopedic education and some of the things my academic colleagues have talked a lot about, especially in recent years, is how to give good feedback or good effective feedback because it's not always so easy to tell someone, hey, you know, you really need to work on this or you're not as good as you think you are. Well, you know, one thing I learned from Lenny Johnson, who was my mentor, Lenny videoed his cases. So my first, oh, when it was cases, I videoed the whole case and then I would, I had an exercycle at home and I'd get up the next morning and I'd write my exercycle and plug in those videos. And so I don't know if even modern surgeons have ever scoped a whole case and then sat through it and could critique what you were doing during the case. Yeah, that's a great point and something, yeah, we can kind of put out there on the record for people because certainly the video technology has been around for a long time and now it's very easy to download it to a flash drive and things like that. Well, the issue would you let, would you let download one of your cases to a flash lobe and then we're gonna have Monday night football and I'm gonna be on, you know, I'm gonna be on ESPN and we're gonna critique your case. Yeah. And I got three people, you know, throwing their two cents worth in and, you know, you didn't put that stitch in right, you know, you know, you didn't see that one, you know, you didn't see that linebacker over there. Well, how come, you know, what, how would you approach what you're doing differently? So we're, we're, we're not often open to criticism of our own, of our own case or in the, in the case of Anna or even arthroscopy, are we reevaluating whether thermal shrinkage is a good operation or not? It was a great amount of enthusiasm, enthusiasm. I mean, even my nurse said, you know, I can, I can shrink a capsule and that'll be fine. You know, and that would be, that was a magic wand because, you know, obviously the instability surgery we did initially had a lot of failures, but there was a lot of denial until maybe after it'd been on the, going on for 10 or more years, people started to say, well, my failure rate is 20, 30% in young people. And that was unheard of from the initial guys on the podium. Yeah. Yeah, that's, I think it's always important to try to keep that perspective. And I guess one of the things I, working with our fellows here, I mean, I really think it's important to always reflect on cases and just think that like, there's, I don't know, to me, there's almost never going to be something that's like a perfect surgery. There's always something you can do better or learn from or take away and work on and try to improve. It's sort of like, I don't know. I guess I look at it a lot like sports, like where you're always trying to do your best. An interesting thing with your fellows, I guess you can do it with the fellows, is say we're going to, you know, when you feel okay to turn them loose for 10 minutes during surgery, just say, okay, we're going to record 10 minutes of your surgery or five, in five minutes, and then 10 minutes of the other fellows and have them sit in a room and watch what each other's doing. Yeah. You may, you can maybe force them to do that because, you know, but maybe the surgeon doesn't. You know, when I was there, I couldn't find anybody who would agree to let me see their whole case. Interesting. Yeah. You know, kind of along those lines, I guess, I mean, we talked a little bit about instability and the massive rotator cuff tears, but yeah, are there anything else that you would mention that's sort of a, maybe, I don't know, a challenge that we need to figure out or an unresolved, you know, I don't know, the next big challenge or frontier in arthroscopic surgery? I think we have, I think the surgeon, I've always said, when you see a patient, I have to decide whether my skills can fit the patient's expectation of what they wish to have from surgery. And maybe try to articulate that more with the patient and with myself. And the other thing I always tell my fellows is, is get a second opinion. I mean, I trained in pediatric orthopedics for a year with Mike Tesh in Chicago, who wrote books on pediatric orthopedics. And he was the champion of saying, you know, get a consult. You want to see Sherm Coleman in my area? He was a big guy on congenital hips. He'd say, Jim, get Sherm on the phone and give me his phone number in Salt Lake City. And so I think you need to get, offer the patient second opinions. And also second opinions, they always have someone they want to see for a second opinion. But if you really want one, decide, well, who is the best second opinion? So I can tell people they ought to go see Dr. Snyder or Dr. Haneke, one of my shoulder friends in San Diego. And early on in practice, Dr. Job was a big name. And I was just a local guy, Scopa Knees at Oceanside. I would say, well, go see Dr. Job. He's at the, you know, he's at the Curlin Joe Clinic. And if he or Curlin want to operate on you, that's fine. I'll be happy to follow you up and just see what they would do. And actually, usually from those referrals, you get more referrals from the patient. And anyway, so a long time, a long time in the long run, it works out. Yeah, that's great. Very helpful. Is there any other sort of, I don't know, lessons or experience from your time at ANA that you'd like to kind of pass on or share for kind of folks like me and younger folks who are new to the organization? Well, first off, I think the people who you think are giants are actually very approachable people. And I found that out playing golf with people like Lenny Johnson, Bob Metcalf, Kasperi. And secondly, I visited a number of surgeons learning arthroscopy. I flew from San Diego to Michigan and saw Lenny every four months for probably two years. Spent two days there. And you can learn by watching other surgeons. And if you want to learn how to, like when Reverse Shoulders came out, before they were available in the United States, I visited Anders Eklund in Sweden, Pascale Ballot in Gilles Walsh in France, Christian Gerber in Zurich. And so you have to seek out the best, but you have to put time in if you want to learn what you can do the best. And then if you want to be president, you just have to show up and people recognize you for doing a good work and you'll become a better surgeon because of that. Yeah, that's great advice. I think when I was at Baylor, we had a spine surgeon who visited and I think I was relatively young and asked him a similar question. And his advice was very similar. He said once a year, he makes an effort to go see another master spine surgeon and just learn from that person. So that was something in Houston I tried to do locally with some of the other kind of folks there. Before leaving, went back and spent a day with my fellowship director and kind of revisited all the sort of high-level ACL surgery that he was doing, for example. Yeah. I think that's great. When I first went in, in practice, one of my good friends, who's a big shoulder, elbow surgeon now joined me and he wanted me to teach him more about arthroscopy. So I told him to put his first shoulder case on in my schedule as the first case. And he would do the case, I'd assist him. And then I told a fellow to stand behind me and write notes and keep notes of what was going on. And as I was mentoring this kid who had had good training. And so that was a way that the fellow could learn, realized he could learn by watching. Sometimes I just want to do and they don't realize they may be able to learn by watching someone. Yeah. Kind of understanding that. There's so many video resources that are available for surgery now that weren't around when I was training. And it sounds like you did as much as you could from your own videos, but certainly didn't have arthroscopy techniques and similar things widely available back then. So I think that those steps of writing down the steps of a case are really important. Just you have that, something you go back to that you put together, that's to you. My best fellow was a woman who wrote down everything. And I remember I did a total shoulder with her and on the third total shoulder, she had it down wired. And I had other guys who scrubbed down 15 of them and they still weren't quite sure what to do with the cephalic vein or whatever. And so that is really important. And my critique about some of the videos is they, and Anna is as guilty as any of those, but they start showing these little clips, like 10 seconds and doing this and that, and they don't make you sit through a rotator cuff repair. So I was fortunate early on, again, Lanny Johnson, I'll bring his name back, is one of the giants of his era. He recorded whole cases from start to finish with a microphone. You know, oops, I can't find that. How come this didn't work? And you would hear all the sides or watch him chase a loose body around the knee or go in the back. And you watch how he managed the whole case. But as Don Johnson is one of the past presidents that nobody has an attention span anymore. So I don't know if they got an attention span, you might get through a whole operation. Yeah, no, I certainly enjoyed attending Dr. Burkhardt's cowboy way meeting where he would broadcast live surgery. And so he'd be there and so none of the, not just the highlights, but kind of the whole deal of, okay, hey, we've got this big retracted, the whole subscap is off. How are we going to mobilize that, bring the common tissue back down and fix it? And so you really get a sense of, I think that's an important perspective. Well, I think live surgery is. And two things, the program chairman says, well, I want to fit it in the 15 minutes. Or I don't want to watch people watch me screw up. So you have to be a very confident surgeon to do those things. And then if something messes up, just do it. I mean, Laurent Lafosse has a famous meeting in Hennessy and it is worth just sitting, going there and sitting through two days of watching experts do shoulder surgery. Yeah. But you kind of mentioned that, I think there is an inherent sort of difficulty or challenge in surgery and that even really talented surgeons will have cases that are sort of challenging for them or don't go as planned. And as a young surgeon, that's a really hard thing starting out in practice. Do you have any advice for how to come back to the operating room after you've had a tough day or a particularly difficult case or sometimes it's the early case in the day and you've got more work to do? Well, you have to, well, it's pretty common. You have, first off, you have to, if you have a complex case, you have to allow yourself enough time to do it. I mean, I could do an arthroscopy like over lunch hour or you'll run over and do a case between seeing patients in the office because you don't know how long a case is going to take. And then you need to know if this is a case that you can bite off more than you can chew. And when we started doing arthroscopy, we didn't have MRIs. So we just had a clinical exam and you might get in there and say, oh, the nasal had a torn ACL. I thought it just tore his meniscus or the tear was bigger. So there should be enough pre-op planning to know what you're getting into, but the surgeon may not take the time to plan. And then secondly, the surgeon will examine the patient because many patients are stiff and have bad results after you fix their scope. Or if you scope their rotator cuff tear, they're stiff, they're still going to be stiff with a painful rotator cuff repair. So you need to know what you're getting into. And then if it's more than you can handle, then I think you should suggest a consultation if your ego can stand it. You know, one of your partners or maybe just somebody here in LA, a big town, so you've got a lot of egos in LA. You know, I could just, in my little town, it was just that I had to send them to LA or to San Diego or anywhere. But I mean, and then the other thing is, I say the real mark of a surgeon is to recognize his own infection and take the patient back to surgery. And so it's easy to recognize another, I can recognize your infected cases, but the issue is, can I recognize my own infected cases? Yeah, that's great. Is there anything else that, I guess you sort of wanna share or put out there as far as kind of younger members of the organization like myself or other people that we should be thinking about for the future or I guess maybe challenges that we might face in the future from the Arthroscopy Association? No, I think you have to, that answers your question. The member has to ask himself, who am I? You know, and what do I wanna be with this? Do I want the organization to teach me something? Do I wanna become famous somehow and teach others through this organization? Or what am I doing in my own hometown, my family and my spiritual life? All these other factors that come into play or, you know, Lanny Johnson told me, it's not how much money you spend or how much money you, actually, it's not how much money you earn and spend. I should rephrase that. The key point in life is how much money you, not how much money you save, but how much money you spend by putting it, right? And so you need to do that. Many surgeons are very happy to just go to an animating, pick up what's learned, you know, and I've always had a note that every orthopedic surgeon is a hero in his hometown. So whether he is a sports doc or, I mean, I had a partner who was in the music and his practice included all sorts of musicians in Southern California that I didn't even know existed. I mean, because they couldn't play their string instrument because their hand or shoulder or elbow, and there was other people who loved dancing and the ballet and maybe they're not interested in, and so you have to, or maybe you're going to be a rodeo cowboy, maybe not in LA, but I mean, a rodeo doctor, but there's a couple of orthopedic surgeons I've met who are rodeo docs or race car docs, whatever. I don't know if that answers your- Yeah, no, I think- I'm trying to focus on Anna, but- Yeah, no, I think just general life advice, career advice, obviously, you know, just you've brought a lot to the organization and been kind of part of that sort of seminal development of the field of arthroscopy and trained a number of surgeons, taught a lot of us at meetings. So your perspective on all of these things, both Anna-related and just sort of the career and practice of orthopedics is terrific. Yeah, I was gonna say, I think- Oh, sorry, go ahead. Go ahead, and I'm gonna- Oh, I was just gonna say, I think that's part of the draw or appeal of orthopedics is taking people from that, getting them back to the activities that they love and enjoy. That was always a big motivator for me, and I think what drew me in. So it sounds like that's a common theme for a lot of folks in our field. Well, you know, what happened with Anna, or it could happen, is Anna is like a specialty without a joint. You know, there's every joint. So now we've got sort of knee societies, and the knee society is the knee docs, there's the knee scopers and the knee total joiners, and they're kind of two different groups. And the shoulder docs are now the shoulder docs that do total shoulders and instability, but there's more shoulder docs who, as they get older in their practice, it turns into arthroplasty. And you'll find that in your own practice, that you may be a young guy now, and you're seeing all these scopes and ACLs. I mean, I just loved doing ACLs. And then as I got older, all I was seeing was revision ACLs because it wasn't taking call anymore. And then I decided under Dr. Schneider's guidance that I would just be a shoulder doc and I quit doing any knees, you know? And so, and Anna doesn't really have a joint in their competitors, like Sports Medicine, you know, they have a sports deal. And so maybe there was the AOSSM, they may be the sports knee docs and the sports shoulder docs, I don't know. Yeah, it's- Yeah, it's the challenges. Yeah, interesting. And I think a lot of us kind of wear hats for multiple organizations at different times now. So, just sort of- Well, it's like the shoulder docs didn't like the arthroscopists. I say, now I go, I just went to the Shoulder and Elbow Society they act like they invented arthroscopy. And the same with the knee docs. They, you know, the current knee docs, you know, may not have understood the people that went ahead of them who didn't have anything good to say about arthroscopy. And then, but there were knee docs and there were shoulder docs, what I call real shoulder docs of the East Coast Shoulder Societies who saw a place for arthroscopy. Yeah, you know, you mentioned a minute ago sort of giving up the knee surgery to focus solely on the shoulder. Was that a difficult decision? Do you ever think back and think, oh, you could have kept going with knees too? Or would that find that that opened new doors as well? And, you know, that subspecialization really helped kind of focus and grow your shoulder expertise. Well, historically, the only fellowship when I finished my residency, which was in 1968, was hand surgery. So I actually had a hand surgery fellowship and, you know, it integrated within my residency. So then as you went on, I started seeing more shoulder patients and I decided I would just quit doing knees in that. I mean, and so that wasn't hard because what happens is your shoulder society practice then starts to build up. But the docs in my area, they weren't knee surgeons or shoulder surgeons, or, you know, I'm sure you don't do any spine surgery now. The trauma surgeons, in my own heart, I really think that the real orthopedics is like fixing broken ankles and rotten femurs. And then everything else is kind of, you know, it's icing on the cake, like scoping your knee. Because, you know, when I grew up, everybody had a trachea and couldn't play basketball. And they just had an ACL and it became their excuse not to work out. So now I have a trachea, you know, obviously I get an MRI and I know I got an ACL. And obviously, because I read the sports page, I need an ACL reconstruction, even though my knee may only bend 60 degrees with my torn ACL. So, you know, it becomes patient driven, you know, and then it's like, how good your website is in drawing patients. And so it's a whole new era of patients. And even for an organization like ANNA, you know, in my era, we were all eager to learn how to do these new instruments. So I was a customer of ANNA, teaching me how to use these instruments and selling me instruments through the exhibits and that. So now you have a group of surgeons who may feel they already know enough. And, you know, and they're hired by somebody so they're being paid a salary, no matter what they do. And they may not have a lot of influence on what instruments your company buys, your institution buys, because you're being paid by the institution anyways. And if you like your big salary, you better do use whatever the institution hands you. So, I mean, this is going to be out of ANNA, but I think it might be the challenges that ANNA is going to face down the line, because the ANNA grew with the help of industry, as industry was promoting a product and ANNA was teaching people how to use the products. Yeah, it sounds like we'll have to continue to find the right ways to partner with industry in the future and kind of source a way to continue to innovate and educate and teach surgeons. And yeah, you kind of touched a little bit on practice independence a little bit, which is, I think, something of a hot topic as well, and maybe a challenge that we face as orthopedic surgeons. Our current fellows are in the midst of their job searches right now. And so that's something that we've been talking to them about and they're talking to us about. And I think, I hope there is sort of a role for physician independence in the future in terms of being able to try and do what is best for our patients. I think it's very difficult. And even if I join, if you join my old practice, we may deal with 25 insurance companies and then that becomes 25 applications to get paid by these companies. In my era, if they joined our group and they were on our hospital staff, that was good enough for Blue Cross or any payer. If Theo's on the hospital staff or he joins SCOE or a good group, we'll just pay him. And now they make everybody do everything independently. Yeah, it's challenging to say the least. I even have a partner, I had a partner who didn't want to take a ER call because it gives him anxiety. But he may be able to join a practice that doesn't take a ER call, but his institution may tell him, well, you better take a ER caller. It was interesting, I was directed by the Navy for two years. So I spent one year in Vietnam and the other year I spent in the Navy Hospital of San Diego. But I still remember every 21 days I had to do general medical calls. Oh no. From eight in the morning to eight at night. I just, you know, calls and that was just, everybody did it and there was no way to get out of it. And there was no way to get anybody else to do it. And that was just the way it is. So maybe that's the way ER call is today. But I think your fellows, because the institutions have the money to pay them, but eventually the institutions aren't going to have the money to pay the fellows what they think they're worth. Yeah, lots of challenges ahead. And nobody's going out of the way to, no insurance company is going out of the way to how to pay you. Even though they might say you got to pay your staff 25 bucks an hour, you know, as minimum wage. So it's difficult. Yeah, I think hopefully we'll be able to find the right sort of leadership and people with expertise and passion to kind of advocate for ourselves and try to get the membership excited about that. And the organization can hopefully provide some resources. It's always a challenging topic. I think Anna may have to look at it from, may have to invite industry and big business and just say, well, and maybe employers and doctors to come to speak to them and how they look at it because they have different glasses than you and I have. But they may, they have the, you know, they used to say who has the chips in the poker game? You know, so they may have a lot more influence on what you would like to see. And so early, oh my God, early out in arthroscopy, there were people that had billing errors. So they would bill for a diagnostic scope of the knee, you know, and then a medial meniscectomy and a little bit of a synovectomy here and a chondroplasty here and they would add up all these charges. And then they would maybe debride the ACL and say they did a reconstruction. And so insurance companies got big bills from some of these private practice doctors and Anna got involved or members of Anna got involved in reviewing these complaints, you know. And so there was an insurance side to everything that was going on. Yeah, that's, you could certainly see an era where these were new. A lot of these procedures came along and probably didn't have an assigned CPT code yet or. Well, and there weren't exactly CPT codes. So they just, and then they have people that paid 80% of whatever the doctor's bill was. So if your bill for a scope was $12,000, they just paid 80% of it. And so now they just tell you, well, first they could tell you the operation wasn't indicated and they're not gonna pay anything or they're gonna, you know, have these lumper codes. So the diagnostic scope codes got put in with a regular code and now is, I don't know where, with the agreement is that part of a rotator cuff repair and that's separate. And so there's a lot. Actually, there's nobody staying awake at night trying to figure out how to pay you more. No, fair enough. But you know, Anna may need a seat at the bargaining table because I've never seen, or I've seen very few. I haven't seen any recent courses or symposiums where they would have, say you're gonna speak on private practice and then somebody else speak on group practice, you know. And then a third say, well, how I see it, I'm an administrator of a big hospital. I mean, Joe Zuckerman, he may have the wisdom because Joe's involved with all these different organizations or an organization like Kaiser where Kaiser is not only the insurance company but is the payer. So they got the whole pot of money right off the top. And I think the Cleveland Clinic, I grew up in Ohio in the West side, including the Cleveland area and they own all the hospitals and the docs and that. Yeah, well, I lived in Cincinnati, Ohio actually for junior high and high school. So it's a small world. What high school? I went to a small school there called Seven Hills. In what city? In Cincinnati. Cincinnati, yeah, yeah. So I went to Ignatius outside of Cleveland so we're sort of all over the place, so. I know. And maybe just move back to the Midwest. Life is a little simpler, but medically it's the same. I mean, the Cleveland Clinic owns almost every hospital in the San Diego in the whole Cleveland area now. So in fact, one of my friends, orthopedic head guys at the Cleveland Clinic at one time, they would then take over your hospital in Van Nuys or wherever you are. They would just take over your hospital in Zion. And then, but then his challenge was how to integrate your local hospitals, the orthopedic staff with the Cleveland Clinic staff and what their criteria were for performance and so forth. Maybe, yeah, yeah. And then I don't know what happened to the spine. I have a partner who's got a lot of spine patents and he's got a spine patent on doing these huge decompressive laminectomies except you do it from the inside out. And so there's a whole movement on minimally invasive spine surgery. And I don't know how Anna stayed away from that. I don't even know if the South America has some lectures by these guys. And I don't know if Anna has ever had a lecture on the spine, maybe, you know. Well, that's kind of a nice way to, I think, tie things together because we've covered everything from the past and the origins and learning the arthroscope and sort of great to hear about how kind of Lanny Johnson and others were such important mentors for you. And then you've gone on and mentored and trained a number of fellows. And then maybe we'll see what is to come in the future but maybe there's a, maybe the spine becomes another facet of Anna and Anna can, and its leadership can help tackle some of the challenges that we'll have in practice going forward. Right, and so the other thing is the, as I get older, the biggest compliments I get are from people who have given advice to them, like they ought to look at this and they taught me 10 or 15 years. I told one guy not to join our group because I didn't think it was a good fit, but he should join another big group in San Diego and he's a big shot there. And another guy, I told him he wouldn't, he shouldn't join our group and he's a president of another country's shoulder society. So, you know, it was very interesting how, and another guy is in Chile, in San Diego, Chile. So it's, you know, so you have, but you have to basically do what you feel you got to do what's best for you and your family or whoever you're hanging out with, you know, and figuring it all out and don't spend all your money trying to keep up with the Sniders. Yeah, but I think, yeah, one thing I would just dovetailing off of what you just mentioned is it's always been important for me to try to seek advice from kind of, you know, people that I've trained with or that colleagues, experts in the field, kind of people with more experience and seniority who've been through different facets of career practice, you know, how to solve, whether it's, yeah, the technical aspects of surgery or, you know, other life things. So that's great that you're able to have such a positive influence on them. Well, the thing is, as you get older, now I can see myself, Dr. Snider does, Dr. Berker, we all have lots of wisdom, but nobody's really interested in our wisdom. Do you have children? Three. Okay, so it's like, you're their wise father, but, you know, are they gonna really listen to their wise father? No, they may have, they may have a son. No, they have two- Another opinion of their wise father. Yeah, no, they're pretty strong-willed, so they're all, youngest is six, they'll have a good idea about what they think is best at this point. Yes, yes, yes, yes. So you get a reminder periodically that you're paying the bills. Yeah, something like that, we'll try. Yeah. That was, I don't wanna keep you over, that was really terrific, just getting to hear some of your experiences with Anna. I think an hour's probably not enough time to do it justice, but yeah, I really appreciate the chance to connect with you and hear your sort of pearls, advice, anecdotes. Thank you. Yeah, and I hope to run into you sometime. Dr. Snyder did tell me that you were part of the group of guys, and he came from a very, his group was a very strong-willed group of guys. Small group, but now, you know. So now you get bigger, then you gotta figure out how to keep all the egos in the group together. Yeah, it's been described like a big, big family. So, you know, there may be times where people have disagreements about things, but at the end of the day, they're all kind of part of the same unit and kind of try to do what's best for the group. Yeah, well, we need more of this world of listening to what the other people have to say. You know, I was fortunate at Ignatius High School. I took four years of Latin and four years of Greek, and then two years, we took a philosophy class. And then when I went to Notre Dame, I said, well, I had to take religion for three years, but I had to take philosophy for four years. I'm not sure what I learned in a philosophy class, but you have to learn to ask yourself questions and realize that people can have other opinions from both how the world should be run, to how your family should be run, you know, to how the surgery center should be run. Yeah, what's the best graft for ACL reconstruction, or so on. Oh, my God, yeah, they're still arguing. That's right. That's right. Well, Noel, thank you so much. That was really terrific. And I look forward to seeing where this project goes and having this in the archives and something that, same with watching surgery videos that future Anna members can look at and understand. Thank you, and if I come to Anna sometime and I see you, you see me just come over and say hello, and I might give you a big blank, like, who are you? You might have to refresh my old brain who this is. Well, that would be great. It was a pleasure talking to you and just do your best. And, you know, I have the saying, let life come to you. So you just let life come to you and see what happens. Well, thank you so much. That's a perfect advice to wrap up with. Okay. I'll look forward to meeting you at a future meeting. Good, and thank you for taking the time to do this for Anna. Likewise. Thank you so much. Thank you.

Dr. Theodore

orthopedic career

shoulder specialization

mentorship

arthroscopy challenges

industry partnerships

surgical techniques

practice management

personal growth

wisdom and mentorship