To lead off, Dr. Burkhardt, I know that you've been with Anna since the earliest days, and I just wanted to ask you what your favorite aspect has been of being an Anna member all these years. Well, I really enjoyed the camaraderie of Anna and the opportunity to make friends, like-minded friends. I forget the exact year that I became a member. I really wanted to be a member. In fact, there's a story about me becoming a member. You may or may not know it, but I wasn't accepted on my first application. And you say, well, what happened there? There couldn't have even been very many members. There must have been a hard-out. But actually, it was interesting because a big part of the application was submitting, I think, 20 consecutive arthroscopy operative notes. And on the op note, you had to have the time that it took you to do the case. So this would have probably been sometime in the 80s, and it was during a time that I was beginning to do arthroscopic rotator cuff repairs, primarily side-to-side repairs, and basically homemade instruments that a local machinist had made to my specifications. And so I know that the membership committee was used to looking at applications, and they'd say, okay, there basically were two main new procedures you could do arthroscopically, you know, removal of loose bodies and partial meniscectomy. And those were pretty quick procedures in skilled hands. So they looked at my op notes, and there were a large number of shoulder surgeries. And it was taking a lot longer to do these arthroscopic even side-to-side cuff repairs because I was tying knots, doing all those sorts of things back then. And so I got a letter back, you know, a couple of months after I applied, and they had deferred my application for another year. And they said, Dr. Burkhart, we can't understand why it takes you so long to do arthroscopy, and we're going to have to see some more op notes next year before we can let you in. So what year would you estimate that was? I think it was probably in the late 80s. I'm not sure exactly. You know, Anna, I was not a charter member at the very beginning. Anna got started, I think, in 1982. And so I was a few years after that. So it may have been between 86 and 88, somewhere in that range, I think. So there was still a fair amount of skepticism about arthroscopic shoulder procedures, although knee procedures were more well-established at that point. Well, yeah. And there was also this undercurrent just in the general orthopedic world because Dr. Rockwood at that time was the most powerful man in orthopedics, and he was calling the arthroscope the instrument of the devil. And then if you add on to that, that you're trying to put it into his domain, the shoulder, you know, then it's doubly the instrument of the devil. So he was particularly upset about shoulder arthroscopy. So were there some pretty epic conflicts and debates with Dr. Rockwood at the Arthroscopy Association? Was he, you know, the open shoulder tradition, were they, you know, were you arguing the merits of shoulder arthroscopy against some of the prominent members of the open community like Dr. Rockwood at the level of the Arthroscopy Association at that time? Not at the beginning because, you know, it really was beneath their dignity to come down to our level. And I'm saying that basically in the words they probably would have said it. And so we were basically blocked from the podium at the other meetings. So if you look at the academy meetings, you couldn't get an arthroscopy paper on. And that's because the power structure didn't want to have that competition. And I think some of them truly did sincerely believe that there was no future to it. And maybe some of them believed that it was causing harm to patients. But I think generally, they just didn't want to have the competition. I know at one point, Dr. Rockwood went up to see Lanny Johnson, who was the premier arthroscopist in the early 80s to late 80s. And he tried to learn shoulder arthroscopy from him and he couldn't do it. So I think there was that element too, is because it takes a certain skill set. And I'm not saying that older people can't learn, but I think it's more difficult because he would have been probably in his 50s at that point. So we didn't really have, later on in his career, Rockwood did come on to some Anna programs and debate, but that was long after arthroscopy had been accepted and had surpassed open surgery in a lot of areas. So in its early going, the Arthroscopy Association was almost a society to kind of promote a technology that was not readily accepted at all, whether it be in the knee or the shoulder. It was a way to promote these techniques when it hadn't gained widespread acceptance. Exactly. And we couldn't get papers published in the mainstream journals either. So the answer to that was we had to start our own journal. And Gary Paling just almost single handedly took that from being kind of a throwaway journal to being a world class journal. So my hat's off to him for that. You had mentioned, you know, you and a number of others were really creating a discipline and you were innovating as you went along. So you had mentioned that you had, what were this sort of sparks that got you to start to machine things and innovate at the local level to help you? You mentioned you were doing side to side rotator cuff repair. Were there anchors available at that point? Did you help create anchors for the purpose of doing arthroscopic cuff repair? What type of innovations do you have to come up with early on? Yeah, the the anchors didn't exist in the late 80s or mid to late 80s, and I think the very first anchor was the MyTech anchor, the G1, I think it was called. And that was, I believe, in 1991, 92, something like that. And it was a pretty crude anchor. It was had a little fishhook on the side to kind of keep it from pulling out. But and in terms of, you know, your question about did I later design or invent any anchors, I've got a number of patents on various other anchors that weren't the initial anchors, but they were, I felt like improvements. You know, there were certain things that I thought needed to be improved. And so that's what what they were. So there's actually one of them. Yeah, I'm sorry, go ahead. And I want to be sure to mention Marlo Gobel. Marlo Gobel from Utah had an early patent on suture anchors as well. And Marlo was primarily a knee surgeon, but he saw the utility in having a way to anchor something to bone. So from the early to mid 80s to the 90s, you didn't even have suture anchors really available to you. You were using modified suture hooks to pass suture and doing a lot of soft tissue type repairs at that time. Right, so part of the idea, you know, was the margin convergence, which, you know, I had observed and Carrie Athanasio and I wrote that paper up, published it in the arthroscopy journal. But, you know, on these U-shaped tears, you could do side to side repairs that would converge the margin over to the bone bed. And it would be so dramatic in some instances. I thought, well, if you roughen up the bone bed and you have some good bleeding, you know, Steve Snyder's crimson duvet. And then, you know, perhaps if you immobilize them for six weeks, it will have a chance to heal. And so it led to a number of observations, you know, one being that you could almost always immobilize these people with impunity for six weeks and not risk stiffness. Or if they did get stiff, you could release them arthroscopically and it wasn't such a big deal. So, you know, little by little, we learned why shoulder arthroscopy was preferable to the open surgery. It was, you know, not only the matter of, you know, less invasive, smaller scars what people wanted, but it was a matter of the rehab could be quicker. The chance of stiffness was less, fewer complications, much lower infection rate. And so, guys in my era, we came along in the era of during our residency training, doing open meniscectomies. So we had all seen what it took to recover from an open meniscectomy, which meant generally at that time, days in the hospital, crutches for at least several days. And it took weeks to recover from it. And to get back to sports after an open meniscectomy would be three months at least. So when we saw then, you know, I did a sports fellowship at the end of my residency. And so they were my fellow, my fellowship directors, Dr. Larson and Dr. James in Oregon, they were just learning knee arthroscopy at the time. So I tried to learn it with them. But, you know, at that point, I started seeing how much quicker the rehab was and how these people felt so good the day after their surgery. So, you know, and then I continue that in my practice and I saw how well people did after arthroscopic knee surgery compared to open knee surgery. And I thought, well, you know, it's bound to be the same for the shoulder. It's bound to be the same for the shoulder. The interesting thing about me is I was designated the main shoulder doctor as soon as I arrived in our practice in San Antonio. And that was because all the senior guys didn't want to treat shoulders because they had too many problems. They didn't do well. They just wanted to do things that did well. It's amazing to this day that patients say, well, shoulder arthroscopy and shoulder surgery doesn't work. You know, that legacy carries on. If you're not doing the right operation on the right patient for the right reasons, then, of course, it's not going to work. But I feel like my shoulder arthroscopy patients consistently do better than my knee arthroscopy patients. It's just amazing that those, you know, those misperceptions persist all these years later just because folks were fearful of doing shoulder surgery. They didn't really know what to do. It's a great advancement. And, you know, the other thing, too, that I think bears clarification is, you know, although I love cowboys, you know, there is kind of a pejorative way of using the term cowboy as someone who's reckless. And so there's also, I think, a very laudable way of using the term cowboy, which is the one I think is, you know, the one that the guy who does the right thing and shoots straight and that type of thing. But at any rate, I think, you know, people had sometimes have the idea that arthroscopy was started by a bunch of guys that were kind of the bad type of cowboys that were doing reckless things. And they were new things, but they weren't reckless. I'll tell you just kind of an example of that in shoulder arthroscopy. You know, I had an undergraduate degree in mechanical engineering. And I thought, well, one of the things we have to be able to show before we can ethically try to, you know, advance this discipline is to show that it's at least as good mechanically that the fixation is at least as good as what we're doing open through the bone tunnels, transosseous bone tunnels. So I took it upon myself to design a couple of biomechanical experiments that I did at the university here in San Antonio with Carrie Athanasio, who was in charge of the lab. And we did cyclic loading experiments on anchor-based repairs. This was in the early 90s. And arthroscopic anchor-based repairs versus open transosseous repairs. And we actually found that the anchor repairs were stronger than the transosseous repairs. So not only was it equivalent, it was superior. And so then once, in my mind, once we had proven that, it meant that we had an ethical basis for moving forward. No one could say that we're being reckless at that point. We just needed to have a way to create a critical mass of surgeons that could supply the demand that people were going to have. So I did my residency training on the East Coast, which is, of course, well behind other parts of the country in terms of arthroscopic cup repair. And the counter-argument always was that arthroscopic cup repair wasn't as strong. Ironically, the mini-open and the open shoulder surgeons were using anchors, which was a technology that was developed for arthroscopics. So they were contradicting themselves. And the other point, of course, that you made earlier was that we could keep these shoulders quiet a little bit longer without fear of stiffness. So even if it was perhaps a little weaker at time zero, which, of course, it wasn't, it was still fine. You didn't have to worry about moving. Mini-opens, you had to move right away because you're pulling so much in the deltoid. You had to move them. You knew they were going to get stiff. So they didn't have a good history, didn't hold up for them. But they had a case that they couldn't maintain over all these years. Now, it's the gold standard, of course, thanks to others. Just changing directions a little bit, would you have, looking back on all your experiences and all the patients you've helped over the years, would you have any advice for your younger self reflecting back when you're starting in practice? Well, I think of it in terms of mentorship. I've had a number of fellows I've trained over the years, and you have to kind of think that way if you're a mentor to younger people. And I've tried to tell my fellows, and I would try to tell myself if I can go back, to be patient, let things develop. But then also, there was a phrase that one of my football coaches used when I was in high school, and it was a quote from Vince Lombardi, the great Green Bay Packers coach, where he said, you know, you need to run to daylight. And Lombardi always said the great running backs ran to daylight. And they would just see that little crease of opportunity where there was a little space they could run to and make some yardage, and I think life is that way. You know, there's not going to be a wide open door there necessarily for you to go through, and you're going to have to just run to daylight thousands of times over and over again to finally get through the door. But I think, you know, you can create doors by seizing on those little moments of running the daylight. So I think that's one thing that I would do. And you don't get in a rush, it's gonna take a long time. So some of your early daylight was recognizing the value of shoulder arthroscopy. That was one of the early insights you had? Yeah, and in that also, being patient, I mean, here I was a young guy starting in practice and they'd given me all the undesirable cases, which were the shoulders. Well, could I turn that around to where they're desirable cases? And I think now most guys love to operate on shoulders. And when you talk about running to daylight, I would imagine that would also apply to all the innovations you've made over the years with biomechanical techniques and research you've done, but also innovations in terms of anchors and technology. So what would you talk in terms of the sparks for innovation or the most impactful innovations that you've seen or that you've helped create? How would you describe those experiences? Well, you know, you've got... I've given this talk on innovation before where I talk about what is the basis of creativity. And you think of surgery as being a craft and it is a craft, we're all craftsmen, but there are two faces to craft. One face is the depth of your expertise. So there's a big, like all through life now, even in academia and business, in surgery, there's emphasis on a narrow field of expertise would be really good in that narrow field. And you can get so entrenched in that that you can't really see 10 feet over to where the answer might lie. And so then there's a case for breadth of knowledge as being kind of the basis for creativity. And basically the breadth of knowledge is what allows you to bring solutions from one domain to another domain. And so I think that is something that people need to think about. If you can get a broader experience, whether it's in, you know, having an undergraduate degree in something different. I was in engineering at a mechanical engineering degree. So I think that allowed me to look at things a little bit differently than some people. But another thing that helped guys of my generation, I think was when we started practice, we were generally general orthopedic surgeons. You know, I had to take trauma call and treated every bone in the body if it was broken or dislocated. And, you know, I had a huge total joint practice at one point, total hips, total knees. So, you know, you kind of have developed insight into how there are principles in one joint that can carry over to another. So I think that, you know, would be maybe another bit of advice is not to get too pigeonholed too early in your career. Were there specific innovations over the years that you think have been the most impactful? Well, I mean, just arthroscopy in general has been huge. Obviously the minimally invasive concept. I think that arthroscopic, I'm gonna talk mainly about the shoulder, if that's okay. But I think in the shoulder, arthroscopic rotator cuff repair has been huge and the way it has evolved over a number of years where I think that in my mind, the double row, I know there are still single row advocates, but in general, I think the double row with its superior strength. And when you look at the healing rates and all being superior with double row, I think, you know, that's been a huge advance. And the fact that you can get such secure fixation that even when patients aren't compliant and they do think too much too soon, they can still get a good result. Because I remember as a resident, you know, the surgeons would try to, I did my residency at Mayo Clinic and the surgeons would try their best not to operate on a rotator cuff tear, unless it was acute. They would either operate within the first three weeks or they'd wait a year before, even a work comp. A work comp had to not improve for a year. They'd have to be off work for a year, basically, before they'd operate on them. It's crazy because it's so counterintuitive now, but of course, shoulder surgery didn't work back then. So why would you possibly, you know, operate on a mechanical defect in the rotator cuff? They didn't have good techniques. They didn't have good data and outcome studies. So they didn't think it worked. So they were really tying their hands to not do it. Yeah. Yeah. Yeah, it's very interesting to look back at the historical aspects of how the rotator cuff treatment evolved over time, because when Dr. Hinchey, who was my senior partner when I started in practice, when he retired, he gave me some of his old books. And so he gave me some shoulder books from the 1940s, 1950s. And it was very interesting. They would have these huge incisions, you know, huge open incisions. And, you know, they might use a graft. They might use, they did some very unconventional things. They might do some sort of a local transfer. They would take down a perfectly normal subscap to try to cover the hole and do things like that. But then they would keep people in the hospital in traction, in arm traction for three weeks. So if you survived that operation, that huge incision, and then if you could survive three weeks in bed, flat on your back and traction, then you had to be put into an airplane splint with your arm like the Statue of Liberty. So then if you could survive that, finally you could go to a sling. It was incredible. It's funny, my father's an orthopedic surgeon. He's older than you are, in his eighties. And I heard about having services for 20 to 30 patients in the hospital and people dropping like flies from PEs. But I never once, I heard about ACLs being in the hospital for a week or 10 days, of course, and casts. I never once heard about shoulder patients being put in traction or being subjected to the same tortures. And that certainly seems to violate the do no harm rule. It's not a wonder that shoulder surgery was, the indications were so perceived to be so limited and strict because that wasn't gonna end well for a lot of people. They were gonna be stiff or they weren't gonna be better or they were gonna be worse. Right, exactly. So shifting gears a little bit, I know you had mentioned that the camaraderie is one of your favorite aspects of being an ANA member and leader. Do you have any particular memories of your involvement with that over the years that stand out to you? Well, I mean, one of the greatest honors of my career was being president of ANA in 2002 to 2003. And I think one of the things we, you look at things that you do as a president, but it's kind of a continuum and you get to sort of develop a bond with the guys a few years behind you and a few years ahead of you so that you can carry on projects that will take more than one year. And so, I had, there were guys before and behind me that were very interested in shoulder arthroscopy and in teaching shoulder and knee arthroscopy and how could we advance our teaching methods. And one of the big things that we did starting in my year as president was these remote transmissions of live surgeries. We did the first transmission of a live surgery up to a learning center course. Which year was that, Dr. Burkhart? Well, that would have been in 2002. 2002. Yeah. And then we continued that the following year. Brian Day was president the year after me. And my recollection on that was we had our annual meeting in Vancouver. And so, Brian, he had me do a live surgery at his surgery center in Canada, in Vancouver. I had to get a temporary Canadian license to do this and transmitted it over to the, a live surgery over to the auditorium. And it was a big hit. So that was a patient that Dr. Day had identified for you to take care of up there? Yeah, yeah, it was his patient. Of course, part of it is people still love the unexpected aspect about those things. They wanna see the near disaster that gets averted. I remember on that particular case, we had single loaded suture anchors and, no, I'm sorry, we had double loaded suture anchors. And I was doing a rotator cuff repair and we accidentally unloaded one of the sutures off of it. So I had done this one time in the lab before, but I reloaded a second suture onto an anchor by shuttling it through the anchor that was there. I went suture through suture with a spinal needle to push it through and then pulled the whole thing through the islet. So anyway, everyone said that was the hot point of the surgery. Seeing how after I had accidentally unloaded an anchor, I could rethread it. Yeah. And that probably led to more interest in pearls, which of course being a key feature, and in those years was, what type of insights our leaders and members had to how to get out of trouble and think on their feet. Right, and that was one of the things that later helped me. We did our three arthroscopic shoulder surgery textbooks and I wanted to be really heavily oriented toward technique and toward pearls and toward getting out of trouble and avoiding trouble. Not just the standard things, but when I was a resident, we had to learn surgery by doing it and also by reading Campbell's orthopedics. And you could read a section of Campbell's orthopedics about a particular operation 10 times and still not know how to do the operation. You wouldn't have a clue. There'd be one little line drawing. And if it was a poorly written couple of paragraphs, you wouldn't know what to do. So that was the beauty of being able to integrate things in my books then where you had the video and you could put in literally a thousand photos into your book and that type of thing, so. Yeah, it's been enormously helpful. And then at what point did you do a lot of teaching on cadavers and in the lab at Anna as that sort of became a useful teaching technology and technique? Yeah, well, the first learning center, I think, opened about in the early nineties, 92 or 93 or something, Howard Sweeney, one of the early Anna presidents was instrumental in that and just shepherded that thing along from the very beginning. And another person that really helped to get those labs started was Whit Ewing, who was previously a president, but then executive director of Anna for a number of years too and they had the foresight to realize how important that was. And it was really helping. I mean, if you think about the teaching aspect of a new discipline like arthroscopy, you have to harness all the teaching tools and all the different arms of media that you can. If you're gonna get the word out, okay, you have to get the word out and you have to have presentations from the podium, you have to have journal articles, you have to have videos, whatever the technology is, you need to harness the technology of industry even. The videos that industry puts out can be quite good. So there was a lot of work to be done because once this kind of core group had shown how good arthroscopy could be and people started seeing how well their neighbor did out of having these things done arthroscopically, there weren't enough surgeons to provide the service. So we had to provide that critical mass of education. We all had to learn how to tie knots arthroscopically. It wasn't something that was part of our training. So it was just a different skillset. We had just basic things we had to relearn and translate them to arthroscopy. Right. This is a similar question that in terms of mentorship we had talked about before, but, and it may be similar as your advice about and your innovation and running to daylight, but what's the best piece of career advice that any one of your mentors ever gave to you? I think, I mean, it's hard to distill it down to one piece of advice. I mean, as you pointed out, the run to daylight thing, I think was huge to have that realization that things are gonna have to gradually develop. You can gradually develop your practice into what you want, but it might take 20 years for that to happen. It's not gonna happen overnight. I think of who my role models were actually when I was a young surgeon. When I was a resident, the most prominent member of the staff at Mayo Clinic was Mark Coventry. And Dr. Coventry was one of those people that basically you felt like when you met him that no man could be as great as Dr. Coventry looked. He just looked like a great person, like he could be George Washington or something. I know that's taken it a bit far, but he was so consistent and he was an excellent surgeon. He was a very ethical person who always had the patient's best interest at heart. And he stressed the value of intellectual integrity. And if you're not sure how your patient, he said, your patients may not be doing as well as you think if you really study your data, study your results. So I think the thing that he made me realize more than anyone else was the value of intellectual integrity. And I'd like to think that I've kept that over the years. The other person was the senior partner that I mentioned, John Hinchey. And John was the consummate surgeon and physician. The patients loved him. He could remember a story about each patient he saw. They'd come in and he'd, you know, if he wanted me to see him for something, he'd introduce me to him and say, yeah, you know, this is Mr. Smith. I took care of his grandson 20 years ago when his grandson fell out of a tree and they had a flat on their car on the way in. So they got here two hours late. He would remember things like that, but he made people feel important. And he was so concerned about every aspect of their care. And so he really taught me, I think, the sanctity of the doctor-patient relationship. He made me realize that he didn't teach it to me, he taught by example. So I think those two things, the importance of intellectual integrity and the importance of the doctor-patient relationship. And so it's so remarkable that those doctors didn't, you know, it wasn't about, they weren't teaching you techniques, they were role models in terms of their character and integrity. You know, Dr. Coventry's famous for osteotomies, you know, different, you know, but it doesn't matter because all those interpersonal components of listening to patients, caring for them, remembering the details, that those are the things that carry forward, even though, you know, all the techniques change over time and the types of things we do. Right. Speaking of which, now that you have a longstanding perspective on innovation and research, what do you see as the, what do you think are the most exciting developments coming our way in arthroscopy and minimally invasive surgery? What do you see as the future? Yeah, you know, I feel like a lot of the things that are on the horizon are a little bit out of my wheelhouse right now because, you know, the things you read about, a lot of it involves biologics and I'm not talking about necessarily PRP and things like that, but just biologic engineering type things. For example, 3D printing of tissues, 3D, I mean, you know, they're 3D printing now hearts to make miniature hearts. I know the Israelis have done that in one of their labs over there. They can't get it to beat synchronously. It just stays in V-fib, which is not a good thing, but they've made a miniature heart. And then, you know, a lot of labs, even in the U.S. now, they have 3D printed tendons and ligaments. And I think there's gonna be a lot of application of that, you know, might eliminate the need for allografts. I think there will be, you know, they'll be able to direct cell lines toward, you know, articular cartilage. You know, you can probably end up getting a total knee replacement at some point made of your own tissues that were, you know, grown in tissue culture, but it'll be a biologic total knee. So I think there's a lot of exciting stuff. It's gonna take decades for that to probably be, you know, permitted by the FDA to be out in general use, but it's still exciting to think about. So we've covered a lot of ground. I appreciate it. One of the questions that we wanted to ask you, given your perspective on the Arthroscopy Association is, would you change anything about your experience with the Arthroscopy Association over the years? Well, no. I mean, the Arthroscopy Association was an integral part of my career, you know, from the beginning. Once they decided they were gonna let me in as a member, that, you know, I served on committees, I served as an officer, and it got me started on kind of this whole educational mission that would have been hard to do otherwise, because even though I was in private practice my whole career, education was a huge part of my mission, I thought. I was really encouraged and aided by so many friends at Anna that were like-minded, and we just were able to encourage each other. Even, I remember there was a point probably in the early to mid 90s when there was a small group of us doing arthroscopic rotator cuff repairs, and I was talking at dinner one night with Steve Snyder and Jim Ash, and we were saying, gosh, we just don't know if we can teach people to do these things, we need better instruments, we need better techniques, and we said, yeah, but, you know, we can do it, so at least we have job security. If nobody else ever learns to do it, at least we'll be able to do it. So, but thank God it didn't come down to that, you know. We got to participate in a paradigm shift, and there were such long odds against that, and it was just very, it's been very gratifying to be a part of that. It's been incredible, and we're very grateful for your contributions, and Dr. Snyder and Dr. Ash's contributions as well. Just shifting gears a little bit again, you had talked about the importance of character in being a physician and surgeon. We all struggle with this at all stages of our career, but difficult cases can be very humbling. Complications happen. What advice would you have for us to, what keeps you coming back in a way that, how do you stay grounded when things don't go the way you want them to? What have you learned about how to deal with inevitable complications? You know, complications are tough. You know, I think it takes some maturity. I think a young surgeon that has complications, you know, needs somebody. He needs a sympathetic ear, almost a father figure in the group that he can go to. And in my case, Dr. Ginchy was that person. Dr. Ginchy was that person, I told you, the senior partner in the group. And he would discuss these things with me about complications he had had, and how he'd learned from them. And it was, you know, he then had to, for example, if it was an infection, obviously, you know, infections are gonna happen. It's not necessarily gonna be the surgeon's fault, but you still feel bad about it. And so you go in and you do the right thing. It might happen, you know, that somebody has 103 degree fever the evening before you leave on vacation, and then you just have to stay home for a couple extra days and get things under control. And so I learned those types of things that medicine and surgery in particular is not your normal 40 hour a week job. And there's other people, everyone goes through these same things, and you have to develop some equanimity to think that, well, yes, the occasional bad thing is gonna happen. Hopefully it's not gonna happen because it's my fault, but that could happen as well. But on balance, I'm going to do a lot more good for people than harm. And so that's what keeps you going. And the other thing, Mike, I think is that one of the things that's great about surgery being a craft, particularly if you can get yourself into kind of a subspecialty where you're doing similar cases over and over, you do get better over time. You get better at diagnosis, you get better at deciding which patients to operate on, which ones not. You get better at doing the surgery, doing the rehab. And so you just become better. And so you become more confident as you get older, assuming that you don't overstay your welcome and stay too long. But I think that's a great thing about kind of the evolution of a surgical career. And if you can choose the time to leave, that's what I did. I felt like I was leaving and I was at the top of my game and I wanted to be in charge of that decision. So yeah, I could have stayed longer, but I didn't think I should. That's a great point. Tell us about that. It's so hard for someone to go out with their skills intact because it's hard to see perhaps ourselves losing a half step or our skills deteriorating. So how do we know when the right time is to hang it up surgically? I think you need to have, if you have the luxury to do this, where you're not feeling like you have to continue to work until you take your last breath because you need a paycheck every week, if you've saved some money and you have the luxury of retiring at some point, I think you should kind of set a horizon as being trying to have the goal of retiring before you think you really need to. And you don't want to get to the point, I had a senior partner one time, not Dr. Hinch, but another one who said, and he was a hand surgeon. He said, if it looks to you like I'm not doing so well or you hear from the OR people, I'm not doing well, I want you to tell me. Well, at that point, it's too late. If the surgery tech is telling me, a shoulder surgeon, that the hand surgeon's not performing well, it's too late. He should have hung it up a couple of years earlier. So I think that it's something you have to just decide on your own. You have to recognize, and you can do it. I mean, I can tell you if you lose, you can tell if you lose a 10th of a step as a surgeon. You can tell if you're just not what you used to be. And you set some limits and you say, what if I lose a little bit more, I'm just going to stop. Or I'm going to stop before I do lose any more. Yeah, it's great advice, but congratulations on your retirement. And I hope that we all can identify when it's a good time for us to step down and we can do it on our own terms. Just a couple more quick questions to kind of tie things up. Reflecting on your career, if a young person asked you, why should I pursue a career in medicine, in orthopedics, in sports medicine, arthroscopy, I'm sure you get those questions all the time. What would your advice be knowing what you know now? Well, I feel like I was so fortunate in my career, I felt like I had the best job in the world. And very few people can go to work every day thinking they've got the best job in the world. And so I had to examine, why do I think I have the best job in the world? It's not because it was the easiest job in the world, but it was so gratifying. It was gratifying on so many levels. There was the doctor patient level where you would see patients come back and doing better and they'd be grateful. And not many people get to experience gratitude being shown toward them on a daily or weekly basis. And so I think that's number one, just going into medicine. I think I had the added benefit of teaching. And so having some influence on the next generation of craftsmen in your craft is important. And hopefully then having contributed to and advanced that craft to make them better craftsmen, hopefully than you are or ever had been. And the final thing is, if you can do it in such a way that your family, you can make time for your family, but also knowing that your family is proud of the profession that you participated in. It's an honorable profession and people look up to doctors, regardless of how they might complain about the medical profession, but now doctors are still the most admired profession. So I just, my son went to medical school, he became an ophthalmologist. So he wasn't deterred by, he didn't go into orthopedics. So maybe he was deterred by the on-call that he witnessed from dad going in late at night. But he says the same thing. He's so happy that he went into medicine. There seems to be something particularly gratifying about surgical subspecialties, because as you alluded to before, as you advance in your career, you learn who to take care of. You can select with good indications who you're gonna operate on. And you have the advantage of really helping people in a very specific way. And as you build your practice more and more people. So it just seems like we have the ability to help a lot of people. And because we're focused on what we do best. I'm sure your son feels that way. He's doing tons of cataracts or whatever he does. And that feels just as great as having a successful outcome from a rotator cuff repair. So we're very, very fortunate in this field in particular, it seems like your surgical subspecialties. Yes, I agree. Yeah, I don't think I would have been satisfied in being an internal medicine doctor. In fact, when I was a resident, the director of our residency program was P.J. Kelly. And Dr. Kelly had been an internist before he decided he didn't like it. And he went back to do an orthopedic residency. And he used to tell us when we were residents, he said that the reason he switched and wanted to do orthopedics, he said, I realized as an internist that all I was doing was chronicling the decline of the human body. But it's just like everything else. And the great thing about orthopedics and particularly about arthroscopy and sports medicine especially, is you're returning high functioning people to their previous level of high function. And it's not like you're just getting people just barely marginalized. Again, you're getting them back to doing the things that they really enjoy in life. That's very gratifying. It's an incredible blessing, but I've taken enough of your time. Anything else that you'd like to leave for the Anna community? Any other thoughts or reflections? There's a great song. Let me think, what is this guy's name? There's a Texas songwriter named Gary P. Nunn, and he had a great song about Texas. And the title of that song was, I could tell you what I like about Texas, but we'd be here all night long. I feel that way about arthroscopy. It is interesting. You can listen to people in other disciplines talk about what they do and how they love it. It seems boring, but orthopedics and arthroscopy never gets old, like you said. That's right. We're biased, but it's true too, I think. That's right. Dr. Berger, I thank you so much for your time, your contributions. I'm glad you're enjoying your retirement. I know you'll continue to contribute and give back as you always have, but we're so grateful for everything you've done and thank you for recording this. Okay. Well, thank you, Mike.

Dr. Burkhardt

Arthroscopy Association

Membership process

President 2002-2003

Arthroscopic surgery

Rotator cuff repairs

Innovative instruments

Mentorship