E53 Ryan Martin on Sports, Surgery, and Simulation

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Chad Ball  00:12

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been broad in range, whether clinical, social or political. Our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research, and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.

Ameer Farooq  00:55

In this episode, we were lucky enough to have Dr. Ryan Martin on the show. Dr. Martin is an orthopedic surgeon at the Foothills Medical Center in Calgary, Alberta. We talked to him about what it was like to be a sports doctor for the Calgary stampeders and the extensive preparation that he does for going into the operating room. Dr. Martin, thank you so much for joining us on Cold Steel today, we really appreciate your time. And for those of us who don’t know you as well, could you just give us a bit of a background about yourself, where you grew up and what your training pathway was?

Ryan Martin  01:46

Sure, I’d love to. Well, thanks for having me. It’s a pleasure. I grew up in Ottawa. And my background was, I grew up interested in athletics and mostly hockey. Grew up playing hockey and soccer but really got into hockey. I got drafted, I was playing Junior for a bit and tore my ACL during that. And it was kind of during that whole process where I was approached by my physics teacher and kind of, you know, turned my direction towards medicine in the sense that she, like many orthopods, an injury sparks interest into medicine and of course that puts you into the sports medicine orthopedic interest. And so it was after that I basically got interested in ortho and set my sights on med school, did med school in Ottawa, and that’s where I met my wife, who’s an Obs Gyn who does an infertility. And we wanted to move out west and wanted to enjoy the skiing and outdoor lifestyle. She was into the outdoors a lot more than I was and she’s gotten me into it as well. And so we came out west and really enjoyed the collegiality of the surgical group here and in kind of that balance between academics during the weekdays and the being accepting of enjoying the leisure and outdoor pursuits of the weekend. And that kind of led to our love of Western Canada. And following that, I did a fellowship in New York City for a year and trauma at the hospital for special surgery and enjoyed that. Did a sports medicine fellowship in Toronto the year after. And following that, got the job here in Calgary where I currently work and I’m doing drama and a sports medicine kind of needling ligament reconstruction practice.

Chad Ball  03:56

It’s interesting, I think, from the outside, it seems like sports medicine and trauma would go together quite naturally. But I think that’s probably an erroneous statement eh? Is it that common? And there is clearly big differences between those two groups of patients eh? Almost almost opposite ends of the spectrum.

Ryan Martin  04:13

No, it is I mean, I think you look at the patients and then you look at the pathology. I think from a trauma perspective, as much as we say orthopedic trauma surgery, a majority of the time we’re concentrating on fractures and we get impressive X-rays and CT scans and by and large majority the trauma surgeons are concentrating on restoring the anatomy of the fracture. Sports medicine though, it’s on the opposite side. So you know, I talk with the patient a bit, but just from a pathology perspective, sports is mainly a little bit more concentrated with the soft tissues. And oftentimes the trauma surgeon is ignoring the soft tissues and then sometimes the sports medicine surgeons are ignoring or not addressing the bone issues. And it’s becoming a little bit more common and I think it’s a great merger of practices. And it’s bringing a little bit of a recognition to optimize outcomes. In trauma surgery or fracture surgery you need to understand to have first, you know, whether there’s a ligamentous issue that’s going on, that’s going to affect the ultimate outcome of the fracture and then when to intervene and how to intervene and the principles of fixation are our difference. Understanding ligament repair and reconstruction, there’s certain principles that are not as commonly employed from a trauma surgery practice. And then you’re absolutely right Chad, like you get the follow up clinics. I have my elective outpatient soft tissue knee reconstructive clinics, and then I have my trauma clinics and the patient population can be different. Sometimes there’s crossover. And the expectations are different. But in some respects, they’re similar that at one point, this person was normal. And as you see all the time, as well, something happens, and then that life has changed. And that happens in sports as it does in a car accident. So I think it’s fulfilling, and I think it’s broadening the perspective of both trauma. And then to go back to the sports aspect, the reconstruction of bone and not being scared to address bone to offload ligaments is  critically important as well. So, you know, I think both gain from having the other.

Chad Ball  07:00

You know, I love that description. And I think it hits home with me in particular, you know, as you insinuate, because in my life, the HPB, and then the general surgery trauma side. You know, there’s a lot of things over the years that have really… I’ve tried to take from one and into the other, and vice versa. And I think it’s made me hopefully better at both, for a lot of the different content, but same conceptual reasons that you’re pointing out. And, you know, one of your partners told me recently that in addition to, you know, all the talents that you have, that amongst that group, no one knows the literature, as well as as you do. And I always thought, you know, that’s super high praise from that individual who I won’t out in public for you. But, you know, that was a really big tip of the hat. So I’m curious how you manage this massive flow of information, and really two super sub-specialty fields. In 2020, what do you read? How do you read? When do you read? And how do you integrate that into your daily practice?

Ryan Martin  08:09

Yeah, it’s a great question. It’s an honor somebody said that about me, I don’t necessarily think of myself like that. But I do read the literature a lot and try to stay up to date, and I’m somebody that doesn’t feel comfortable doing something surgically if I’m, you know, if I haven’t read something about that in the last kind of six months. And, you know, I definitely want to be prepared before going in. With respect to the literature, it’s interesting, because you can know the literature, I think, to different extents, and I think a lot of my colleagues know certain aspects of the literature a lot stronger than I do. And I separate those, you know, from the large clinical outcome studies and in surgical practice, that’s something that, you know, I read, I’m interested in and I’ll follow those. But I am somebody who certainly believes in… my passion or interest is about mastering techniques and surgical techniques. And I think if we can really concentrate on the details, a lot of the times in these large trials, it’s hard with surgery to really incorporate how those details are being addressed. And for me, I have a lot of interest in improving my technique surgically to try to improve my outcomes and understanding the mechanics of the joint that I’m working on. And so that’s a large portion of the literature that I read: is to keep me updated on that and to make sure that I’m always trying to push my surgical abilities. And just as a general rule, I have a paper a day, so I get in early. I am definitely more of a morning person. And in addition to planning for a surgery, you know, something, I believe in strongly that I take a long time to plan every one of my surgeries. And oftentimes, you know, when you get a complex case, or even sometimes a routine case, a question comes to mind, and I’ll look that up and get a paper. And I try to get a paper a day, and then build off that.

Chad Ball  10:27

That’s a great suggestion. I mean, you always see that in hyper performers like you, right? It’s about being organized. And it’s about, you know, sticking to a routine, whether it’s a pro athlete, or whether it’s a surgeon probably. And I think that’s a great piece of advice for sure. One of the other things that you do that kind of fascinates all of us from the outside is your work with professional athletes in particular on the sports medicine side, and I don’t think it’s a secret that you’re one of the one of the Stamps docs and do a lot of work over there with them. Maybe at the risk of too much self disclosure: like you, I played major Junior hockey, and then University hockey. And I always assumed as I entered medical school, I would be a sports medicine Doc, and I had a little different experience. Same thing, you know, what stopped me was a knee injury. But when I was I was living in Vancouver at the time, and I went and hung out with some UBC sports med folks that I’m sure you know, and I love these guys to the very end of the earth, but I looked at that patient population and went, all these guys are sort of… these pros are all princesses. And the psychology of that, despite being driven, you know, to get back to the field or get back to the ice, which was really interesting and attractive. I sort of went the other way. And I’m curious how you ended up doing that? And how that came about? And how these pro athletes, how you deal with them? And how you interact with them both physically and psychologically? What does that world look like to those of us that are ignorant to it?

Ryan Martin  12:05

Yeah, I mean, I can certainly understand your approach and the problems that you had with it. They’re certainly different to deal with. I think I find a huge amount of enjoyment for it. And with it, I think I had a similar experience to you, but I probably, you know, I saw some, I guess a different challenge in it. And I think there are people that say, well, you can treat pro athletes similar to anybody else. But, you know, I think the reality of it is that they are different. There’s many intricacies that I find interesting that play into your decision making with a pro-athlete that just doesn’t exist with somebody that doesn’t revolve around making their living playing sports, you know? You have to incorporate aspects like where they are in the season, and the psychology of that and where they are in their contracts here. And, you know, how important is it for them to return? And so I think I found these challenges. And I think it’s interesting, because it’s almost a skill set in itself. Like we say sports medicine, and I think myself, one of my interests is trauma, surgery and ligament reconstruction and just generally trauma around the knee. And then the sports medicine practice is separate. And the sports side, when we say we’re a sports medicine orthopedic surgeon, is understanding how to deal with the athlete and understanding that psychology. Just that, in itself is a skill set that I think I’ve initially lacked. I’m gaining in it, but there’s always areas of improvement. And I find that it’s the more I learned, the more interesting because it just adds another set of variables that you need to incorporate into your treatment plan. I mean, the other side of it is how much I’ve learned dealing with them. Like no one’s going to challenge your reconstruction more. And there’s less room for error surgically. So it’s a time where you really have to put your best product…not that you know, I don’t you don’t try to put the best product or the best surgery for every one of my patients but…no other patients have the ability to spend all day rehabbing their knee afterwards. You really get to see what the potential is following your reconstructions, and I find that very rewarding when it’s successful. But it’s also, you know, when it’s not successful, you learn a lot, it’s incredibly challenging. And then the other aspect that we…I think a lot of people go into sports medicine thinking that they’re going to be the savior, and they’re going to be able to do anything and return these athletes to play. And the reality is sometimes injuries are suffering. Some of them are quite severe, where there’s almost a skill set in itself: breaking that news to the athlete that their season’s over, and potentially their careers are over. And then how to do that, the “Breaking Bad” news, which we learned in med school, but breaking bad news to a pro athlete is a variable that we don’t learn in med school. And that’s been something that’s been kind of rewarding to be involved with them. And I enjoy it. It also, I think, you know, your major Junior experience, in trauma surgery in itself, one of the reasons I’m sure you enjoy and I enjoy is the teamwork. And how, you know, oftentimes you and I are having to tackle a patient to then develop a plan together and that’s similar with sports medicine. You’re involving everybody; from athletic trainers to their strength and conditioning coach to management, agents. There’s multiple people that are participating in the decision for this person’s care. And I find it interesting and kind of an engaging challenge.

Chad Ball  16:45

Yeah, I mean, I’m so glad you described that so eloquently. Because it’s a fascinating thing to think about and to look at from the outside. And probably the truth is, you know, you’re right, it is different to tell someone that they’re going to die of their pancreas cancer because you can’t get it out. But, you know, that happens privately in a quiet clinic with you and one or two family members maybe, and the patient. But, you know, when you fail, not that you ever have, but if you fail, that’s probably on the front page of the news that the quarterback is in trouble. And I imagine that’s a whole different, not type, but whole level of pressure quite frankly.

Ryan Martin  17:21

Yeah, you get the media, but then now it’s social media. So your incisions are on social media, your X-rays are on social media, your work, like I’ve seen it. So everything you do is for show and open to comments. And I find it interesting because it supports that every single thing you do should be well planned and tried to be executed as best you can. But it does make a difference. So I think for those that say you should treat the athlete the same. You want to obtain the same outcome, but it’s certainly not the same treatment. You know, there are differences.

Chad Ball  18:20

Yeah exactly. The methodology and the psychology of it, as you point out is fundamentally different. You know, again, at the risk of disclosing too much, when I was in Indiana doing my HPB and transplant fellowship, of course, that’s where a pretty famous cyclist was treated for his metastatic prostate cancer. And I was talking to the neurosurgeon that did his craney. And the recount of that interaction between that person and the surgeon was fascinating. You know, the person, uber famous, uber  powerful, comes in and sort of says, “Are you good enough to be operating on me?” And the answer from that really senior, really superb human being and neurosurgeon was, “let me make this clear, I’m better at my job than you are riding a bike”. And I know that sounds flippant and funny, but having got to know him over the course of a year and a bit there, that’s probably exactly what that athlete needed to hear, to feel confident and comfortable with what was going to go on. And by all accounts, he nailed it completely. And like you point out, that psychology is so fascinating at that elite performance driven level.

Ryan Martin  19:42

Absolutely. And I think it is one of the unique things too. That oftentimes, you’re seeing somebody that has seen other specialists, you know? When it’s not an incredibly acute injury, there’s oftentimes that you’re just one of the surgeons that they’re getting an opinion from. And so it’s interesting because that’s certainly one approach, is to try to instill confidence in the athlete. But sometimes that’s not the approach you want to do. I mean, there’s times where you want to be realistic and you do get this approach where surgeons might want to operate on somebody famous. I think that some of these athletes are at risk of being operated on just because of who they are. It’s certainly not when you have metastatic brain or pancreatic. But when you’re dealing with orthopedic issues, there’s a lot of gray areas in orthopedics. And when somebody famous walks into an office, you know, the tendency I think, for some people would be to want to operate. I’m probably not using the right words. But I think one of the things that I’ve really tried to be cognizant of, is that I’m not recommending surgery for who that person is. And in trying to sell them on an operation, and suggest that I’m any better than somebody else. I mean, this might be my opinion, or what’s best for that particular person. But I think that is another unique aspect of athlete care is that they are at risk of being off to an operation or promised an outcome, when in reality may not be the thing that’s likely to occur.

Chad Ball  21:37

That’s so well stated. You know, it’s funny, you touched on it a few minutes ago about what we learned in medical school and in residency and our fellowships and what we don’t. Clearly you’re such a humble guy, you’re probably being overly humble, but how we learn as we practice for a while. And you’re right. Like breaking bad news and interacting with those folks, and when to say and who to push and who not to. And it all comes with experience. And it’s like, don’t you think it’s amazing how much you do learn from the nuance side of things in your job. And sometimes you get it wrong, and you have to apologize. But oftentimes, you get it right. And it just seems to get better and better as you go.

Ryan Martin  22:18

No, absolutely. I mean, when you take pride in your technique, and you’re trying to master your technique and get better at the surgery, and then you realize that, wow, so much of the outcome is dependent on the soft side of medicine.

Ameer Farooq  22:36

You’ve given so much great advice, I think, for new trainees and new grads, but I’m gonna be selfish and pick you a bit more deeply on this. Just because I just finished my residency and I’m doing my fellowship. You’ve been practicing for a while now. But do you have any advice for freshly graduated surgeons heading into their fellowships or starting their first jobs? What are sort of your tips and tricks for getting the most out of their fellowship and then into practice?

Ryan Martin  23:08

That’s a great question, I think. Yeah, I think it’s some of the advice thatI kind of alluded to earlier. I think surgery is different than summaries of medicine, especially when it comes to these large clinical trials. And the outcomes that are derived from them is that a lot of this stuff is technique based, and I don’t think we concentrate as much on technique. I think a lot of the outcomes do depend on who’s doing the operation. And I’m a huge advocate towards concentrating and mastering and constantly trying to improve your technique. So I do suggest challenging dogma but also being you know, humble enough that it’s not likely that you should challenge dogma enough to expect that your outcome is going to be drastically different than something that occurs or has been accepted as dogma in this specific surgical specialty. The other things that I really have been quite passionate about is objectifying and trying to measure your outcomes, your own personal outcomes. Because of course, you can follow things in the literature, but what works in your hand? And there’s no better way than if you can collect your data and being objective with it. Not just saying, oh, you know, the last five I did, we’ve always heard that. We’ve heard that from numerous people through our practice, and oftentimes, that’s completely inaccurate. So I try to collect objective outcomes on most of my patients, all my soft tissue reconstructions, I collect patient reported outcomes. I try to collect stress, objective stress outcomes so that I can follow my outcomes and keeping surgical journals. Looking here at my desk, I’ve got eight volumes of journals that I started since practice, and I take note of my technique, take note of the literature, go to the literature, and constantly try to improve and push yourself. I think there’s a tendency of wanting to be comfortable in the operating room, especially as a new trainee or as a new grad. There’s going to be times in most of these operations, there’s going to be some aspect that makes you nervous, that’s going to be uncomfortable. I suggest that you try to maintain that through your practice and throughout your career. Because I think if you’re too comfortable operating, then, you know, maybe your incision is too big, or the technique is too simple. And so I’d suggest to push yourself surgically, continuously to improve on your techniques. But also, don’t try to automatically improve your techniques in multiple aspects at once. Take it in stages, or else, it just becomes too overwhelming. And lastly is: my big push is be prepared before you do that operation. Plan it out. Think about it. And oftentimes, when you prepare for the operation, I think that is when a lot of the questions come. Certainly for me, that’s where I get most of my questions that I try to look for and can find that through is the day when I’m preparing for that operation. And with trauma surgery, we’re often planning fracture surgery, we get to go through some CT scans, we get to draw out, or I personally enjoyed the drawing every fracture and trying to visualize it to fix it. And a mentor of mine once said, If you can’t draw it, you can’t fix it. And so just maintaining that constant drive to improve yourself. And the journals are great, I find because there are often operations that you don’t do as frequently as you’d like. And you finish it and you feel confident. You learn that, you’ve learned something through that operation. And then the next time you do it, you’re thinking, oh great. You know, I remember doing this, and I remember something about this and you just can’t recall. Whereas if you write it down, you can always go back to it and you just build upon it. And then I think it’s a really good area of growing your practice.

Ameer Farooq  27:35

I want to drill down on a couple of things that you said. I think one of the things is about your collecting outcomes. When you say you collect outcomes does that mean, like do you have your own database where you’re keeping track of this kind of stuff? Do you have a nurse recording things for you? How does that incorporate into your workflow? Because I think many physicians and surgeons would like to track their outcomes. But in actual practice have struggled to do so because it’s onerous and time consuming. And they don’t have a good way of building it into their workflow. So how do you do that?

Ryan Martin  28:14

Yeah, I kind of built it in through my practice through my EMR as they came back, and so before a patient comes to clinic, I have a box that’s called an intake form, where I click off what outcome score, I want that patient to fill out. And I’m not so much doing it to potentially… it’s not really for research purposes, it’s just that, you know, for instance, with knee ligament reconstruction, depending on what reconstruction you’ve done, there’s certain validated outcome scores that you can collect. And so they’ll fill those out in the waiting room. And so I’ll have that data. And I can also, you know, one of the things with orthopedics that I guess is different than some surgical special specialties is that we don’t often actimize, we’re often putting things in and our evidence of what we put in is often there in a footprint in an X-ray. Or for me, a scope picture of where my tunnels are for ligament reconstruction, let’s just say. So when I see that patient and I examine them and I might get a certain laxity exam, I can then go back to my EMR and reference where I put that tunnel, you know, how their outcomes of it have trended. So, I know there’s lots of us in practice that look as a group, but I’m certainly somebody who has really focused on really, in detail looking at each individual case and trying to draw some examples. Of course sometimes you can over emphasize certain aspects just based on that one case, but that’s just really how I i approached it.

Ameer Farooq  30:03

The other thing I wanted to pick up on is the whole preparation thing. And I think I’ve, you know, I appreciated that a bit as a senior resident, as a chief resident. But I think even more now, as a fellow, you really started to realize, like how important it is to prepare for the OR. We sort of think that the staff guy knows the operation perfectly, and they just come into the OR, and they’re just ready. But I think in reality, now that I’ve sort of had the chance to speak to my staff, as a fellow, you actually start to realize how much more time they spend reviewing CT scans, reviewing the patient’s medical history, like really understanding exactly what’s going on, and as you say, almost like drawing it out and picturing it and mentally visualizing it before they do the operation. Can you break down in detail, like when you say you’re preparing for an operation, I know it’s a little perhaps different in orthopedics, then perhaps in general surgery, but in broad principles, when you’re preparing yourself for the OR, like let’s say, when you were in fellowship, versus now, what does that preparation look like? And how do you sort of visualize things?

Ryan Martin  31:18

Well, it’s interesting, because the whole being prepared for cases really, you know, have been built into me on multiple mentors of mine and Buckley is a huge planning doctor. Dr. Buckley here in Calgary is a huge advocate for planning trauma surgery. And then I went and worked with my mentor, Dr. Helfet in New York and HSS. And if you didn’t have a surgical plan on the wall, there’s no aspect of that surgery that you were going to partake in. And so you build in that kind of belief of getting prepared. So the aspect for me is that I, you know, with orthopedic preparation, most of the soft tissue stuff that I get to do, I have an MRI of an X-rays and so I sit down, I come in early, that’s where I plan my operation, I have coffee, I have music going, and I’m looking through that MR and X-ray in detail, and I’m drawing them out. And measuring all the angles and making sure that I’m trying to take in every variable. Before every case, I write a problem list. And these are kind of what I anticipate encountering during the operations and being able to write down the problem list is really, you know, as you gain more experience, your ability to predict that problem list becomes more and more accurate. But trying to predict where you’re going to run into problems has been a huge help for me. And then drawing things out also brings out these issues that I didn’t plan or that I didn’t encounter. I didn’t think about when I just was trying to plan in my head. You know, I first came back and almost felt it…not as a weakness or anything, but when you have this detailed plan on the board, I think some people might think, wow, you have to plan about everything. And so I tried to hide it. Now, it’s something that I just put up on it. It’s part of whatever operation I take part in. It’s part of the step.

Ameer Farooq  33:49

But it’s amazing. I mean, again, it just highlights how much preparation and planning the experienced and the high performer really does. I mean the military uses that, the five P’s right? “Prior Planning Prevents Poor Performance” as their acronym and I think that’s just a tangible example of what that looks like in the operating room.

Ryan Martin  34:14

Well, I was just gonna say, I mean, we drew on the pro athlete before but you know, another thing that I’ve kind of learned is I’ve been able to be on the sidelines for some larger sporting events and something that really stuck with me was earlier on in my career, I was covering a game as the traveling doc for the Stamps when they were playing Ottawa and it was an overtime game so it was late and it was probably past midnight or we’re on the bus and what happens is you get on the bus, you find a charter flight and you board a charter flight you fly home and you get home at three or four in the morning. And so it was an overtime loss. And the first thing that Bo Mitchell did, he was sitting a couple seats ahead of me, the first thing as soon as he got on the bus, there was no chatting, there was nothing. He sat down, got an iPad from the coach and started going through his plays. And he actually wasn’t close by on the flight home and basically till three in the morning, he was still on that iPad, discussing with the coach going through everything and going through their errors and what they could have done better and improving till three in the mornin. And I’m looking at that, and of course, you get to learn that, you know, we’re the same. We’re trying to master what we do. Our technique is a little bit different and our environments a little bit different, but it’s still the same thing. We’re trying to improve our skill set. And so I learned a lot from that one event.

Chad Ball  35:50

That’s a great story, Ryan. There’s a hemorrhage control course that we run in Canada on the general surgery side of things. And it’s essentially a video based course called bloody simple, and I think it’s done really well. And it continues to grow. But one of the things that we talk about in the course and one of the pictures we show is a famous painting or picture of Peyton Manning during preseason, and he’s got his ankle in the tub, because it was injured. He’s got his, you know, his Denver Broncos helmet on. So he’s listening to the offensive coordinator, calling the plays and then he’s got the iPad, and he’s watching it. And, you know, sure enough, we think we all know that he’s sort of perceived anyway as the master of preparation and the intellectual component of quarterbacking. But, you know, that was preseason, and he was injured, and he was physically doing rehab on his ankle, he was still preparing and still visualizing. And I think we can learn a heck of a lot from pro athletes in that process. And we, you know, it’s sort of your underlying probably assertion is across surgery in general, we really don’t do enough of that.

Ryan Martin  37:00

Right? I mean, how many journals do we read that this surgery doesn’t work? And we have it in orthopedics, that, you know, for certain fracture, you should or should not operate? Or for certain, you know, that’s just one example or certain ligaments, you should or should not, we don’t talk about the variability in surgeon, just what variables have you taken in before you got to the operating room? And then how you are you carrying out your task? And I agree, I think, you know, I try to I almost rate every surgery I do internally and how well it went. That’s an outcome that, you know, obviously you don’t want to show everybody, but it’s something that you keep internally, and you can kind of track that to how well the patient does. But no, you’re completely right. I think we should be humbled to the fact that most of our operations, we can continue to improve.

Ameer Farooq  38:01

Before we started the show, you were telling us a little bit about your knees simulator, which I think is again, an extension of your mentality about being prepared coming to the operating room. Can you tell us a little bit about what you’ve developed? And how that kind of came about?

Ryan Martin  38:18

Yeah, well it’s a huge team effort. Early on in my practice, I kind of was introduced to a group at the University of Calgary. And one of the professors is Carolyn England. And she’s a biomedical engineer that trying to develop a bone material that was accurate from a tactile perspective, to simulate surgery. And we kind of got discussing and then that grew with, obviously I alluded to one of my passions which is maximizing the preparation prior to getting to the operation. And I saw a huge opportunity to build and ability to make an arthroscopic tactile simulator. I think, from a surgical education perspective, there’s a lot of resources, I guess. We’re going to try to maximize virtual training. And I think that’s a great aspect. And we’ve relied upon categoric training in orthopedics and I’m sure other surgical specialties as well, but you don’t know what you’re getting with the cadaver. They’re often old, which is not who you operate on when you’re doing a sports medicine ligament to surgery practice. And they’re mainly arthritic, which you know, that’s what you’re trying to prevent. And so it didn’t accurately simulate the environment that we were doing these techniques in. And so with that, it’s been a five year venture. I’m now the Chief Medical Officer of, it’s called Ammolite BioModels. And what we’ve tried to build is an environment that replicates that tactile environment of operating. So we’ve made a knee positioner to try to position the knee like you would when you’re repairing a meniscus or doing an ACL. And then the bone material, making it accurate, the meniscus feel of when you repair a meniscus, and having something. So I’ve had the benefit of having those in my office that I get to play around with different techniques and see. If I tension that ligament at this range, or if I drill a tunnel a little bit off in this direction, what it ends up doing. And so that’s been a huge benefit from my own kind of, selfishly, my own development as a surgeon. But I strongly believe that before we introduce new techniques, which is a whole other issue, I think in surgery, is like where’s that boundary of when you should be practicing it before you go into the patients and when you’re actually doing it for the first time. But I think before we do that, we should have access to these relatively low cost models that allow us to rep out before we do. Going back to the professional athlete you know, the golfers, the quarterbacks, how many balls are they throwing in practice before they do it in game time? We’re surgeons.  We haven’t had that ability in the past. And I think it’s something. Simulation and being prepared and maximizing that before you get to the operating room. This is the future.

Ameer Farooq  41:45

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