Chuck and Chris welcome Ryan Nunley to the Podcast. Ryan is a total joint surgeon who has an amazingly busy clinical practice. We discuss practice efficiency, handling VIPs, and share updates on computer navigation and robotic surgery. There is so much we can learn!
Subscribe to our newsletter: https://bit.ly/3iHGFpD
See www.practicelink.com/theupperhand for more information from our partner on job search and career opportunities.
See https://checkpointsurgical.com or www.nervemaster.com for information about the company and its products as well as good general information about nerve pathology.
Please complete our Survey: bit.ly/3X0Gq89
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Chuck and Chris welcome Ryan Nunley to the Podcast. Ryan is a total joint surgeon who has an amazingly busy clinical practice. We discuss practice efficiency, handling VIPs, and share updates on computer navigation and robotic surgery. There is so much we can learn!
Subscribe to our newsletter: https://bit.ly/3iHGFpD
See www.practicelink.com/theupperhand for more information from our partner on job search and career opportunities.
See https://checkpointsurgical.com or www.nervemaster.com for information about the company and its products as well as good general information about nerve pathology.
Please complete our Survey: bit.ly/3X0Gq89
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Welcome to the upper hand podcast where Chuck and Chris talk hand surgery.
Chris Dy:We are two hand surgeons at Washington University in St. Louis here to talk about all things hand surgery related from technical to personal.
Charles Goldfarb:Please subscribe, wherever you get your podcasts
Chris Dy:in thank you in advance for leaving a review and rating that helps us get the word out, you can email us at Handpodcast@gmail.com. So let's get to the episode.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm great. How are you?
Chris Dy:I'm really, really great. You know, I have this fancy mic, as our guest just pointed out, you know, trying to keep up and up on the audio quality.
Charles Goldfarb:You well, you're no doubt you're impressing the masses. And we do want to introduce our guests. But you know, because we are not just a podcast. We are also a YouTube podcast, they can see the audio visual. So that's important that you impress I remember
Chris Dy:early on in the pandemic, when we were doing all these webinars and whatnot. I got this really cool gold microphone as the Yeti that attracted a lot of a lot of comments that made me look like a mid 90s rapper is what I was told. So I was happy with that.
Charles Goldfarb:So I guess Can
Ryan Nunley:I can I share it? I should share a picture of you and your your rapper outfit from a woman's birthday? Oh,
Chris Dy:yes, yes, yes, that's something that might surface on the interwebs at some point that was told the residents were happy that I gave them easy fodder for the roast. I'm sure we'll
Ryan Nunley:I'll have to share that with Chuck here.
Charles Goldfarb:I think I've seen it and I quickly tried to forget it. So the voice you hear is Ryan Nunley. Ryan is a reconstructive surgeon focused on the knee and he's one of our partners here at Washington University. His accomplishments are many and I mean that sincerely. I am not prepared to do a like a visiting professor introduction. Ryan did his residency here. Did you do your fellowship here too? Yeah, I did. His fellowship.
Chris Dy:Clearly not the Visiting Professor introduction.
Charles Goldfarb:Yeah, well, anyways, and then he's been in practice with us. How many years is it now?
Ryan Nunley:Since 2008, so I guess 15
Charles Goldfarb:Wow. And Chris, when did you join like 2015?
Chris Dy:Exactly. Thank you. I'm glad you know. Let's be clear. Ryan Ryan's the man. He is an amazing arthroplasty surgeon. He is our go to person at least I probably shouldn't say this on the air, but he is my go to person when I send people for arthroplasty a consideration. Although we have fantastic partners. And Chuck, he's your surgeon?
Charles Goldfarb:Yes, well, he is my surgeon. And I think we've talked about this a little bit on the air. I am the time of recording. I'm two and a half weeks out from a computer navigated uni knee replacement, which is going incredibly well. And we're going to sort of use that perhaps as a launch point for discussion. And we thought Ryan, you know, this is sort of part of a new perspective. We're bringing asking partners from different subspecialties to bring information which we believe will be helpful to the listeners. So we had Marshall Berkes on which was maybe more focused, we talked about clavicle fractures. But I think Ryan's expertise and seeing the tech advancements in arthroplasty will really serve the audience. Well,
Chris Dy:Absolutely, just so you know, Ryan Marshall actually got a couple of emails based on his appearance on the upper end. So perhaps your expertise will be growing even more and your reputation will be expanding. Before we jump into formally having Ryan on I think we should thank our our Practice Link sponsor,
Charles Goldfarb:perfect. The upper hand is sponsored by practicelink.com. The most widely used physician job search and career advancement resource.
Chris Dy:Becoming a physician is hard finding the right job doesn't have to be joined practicing for free today at www.practicelink.com/theUpperhand.
Charles Goldfarb:So Ryan, Chris and I talk a lot about efficiency. And being busy in our home in our humble little world. In our humble little mind, we think we're both pretty busy and pretty efficient. But I have to say I hold you out as someone who I absolutely know, is busier and has to be there for more efficient than Chris maybe not me a little bit. So tell us a little bit about your practice, if you will.
Unknown:Yeah, so first one thing just to correct you so the audience knows, yours was computer. It wasn't computer navigation, but yours was robotic. So we'll get to that maybe in the technology part where it's gone from navigation to robotics. But in terms of efficiency, the The hard fact is that if we look at the baby boomer population as they mature, there are more and more patients this year than ever that have to Number 65. And naturally as they get older, they require more orthopedic procedures, specifically, hip and knee replacement being some of the most specific needs that they have. So with that, you have to figure out how do I see the patients my waitlist to get in for a new patient is six to eight months, I get constantly barrage of emails, calls to get family members friends. And so either I could turn the doors, shut the doors and say I'm only gonna see X number of patients or learn how to be more efficient, I think many of us are feeling that, that push, especially as we've really not expanded the size of med school admission and orthopedic residency. So we're same number of physician providers, but growing patient demand. So some of that is using technology. Some of it is also figuring out ways that you can be more efficient both in the operating room with the same team. I think it's probably a little easier in my world where I'm doing. One room is going to do six primary hips and the other room six primary knees. So the the dis, the change over the room, the time between every team member knows exactly what their skill set and their job is that we can become more efficient from that perspective. A couple of things that my practice, actually after the pandemic really helped was the use of telemedicine. Some people love it, some people hate it, again, maybe a little easier, and the hip and knee world and the hand world where the physical exam is not as important. Sometimes, you can see from an x ray patient as a terribly arthritic hip, or they have a failed implant and doing the telemedicine. So, to my efficiency every morning, I start with telemedicine at 620. And I see five patients before my clinic starts at 730 or before my hour starts. So four days a week I'm doing that then adds 20 more patients on and it adds very little stress to my team because they don't have to check the patients and they don't have to get there earlier. Patients absolutely love it. Because they can sit at home and have a cup of coffee and I'm running a few minutes late. It's not like they're driving two hours here to wait two hours in my waiting room. So I've used that to my advantage, especially with our physician extenders, nurse practitioners and physician assistants who may have worked up to patients or other partners or sports partners who have gotten x rays, says Miss Jones has bone on bone arthritis of their knee doesn't need a sports procedure, but needs to see Dr. Nunley since they've already performed an exam and have an x ray in the system, I can review that and quickly have the patient on my schedule for surgery. If that's the road, we're gonna go. So that's sort of the efficiency and the clinical side, that sort of stuff.
Chris Dy:First off, I'm humbled by that. So that's pretty incredible. You know, kudos to you for utilizing telemedicine in that way. Yeah, there's so much that you said that I want to dive into the first thing I want to ask is how do you handle the you know, emails from partners and from, you know, acquaintances and other you know, people at the medical school saying, hey, hey, Ryan, can you can you get this patient in? You know, our I need to see you or a family friend needs to see you. How do you handle that?
Ryan Nunley:Yeah, can add a layer of stress? I mean, I think one thing is that these patients typically are already at a point where they need something surgical, it's not just they're coming in, because they have a little knee pain, too, I do think that it helps with our outreach to the community. So other providers who can email Yeah, and quickly get it in. And then three is probably be just being organized. If you get a text message and email on my chart, you know, it's coming in from all these different angles. Having a point person, so one of my nurses, she always calls it the VIP service. She's like, every week, I get 20 VIPs. And they're not necessarily these are VIPs. But these are people who have directly contacted me. And so I think from that perspective, one, it's being efficient to respond back to those individuals who are reaching out to you, for example, nursing, or give me a sticker with their mom's name, can you get my mom in, I just quickly take a picture of it and I text it or email it to my team, otherwise I forget about it so you can get lost in that. So having a protocol in place that makes it efficient for you, as well as for your team, it's important.
Charles Goldfarb:That's really well said and I'm sure Chris gets some of those. I definitely don't get 20 a week, but I think your point of having a system and responding and or just checking it off your list. ASAP is vital. I'm really good with staying up with email. I you know, texting if someone texts me I try to text right back because if I don't, it just goes down the line and I lose it. And you're right. You're getting it from all sides verbally. Epic texted email. It's your system sounds really good.
Ryan Nunley:It's funny how you said that you're good at email, I'm the opposite. The text messages, I don't have all the spam, right? I come out of the ER, and I'll have 200 new emails. And so I'll try and delete, delete, delete, and there may be an important one, get, but then I come out there or there's more. And so then all of a sudden, I feel the opposite that text to me is much better. But guess maybe it's different amount of inbox messages.
Charles Goldfarb:Yeah, for sure, for sure. So talk to us a little bit more about your use of APPS or physician extenders? Do you use them in the clinic? Do who helps you in the or besides residents and fellows? How do you balance? If you do I'm not even sure you do. trainees? If that's the right term in 2024.
Chris Dy:learners learn?
Charles Goldfarb:How do you balance learners and, you know, staff? Sure.
Ryan Nunley:So I think the first thing is, you know, when you look at a practice, while you may be the captain of the ship, every member of the team touches and influences and has contact points with your patients. So it's like any great relationship, if you have a good relationship and you trust and you and you're able to utilize them, then it's meaningful. I'd say there's a great book called Traction by Gino Wickman. And it talks a lot about putting the right person in the right seat. So you could have a great assistant, but maybe doesn't interface with patients very well, it's better in the back office. So you may have somebody who's really great at doing the hands on stuff, but it's terrible at the computer work. And so getting that right person. And I think the same goes for the advanced practicing partners, we have great ones that can really do a nice job inject things, you know, routinely, and you guys may appreciate this, if you're not doing all your own injections, but you have somebody else Oh, and when your nurse practitioner did it hurt, it was miserable, I only want you to do it. Well, that's not really helping you. So getting a partner in that sense that does it the same way you do trust you as a responsible, and they can be great, because they really do interface with the patients quite a bit for the non urgent stuff. So I see all my own patients, but for annual follow ups of X rays, one year, five year 10 year, if they're doing well, usually we'll send them to our physician assistants or for routine injections that come in every three months. So it's a great resource to have, as long as you trust the person and they do a nice job. I think that helps terms of the learners, our residents and fellows I my clinic is busy I typically see outside of telemedicine about 55 to 60 patients in clinic. And part of it is they also have to learn how to be efficient, the orthopedic exam for hip and knee a little different than hand, it's a little different than medicine. And they have to be able to quickly go in and say is this a patient who needs services or is this a person who needs their handheld after surgery is this person who has a complex problem. So you don't need to spend 15 minutes with each one, some need a minute, somebody 10 minutes, some need 30 minutes and to get through that and an efficient way and having them make decisions. So I really make them go in and see the patient come up with a full plan. And leave me the the notes and let me sort of go in independently. If we come up to the same conclusion, then we sit around and talk about ones where there's discrepancy in the or same thing. You know, it's a graduated autonomy, they have to at some point, have the reins turned over to them. So making sure that they are comfortable with every step and knowing we can outline these steps in advance because a lot of what we do is repetitive that they should know it should take you three minutes to get to this part of the case. And this part should only take you five minutes. And I do encourage them at the beginning of the rotating stage. If you think about how you can save one minute on every single case, over the course of six weeks, you should be 30 minutes faster by the end once you've done it. So emphasizing those points teaching the finer details of how they don't have to do every step of the case, for example, putting every one of the retractors in and then turn around to do the next step. We have two other assistants there myself and usually at first assist from the hour. That should each be doing our own work so that it's very fluid and efficient.
Chris Dy:Like God, you're speaking Chuck's love language right now.
Charles Goldfarb:It's your sort of efficiency.
Chris Dy:This is the the six love language that isn't often described. So I think your points are really good about you know, all of them, but particularly the, you know, coming in the learner and the examination and coming out of a room. You know, oftentimes, when I start working with a new learner, I give them the Goldfarb speech about you know how you have to come out of the room with a plan. Well, even if your plan is wrong, you need to have a plan. And I remember hearing that being on the receiving ended that with Chuck, you know, I think Chuck probably wants to unpack a little bit of what you talked about. We probably should talk about some of the technology stuff since we're pretty far in right now. We should thank our sponsor, Checkpoint Surgery. Well, they're hosting a webinar in April on selective and hyper selective neurectomy. I don't even know what that means, and its role in managing extremity spasticity. Dr. Scott Kozin, one of chuck's bros will facilitate the webinar and Dr. Katy Wu from Mayo Clinic who has a friend of WashU will share how her program is expanding the utilization of this strategy to the lower extremities.
Charles Goldfarb:To learn more about this course, and other upcoming educational programs supported by Checkpoint Surgical, including our own here at Washington University, please visit nervemaster.com Hyper selective neurectomy That immediately makes me nauseous. So I don't I don't want to learn more about that. Oh, come on, don't
Ryan Nunley:lose the nerve master was
Chris Dy:wonderful. I'm amazed the Checkpoint got to that URL before I did. That's dammit. No. So we have our peripheral nerve course actually, the the the plastic folks asked us to call it the Washington nerve course not the peripheral nerve course, apparently, there's no difference now. But we have our Washington nerve course coming up about three weeks from when this episode drops at spots are filling up fast, there's actually only a few more spots. So by the time this airs, there may not be any more spots you can get on the waiting list. If people don't show up. Ryan,
Charles Goldfarb:there's there's space for you, you know, there's always room to expand? Well, you
Ryan Nunley:know, there's the uncomfortable pullout operative nerve foot drop that occurs occasionally. That's always very gut wrenching moment when the nerve doesn't function on the first post op checker in the morning. So I may have to attend them and see what there is no out there.
Charles Goldfarb:Let me know how it goes.
Chris Dy:I don't think you'll have to attend. I told you so you drew a distinction between computer navigated versus robotic knee replacement. And you know, knowing that most of our listeners are, you know, orthopedic or plastic surgeons and training, you know, hand surgeons training or hand therapists, can you just kind of give some broad strokes about you know, what, what does it mean to have a robotic assisted knee replacement? And what does it mean to have computer navigation used in arthroplasty, or joint replacement?
Ryan Nunley:Yeah, so I mean, the goal of either of those is really to make the surgery more accurate. You know, when we look at how you do some of your surgeries, if you're going to do an osteotomy, you sort of preoperatively plan, you're going to cut this and say the old adage of you measure twice, cut once to a principle, well, that's a lot of what we're doing every day with a hip or knee replacement. So probably at this point, now, almost 20 years ago, navigation was a utilization of technology to put pins at a fixed point into the bone with the rays that a sensor could pick up that can tell motion and angles, and then allowed surgeons to try to reproduce the cuts more accurately. And it seemed to fade out over time was very, for lack of a scientific words, klutzy, there's sort of difficulties with the data in and the data out and then sort of Fast forward to probably about 12 years ago, the robotic side. So as you saw in the general surgery world with the DaVinci utilization of robotics, and for probably the first five to seven years, there was slow uptake. But with that a lot of the major orthopedic companies have put a ton of time and resource into updating the robotics making it simpler, faster, more reproducible. And with that, now, the growing trend and total joints, especially in the new world, is that the large majority, if not by the time, we get to the end of the decade, here, probably all of them will be done in some form of a robotic assistance just because it takes the human factor out of it, the AI the capture speed of the cameras. So when we say robotics, it doesn't mean that the you push a button and you sit back and have a cup of coffee, like are anesthesia providers and read the paper, it's more that you actually have to take in design the knee and three dimensions, three dimensions, figure out where you want the implant to go. And then the robotic arm holds the saw. So you'd have to put mounting blocks onto the bone to make the cuts. And so it keeps the accuracy by just allowing you to pre plan that on the screen in three dimensions with the CAD models. And that is simulate with the soft tissue tensions would look like. And, again, the advent of that has really made it much more of a reproducible surgery. And then it allows us to sort of question some of the original premise of what our climate targets were now that we have robotics where we can more accurately do it. So you're seeing a huge change and the discussion of not just the traditional type of implants but now really the alignment and the goals that we should to restore the kinematics to the knee.
Charles Goldfarb:So okay, obviously I didn't have a clue because I screwed it up. What you do Uh, but my wife loves to like, it's so interesting. I'm so like precise and anal retentive about my life. But for this surgery and other things, like surgeries, I just sort of say, okay, you know, I know Dr. Nunley's gonna take care of my surgery, I'm not delving into the detail. And she got really frustrated me that I didn't know what was going to happen when and where and why. And it gets, it's just a form of neglect, I don't know. But thankfully, I put my, my knee in good hands. I had x rays nine months ago. And then I don't know, three, four weeks before my surgery, a CT scan. And so what part? Are you adding work before the surgery? Or is all this done literally inter operatively, with the robot with the CT scan? And what's the preparation? And how long does that add as an add to the surgery? Just help us understand that process? Sure. So
Ryan Nunley:great question. The X ray, as you know, is a two dimensional image. So it gives us sort of a screening evaluation to know that you have arthritis, what your sort of basic alignment looks like the CT image takes selective images of your hip, very detailed of the knee, and then selected images of your ankle which can give us alignment and rotation. From that point, that's all uploaded into the system and onto the robotic computer in advance of your surgery done by the by actually the company representative. So no extra time after there other than ordering the CT and making sure for my staff that that it gets uploaded. Inside surgery, we use a special instrument to touch various points within the bone to map it so that the CT scans up on the screen. Now you have to map it to where it is in space, the actual knee. So using a guide to tap several different points on the knee, it validates that you've now aligned it up. And with that, then you can take the knee through functional range of motion stress it to see what the soft tissue tension looks like. And from that you have a full screen, that within a couple minutes, you adjust here, the angles, the slope, and so you get a graph showing you when you've sort of hit the target that you're trying to achieve. So that workflow adds for somebody who's very efficient, maybe two to five minutes of time in the ER, but it saves you on the back end, because now you're not having to mount the blocks onto the patient and make cuts and then take the screws out and remove the blocks. So you as soon as you approve the plan, you go to the robotic arm and it just hold your hand in those positions that you're you've set to achieve the goals. And then you put your trials. And so after the first couple cases, learning curve short, probably doesn't add a whole lot of time on to the case, maybe less than a couple of minutes. You know, the negative as we were a little bit outside of the technology world is the cost associated with things right, we're all very sensitive to cost and new technologies. Just to put it in perspective. The robotic arm runs the hospital about 1.4 to$1.6 million. If you get all the bells and whistles for the capital charge, then there's a service contract of your company representative of your product specialists that's between 100 to 200,000. And then there's the disposables. It's a different type of sawblade. It's a different type of rays that go on your probes and things that are disposable, that can run anywhere from five to $900. So there is a cost born into the healthcare system, which the CEO and CFO don't really like. But there there is efficiency or there's improvement by potentially reducing readmissions reoperation. And for you, Jack, obviously, you want one surgery you want to done well, once you don't want the thought that, gosh, if I was off by two or three degrees, you have recurrent swelling and pain you may not get, you may not achieve the best goal possible. So I think that's what it is helped us reduce the outliers. So we have lower reoperation, higher patient satisfaction scores, and that's a win to our community. And
Chris Dy:you are very good at patient satisfaction scores from what I recall so I guess
Ryan Nunley:my wait time to get in clinic.
Chris Dy:Get him a reason. So in classic Chuck fashion, I want to ask you, you know, say two things. So you know, I guess the first one is you've touched on cost. In our last episode, Chuck was talking a little bit about some of the challenges with, you know, the insurer approving navigation, which clearly he was wrong, because he wasn't actually getting... So maybe that's why they didn't approve it. But one of the challenges on your end in terms of getting that approved, is there additional work or a different CPT that's associated with navigation, or robotics or technology in general for arthroplasty? And the second thing I wanted to ask is, you know, I remember when, you know, everybody turned to doing for example, you know, lap appy, so a laparoscopic appendectomy and very few people are learning how to do an open MP. So what do you think this does for our learners who are coming up in the age of technology? Could they do a primary hip a primary knee without the bells and whistles on of navigation and technology.
Ryan Nunley:Chris, you're asking great questions. So the first one about the insurance and approvals. Like anything different insurance companies have different approval process. But yes, there is some pushback from the private insurers with regards to getting a CT scan approved, even though it's a pretty low cost imaging, since it's not really, if you really do it the right way. And you're in surgery center, or imaging center, you could probably do without the professional fee, since it's just looking for alignment. But you still get feedback. And that does sometimes generate some peer to peer calls. And most of the time, there is additional code for the surgeon for using navigation or robotics. Rarely is that paid for. So we just sort of write it off, because we think it's what's right for the patient. In terms of your question about Yes, going to advanced technology and utilization inside the surgical decision making, what happens when robotics or navigation goes down and it does happen. We had a case the other day, a 85 year old patient, where the pins going into the femur, the bone was so soft, halfway through the case, the pins had loosened enough, where once it read, the system recognizes that you're out of the optimal range or that it's not mapping correctly, your whole coupling goes away. So you do have to have a bailout. It's interesting, as we interview our fellow potential fellows for our fellowship, that many of them coming out of training, who have only had robotics really want to go to a program that teaches them not just robotics, but also conventional because of the situation I just explained. Or they may go to a job at a hospital that promises divide them a robot, but may not have it for the first year or two. So I do think that there is an art form to knowing not only the technology and how it makes things better, but when it doesn't go well or fails you in the middle of something you have to be able to bail out. So that is a challenge that as we get more dependent on the technology, I think we still have to remember the basics.
Charles Goldfarb:You Yeah, all really interesting. It's I think I was talking to Chris, I think it was on the podcast, I always get confused about what we talked about and what's on the pod. But I was really frustrated when I heard that the insurer was not going to pay for the, for the robot for my surgery. And so I called the insurance company like AIG, it just hit me the wrong way. Like, because I just felt like it was wrong. And it was the classic Well, you know, it's experimental. And, and then I started doing the literature review, maybe on the wrong topic, I may have been looking at your theater net. But anyway, that talked to your staff, and they're like, yeah, it happens. Don't worry about it. But yeah, just super interesting how, and I get it from an insurance standpoint, and I get it the cost from a hospital system standpoint, it's a real consideration. And some people certainly talk about both computer navigation and robotics as a marketing tool. I personally and and I'm sure you agree, and may have far more intelligent things to say about it, it feels it feels really important for the future. Because as I understand it, my medial compartment was the worst you've ever seen. The arthritis was horrible. And you probably have to have robot help, and it was so bad.
Ryan Nunley:Well, I would say yours was bad. I've certainly seen worse. But now yours was in you really limped around for quite some time. And I think you were tired of your wife complaining that you couldn't keep up with her. So yeah, it was the right decision. But to your point, I think when you look at technology, one of the advantages of the board looking or even knowing from the past is that the costs will start to come down. Right new technology, ceramic heads were an upcharge of $500. Well, then they realized that everybody's using it the contract, they just renegotiated down. Same thing with some Atlas technologies. But you know, the company's to your point about marketing. The companies certainly recognize that selling robotic arms in the disposables, helps their bottom line. So they push it and they definitely market there are certain areas of the country, whether it's robotic total joints, or if it's who knows some other specialized hand procedure into scopic, carpal tunnel. So you know, there is a there is always a natural tendency for some physicians to use it as a marketing tool. And there's billboards that will you know, you'll see commercials on TV, we at Washington University, as you know, we have no billboards we have no fancy marketing. I think at the end of the day, sure these technologies can help you but if you're still not a surgeon who takes the time to make sure all the other components are optimized the patient have good outcomes. You still have other issues with readmissions that the robot does not solve all your problems. It's just another tool like anything else and you have to use it that way. So I'm not really big on using it as a aren't getting more using for what I think is best outcome for our patients.
Chris Dy:Yeah, I mean, the direct to consumer advertising, especially in the arthroplasty world is pretty real. You know, people see it all the time. And I think it generates a lot of questions. I mean, the closest thing we have in Hansard or world is like you're saying, you know, endoscopic or some of the ultrasound guided carpal tunnel stuff. And then also the collagenases gets pretty advertised pretty heavily. There's a John Elway commercial for, for the collagenases that often gets referenced when patients come in. And it's good because it does raise awareness. You know, just in general, as we bring things to a close, I wanted to ask you one question. I mean, you know, so obviously, it's out there that you operated on, Chuck, I mean, how do you handle operating on, you know, people that you know, pretty well, either partners or spouses or friends or family partners? Is that the do anything differently? Do you approach it differently? Is that a sensitive thing? Would you operate on the family member, for example?
Charles Goldfarb:And maybe I'll jump in before I actually talked about this not with Ryan? Because I'm curious to hear Ryan's response and who did my surgery but I specifically would never say I want as a surgeon, I would never say to you that I want you to do my surgery, I want things to go exactly like they always go and I think the three of us probably have I don't know Ryan's philosophy. But it's a super interesting question. And like, there are some surgeons that hesitate to operate on partners, because I guess concern of outcomes and stuff. So yeah, it's a great question. I really look forward to the answer.
Ryan Nunley:Yeah, so I think you're right, I probably operated on, I don't know, maybe 20 of the nurses or their spouses or their family members. And they are so you see them daily. And I think one, you have to recognize what your skill set is, right? If it's something that you don't routinely perform, and somebody says, I love Dr. Donnelly, I want him to do hip resurfacing, and I haven't done that in a long time, I would say, you know, I'm not probably the right person for you. And you have to be able to be willing to acknowledge that we're not God's gift to surgery. And there's some things that we do well, some that probably we somebody else can do well, second is, you know, making sure that everything goes well, because you will see these patients, but it's the same as you would for anybody else. I mean, I run into people in the grocery store, or, you know, at the airport that I've operated on, so I try to treat every person as if they're a family member, you know, take the time answer the questions. And to to the efficiency standpoint of it, if everybody has a job, then everybody has a jobs. So, you know, for Chuck's surgery, I did the whole thing, but I also close all of my wounds, because I'm that super anal about that. I think that to me is the reason I have such a super low infection rate. It's not because I'm such a great surgeon. But for me, I spent a life time and a lot of my research and teaching on wound management, because every orthopedic surgery has a wound that needs to be closed and sealed and a little drainage is actually a disaster. So I do try and do things exactly the same way every time. Because there's a reason we came up with those protocols. There's a reason that I felt like this works well. And then when you start to deviate, that's where you I think can run into problems. So from that perspective, I think it's one treat everybody like their family member and that you'd want the best for them, I would not probably operate on my wife, she's totally non compliance as one of our partners operate on her and said, no weight bearing and I pulled up our rain camera two days after surgery, she's walking to the house with their crutches, and I call her out on it. So I would not offer for somebody why. But I would operate on either your wives because I know they're much more compliant.
Charles Goldfarb:I have one easy and one maybe harder question. And then we can bring it to a close, obviously, unless you have other things you'd like to mention. I should say though, not only is Ryan efficient, not only is his practice volume, incredible, you have been prolific in the research world, and and I mean, you really balanced a lot of things, which will be my getting into my second question. My first question is to the wound management. I don't really know what it's called, What's the mesh stuff on the skin? It's awesome. Like, if you told me, You got to spend an extra 50 bucks to put this mesh stuff on and I would have to pay if you said do it, I would do it. But it seems like cost to the system. But it really is incredible. And it gives me confidence that my wound is not going to break down. So a That's my first question. And then the second question is, I'll use the 2024 lingo, talks about work life integration, not balance integration.
Unknown:So the first question is, yes, part of my philosophy about wounds is that I hated staples and drainage was the albatross for the toe joint surgeon in the infection because now you're washing it out after a long clinic or long Oh, our day. So doing research and that's a full hour dissertation. I'm glad to talk to you offline. But the mesh that you're referring to is it's a using product name. It's by Ethicon it's Prineo and so it's using the typical Dermabond glue but the glue over a linear incision like the knee when you start to bend it with therapy puts a lot of strain on adds a little bit of glue wasn't substantial enough. So the mesh is about an inch and a half wide, so dissipates that tension across there. And the beauty of it is that one, you can take a shower right away, everybody feels more human, they can take a shower after surgery to going along the philosophy of decolonizing. The body now you've been in the hospital, especially if you stayed overnight, you potential for nosocomial type of contamination and colonization, you get rid of bacteria when you shower in three, it allows you to just leave it on and take it off with no sutures come out no staples. So in the world when we were in COVID, and you couldn't get patients back in and couldn't get them to therapy or home therapists. It was also nice because there's no home maintenance or additional work, that patient just takes it off on their own in three weeks. So it really has been great. The downside is just for those listeners that there is about a 2% allergic reaction, it tends to be patients who have had adhesive allergies. And so when when that does happen, it looks just like an infection. We've never had one turned into an infection, but it scares the hell out of you because it turns bright red, and so we treat it with some oral steroids and Benadryl, just from inside. For anybody who does try and use it. I always put that out there. In terms of work life integration. This is probably the part of my life that I struggle with the most, I will be frank and honest. You're pulled in 100 different directions, patients demands seeing because they can't get in for six months, patients having complications after hours, you've got plans to go to your children's basketball game, you know, meetings research trying to be on the podium and do all of that. Jim Urbanek was very close friend to my my father worked under him and he gave me some great advice early in career he said my first 10 years in practice, I said yes to everything. Absolutely. This project. This means my last 25 years, I tried to find every excuse in the book to say no. So my point of that is that, you know, burnout is real. I'm now 47 years old, I'm doing 1200 cases a year. You know, my back starts to hurt, I feel guilty. My kids are getting older, that I try to be finished every day by 530. I try not to plan things on the weekend, I try to Ford look at important things and in our lives, our family's lives, to make sure I'm there for those important things. But it is probably the thing that I look at every three year most critically about how I want to change and be more effective both my home life and my work life.
Chris Dy:I can I can bring things to a close a little bit. You know, I see you at the games. I see you at the practices. And I will say that this week I was admittedly removing a screw from somebody's patella while I was doing their tarsal tunnel release. And I thought about you because I couldn't remember what the name of the of the of the skin closure that you use. And I looked at the resonance was that thing that nunley uses, because we had just talked about it when we were hanging out aside next to Dr. Aleem grill when you and I are chatting, so you know, we all struggle with it. I think that you are clearly making an effort. And we were spending some good time together over the weekend. So kudos to you for everything you've done. And thank you for joining us on the upper hand.
Ryan Nunley:Thanks for having me, guys. So great partners, and I love the cross collaboration.
Chris Dy:Yeah,
Charles Goldfarb:thanks a million. Thanks for joining us for a brief period after rounds on the Saturday morning. So now go home, hopefully and enjoy the fam. Hey, Chris, that was fun. Let's do it again real soon.
Chris Dy:Sound good. Well, be sure to email us with topic suggestions and feedback, you can reach us at handpodcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcast.
Chris Dy:And be sure to leave a review that helps us get the word out.
Charles Goldfarb:Special thanks to Peter Martin for the amazing music. And
Chris Dy:remember, keep the upper hand come back next time