Ruth Delaney "You have to remind yourself that you deserve to be there"

00:00:13: Welcome and hi to everyone listening.

00:00:15: This is the morning coffee podcast.

00:00:19: I am your host, Sebastian Lappen from Zurich, Switzerland.

00:00:21: And with me, of course, today, again, is Marco.

00:00:25: Marco, so nice to see you, to hear you again.

00:00:27: How are you doing?

00:00:29: Thank you, Sebastian.

00:00:30: I'm doing very well.

00:00:31: So my name is Marco Navargo.

00:00:33: I'm coming from Slovenia, from Valdolter to Piti hospital, where I'm specialized in shoulder surgery.

00:00:41: And today, I'm really happy about the conversation we have with a very special guest, with a very special lady.

00:00:51: So she's a Harvard-trained orthopedic surgeon, specialized in shoulder surgery.

00:00:57: And during her career, she won multiple research awards, including best research paper of the Irish Shoulder and Elbow Society.

00:01:08: She won the Charles Near Award of the ACES.

00:01:13: She also won the best non-clinical research paper during her Harvard combined orthopedic residency.

00:01:22: And she was the president of the very successful, the thirtieth edition of the CESEC annual congress, which was organized in Dublin in two thousand and twenty two.

00:01:34: So without further ado, I would like to welcome with us Associate Professor Ruth Delaney.

00:01:44: Thank you very much, Marco and Sebastian for having me.

00:01:47: Thank you so much for joining us.

00:01:49: So we always like to start our episodes because we are called Morning Coffee by asking our guests how and where do you usually drink your first coffee in the morning?

00:02:00: Okay, this might be an unusual answer, but I'm not really a coffee drinker.

00:02:05: Um, yeah.

00:02:07: So unless I am really tired or jet lagged or something, um, yeah, usually, um, really, I don't really drink coffee.

00:02:15: So I'm sorry.

00:02:16: Maybe I'm, uh, maybe I'm a freak in this surgeon world.

00:02:21: Are you a tea person then?

00:02:23: No, I'm not.

00:02:24: Um, probably my addiction later in the day is diet cook.

00:02:30: I can relate to that because I don't drink coffee as well.

00:02:34: Uh, I drink it rarely.

00:02:36: when I'm really, really, really tired.

00:02:38: Otherwise, I stick to plain water mainly.

00:02:43: So you were born in a two in Cork, Ireland.

00:02:49: And in your youth, you were very much devoted to sports.

00:02:55: So you did a lot of swimming, hockey, but mainly tennis.

00:03:01: So you were the member of the Irish National Squad.

00:03:04: You were a best holder of national championship titles.

00:03:09: You were also the captain of the USS Tennis Team.

00:03:12: You were the national champions in two thousand and one.

00:03:16: So could you tell us how did the occupation with sports influence your later decision to go into orthopedics?

00:03:27: And did that also help you navigate your orthopedic surgical career into shoulder surgery?

00:03:37: Yeah, I think you know it's very common in orthopedics for many of the surgeons to have a background in sport and it was the same for me I suppose.

00:03:47: growing up I really enjoyed sports especially tennis.

00:03:50: but yeah multiple sports and you know played to a fairly serious level.

00:03:55: so I always felt I wanted to do something that might have some relevance to sports.

00:04:01: So I thought about things like being, you know, a PE teacher, a sports teacher in school.

00:04:04: I thought about being a physiotherapist.

00:04:07: I liked sciences as well.

00:04:09: And so medicine was attractive, you know, appreciating that medicine was much more than just things to do with sports like orthopedics or sports medicine.

00:04:17: But actually, all of the rest of it then became interesting.

00:04:20: So I suppose having been drawn to it in that way.

00:04:25: I then found during medical school, I liked things like general surgery as well.

00:04:29: I really liked the operating room.

00:04:30: I liked anesthesia.

00:04:32: So, it always came back to orthopedics as something that combined all of those interests.

00:04:40: Even though, again, there's much more to orthopedics than just the sports side of things.

00:04:43: You know, during training, I really enjoyed trauma and, you know, lots of different aspects of orthopedics.

00:04:51: and I suppose having had children's injuries myself and shoulder surgeries I learned a bit about shoulder really early as a medical student and then found it an interesting area because you could do some of almost every aspect of orthopedics within the specialty of shoulder.

00:05:08: You could be a trauma surgeon, a joint replacement surgeon, a sports surgeon, all of that stuff.

00:05:13: And also, the fact that shoulder was still evolving, it was so much still we hadn't figured out.

00:05:19: And so, yeah, I think, of course, what you've done earlier in your life influences the path you take a bit later on.

00:05:26: And I think, you know, in general, sports has some parallels with surgical training and being a surgeon.

00:05:33: obviously the stakes are a lot higher as a surgeon but some of the things you learn in terms of discipline and commitment and resilience those translate from sport into surgical training and into your career beyond your training.

00:05:51: Is it maybe also a little bit the competitiveness in sports that kind of prepare you for your life as an orthopedic surgeon?

00:06:01: Yeah, I suppose so.

00:06:03: That's probably what gives you a bit of resilience and toughness.

00:06:07: And I think you probably need that to survive your training and also probably need it even more as you build your career and navigate your career as a surgeon.

00:06:18: Did you also have any kind of shoulder injury so that you were exposed to either a physical therapist or to an orthopedic surgeon early on?

00:06:31: Yeah, I had shoulder instability as a tennis player and ultimately had surgery.

00:06:35: So yeah, I was exposed to physiotherapists, surgeons, the process of having surgery, being in a sling afterwards, all of the things that the patients go through.

00:06:45: So I suppose that influenced my interest because of course you're motivated to read about something when it affects you directly.

00:06:54: And I would like to think it probably helps later when you're taking care of patients that you can have a bit more empathy.

00:07:03: You then went to med school at the University College of Cork School of Medicine where looking at your CV you apparently did quite well.

00:07:12: you got multiple scholarships.

00:07:15: and you got your medical degree in two thousand six with first class honors and then you also did the masters of medical science and sports and exercise medicine.

00:07:23: so like i said it looks like you did really really well in university.

00:07:28: so can you share with us what was your secret from for that success quite early on and do you maybe even have some tips for medical students listening?

00:07:38: yeah i think it's about um being in the right environment.

00:07:43: i was lucky ucc um was a really great medical school in multiple aspects, and I still got to, you know, play some tennis and have other interests there.

00:07:52: So I think, you know, maintaining a balance, yes, you're completely committed to what you're doing and your priority is your medical studies, but Still doing other things.

00:08:05: I had been on a school exchange to Germany and I really was interested in the German language.

00:08:08: So I was a member of the German society and university.

00:08:11: I was a member of the tennis club.

00:08:12: And sometimes you won't have time the way other students will have, you know, because your studies are a little bit more involved.

00:08:19: You have, you know, in the early years, anatomy labs and things like that or other practical sessions as well as your lectures.

00:08:26: Of course, then you start to do the clinical stuff and you're in the hospitals and you're in slightly a different world.

00:08:31: But it was still helpful to have a balance and that's something that probably helps you later in life as well because it can be a struggle once you're out there in the world as a surgeon to still maintain some other interests.

00:08:43: So I think that helped.

00:08:45: I think having good friends who are similarly motivated but who can help, you know, diffuse stress because all of us are a little bit different.

00:08:56: We stress at different times about different things.

00:08:59: So I think, you know, managing that and having a good circle of friends around you is really helpful too.

00:09:06: So after your basic surgical training, which you did in Cork Ireland, you did a Harvard combined orthopedic residency program during the two thousand and eighteen two thousand and thirty.

00:09:19: Could you share with us what was the application process like?

00:09:23: And how difficult was it to get accepted?

00:09:27: And why did you decide to go to the United States to go abroad?

00:09:33: Okay, I'll answer the last one first.

00:09:34: So at the time, the training system in Ireland, which is different now and has been kind of revised, It was a bit disjointed and a little bit disorganized.

00:09:46: And it just so happened that my first rotation after intern year on the basic surgical training program was something that just wasn't really a good job, a good rotation for surgical training.

00:10:01: In fact, it was removed from the training program a year or two later.

00:10:05: And I was really frustrated by that because your intern year in Ireland at that time sort of stood alone, you did six months as a surgical intern, six months as a medical intern.

00:10:14: And then you got to decide for surgery or medicine or anesthesia, GP.

00:10:20: And so you get to that second year of training, which is your first year of basic surgical training.

00:10:25: And you're now a surgical trainee, and you're really motivated to learn to be a surgeon.

00:10:30: And actually, that just wasn't how it was at all.

00:10:32: It was super frustrating.

00:10:33: So I just thought, okay, I'll apply for a residency in the US.

00:10:38: I don't think I'll get in.

00:10:39: But it's something to do.

00:10:40: It's some way to channel my frustration.

00:10:44: I happened to have done the USMLE step one during medical school in about the third or fourth year of our five year medical school program, mainly because some of the senior orthopedic residents had told me that they were struggling because they really wanted to do fellowship in the US.

00:11:03: But of course, you need all these medical licensing exams.

00:11:05: And if you've been Doing orthopedic training for a number of years and you're really near the end of orthopedics it's very hard to go back and do these basic science exams and general medical exams.

00:11:17: and some of them just said okay I'm not gonna do that.

00:11:19: so that then eliminated.

00:11:20: The US as the fellowship option for them.

00:11:23: so it just made sense to do the US.

00:11:25: Emily when I was in medical school and studying that stuff anyway and so.

00:11:30: I had done step one during medical school.

00:11:32: I did step two.

00:11:33: I think as an intern because we had no other exams as an intern.

00:11:36: And again, with the idea that this would be useful later for fellowship options.

00:11:39: That's all.

00:11:40: And then suddenly the following year, I thought about applying for residency.

00:11:44: I talked to some friends.

00:11:47: One was a good friend of mine from medical school who was American and had now gone back and her husband is a surgeon in the US.

00:11:54: She's a pediatrician.

00:11:55: And I sort of asked them, okay, well, you know, what even time of year should i apply?

00:12:00: is it too late?

00:12:01: is it now?

00:12:02: and this is about july august of that year?

00:12:04: and they said no this is exactly when the american medical students applied.

00:12:07: go for it.

00:12:08: and then i'm a couple of friends and colleagues here were really supportive and said you know.

00:12:13: What have you got to lose?

00:12:14: just apply.

00:12:14: so i applied.

00:12:16: i didn't really think it would go anywhere.

00:12:19: And I never really told anyone this at the time because it was sort of embarrassing.

00:12:23: Like all of the other applicants from the US, you know, they have multiple interviews.

00:12:27: They're on this interview trail and they're all meeting each other at all the different programs.

00:12:31: I had one interview.

00:12:32: That's all one.

00:12:33: But I guess that's all you need.

00:12:35: But at the time, of course, I wasn't going to tell anyone.

00:12:36: this is my only interview, you know.

00:12:39: And I don't know why they, you know, took a chance on me at Harvard, why they were open to interviewing me.

00:12:45: But I guess they're you know a bigger residency program.

00:12:48: at the time it was twelve residency year.

00:12:50: i think it's uh still about the same.

00:12:53: um.

00:12:54: so maybe they kind of had a little bit more possibility to take risks and look at img's international medical graduates.

00:13:02: um but i kept the letter that they sent you know um offering me an interview at you know with massachusetts general hospital on there.

00:13:12: and you know I just thought oh this will be cool.

00:13:14: I'll keep this letter you know as like a souvenir.

00:13:17: because that's all.

00:13:18: that's as far as it's going to go.

00:13:20: um but I did my homework.

00:13:21: I prepared for the interviews I took it seriously.

00:13:23: I you know had my CV ready.

00:13:26: of course I like looked up all these versions that were going to interview me and really tried to sort of pick in each room like what I would sort of try and emphasize because you know if you're going to do something do it fully do it properly you don't kind of have to it.

00:13:38: and I still didn't really think I had much of a chance of getting in because it is difficult.

00:13:44: Anytime you switch system between countries, it's going to be difficult.

00:13:47: And particularly trying to get into orthopedic residency in the US is tough.

00:13:51: It's very competitive.

00:13:53: And there are multiple factors, you know, some of which you can control, some of which you can't.

00:13:58: And so often, I'll have medical students and young residents coming to me now trying to get it advice about how to do that.

00:14:05: And there's no one magic answer, of course, you know, it's a combination of factors, but you optimize everything you can optimize, just like in surgery, I suppose.

00:14:15: So yeah, I did the interviews in say January of two thousand and eight, and then there's a process in the US, the residency match where you sign up, you have to essentially sign something that says, you know, I commit to going if I match to a program, you know, because they're relying on a supply of residents to staff their program.

00:14:38: So you can't just sort of do the interview, get an offer and then decide, no, I'm not going to go.

00:14:42: So you do commit early to going, even though you don't know whether you'll get in or not.

00:14:47: For me, it was simple because I only had one interview.

00:14:49: So I knew if I get in, it's hard, but if I don't get in, that's that.

00:14:52: Whereas for most people, there are multiple places that they could end up getting their offer.

00:14:57: And it's a little bit scary to have to just commit.

00:15:00: And then in March, you find out whether you matched and it was St.

00:15:04: Patrick's Day.

00:15:04: that year was match day.

00:15:06: And I was pretty shocked, you know, I'm thinking, oh my God, what have I done now?

00:15:09: I'm committed to five years in the US.

00:15:11: It's March.

00:15:12: I have to go there in June.

00:15:13: I have so many things to sort out.

00:15:15: I have to figure out what type of visa to get, all this type of stuff.

00:15:19: And it was really complicated paperwork and all of that.

00:15:23: But, you know, I think if you're motivated and you've been handed a great opportunity, you work through all of that other stuff, all of the life administration that's involved in moving country and dealing with all of that.

00:15:34: So that was kind of how I ended up going there.

00:15:38: And it was a bit intimidating, you know, you get there and almost everybody else is from like a big name Ivy League, American Medical School, and you have to really remind yourself that you deserve to be there and you're as good as everybody else.

00:15:52: But it was overall a fantastic experience to train in such a big academic medical center and be exposed to all sorts of things.

00:16:02: I enjoyed even the first year where we were doing other stuff, like a lot of general surgery and everything else.

00:16:09: So it was a privilege to be there.

00:16:12: And of course, it's easy to look back and only remember the good bits.

00:16:16: But overall, it worked out really well.

00:16:19: I was really glad that that's what I ended up doing.

00:16:23: Can you tell us a little bit more about the interview process and what kind of question would they ask?

00:16:29: Were there any crazy tasks that they asked you to do or was it more about your person, about your life or more about maybe the orthopedic field?

00:16:39: Did they want to test your knowledge,

00:16:40: etc.?

00:16:42: Yeah, I think different programs take a different approach and I've heard that there are some programs that you know, try and test your orthopedic knowledge and the interviews or give you some crazy like practical tasks to work out and that's somehow supposed to assess, you know, your aptitude to be a surgeon.

00:16:59: But at Harvard, it wasn't really so much like that.

00:17:02: And I think, you know, it's a really difficult challenge to figure out who are the people that will make good orthopedic surgeons or good surgeons or good, whatever, you know, type of specialty.

00:17:12: because When you're still just a medical student, you know, it's hard to know, like, how can you tell who's going to have good hands?

00:17:20: Who's going to have the resilience to make it through surgical training?

00:17:23: And probably the same when you're selecting, you know, students for medical school and in the various different systems.

00:17:29: So at the time, and I don't know if it's changed the way that the interviews worked at Harvard was they had two interview days.

00:17:36: So half of the candidates were interviewed on one date, half on another date, and they held them either at the Brigham or at Mass General.

00:17:42: So my interview day was at the Brigham.

00:17:45: And there were multiple rooms that you were scheduled to visit during your interview.

00:17:51: So most of the rooms had two attending surgeons in the room.

00:17:56: And part of kind of the prep that I did was like, you know, you've got a schedule and you've got the names of who was interviewing you.

00:18:01: So you look them up, you figure out what's their subspecialty interest, you know, Where have they been in the past for fellowships?

00:18:10: Is there something you can find common ground with them to talk about?

00:18:13: Is there some research thing you've been involved in that relates to their area?

00:18:17: So you kind of make a strategy beforehand.

00:18:20: You don't just sort of wing as when you go in.

00:18:23: And most of the rooms, they were kind of interested in whether you'd be a good fit for the program and how you'd be to work with.

00:18:31: Sometimes like there'd be something that you know I felt maybe not very good at like one room.

00:18:38: They said okay you know really sell yourself to us.

00:18:42: And as an Irish person that's not really how we're brought up culturally to be.

00:18:45: where's the Americans?

00:18:46: that's a very natural thing for them to be able to do so.

00:18:49: it's uncomfortable sometimes and you have to really force yourself to sell yourself.

00:18:53: and there was another room where.

00:18:55: There were two surgeons.

00:18:56: you know in pretty normal room you walk in and there's a desk and there's two.

00:19:01: people sitting behind it and you sit in front of them.

00:19:03: But there was these two surgeons, one was a spine surgeon, one was a sports surgeon, and the sports surgeon had kind of a quirky personality.

00:19:09: And he was doing things to try and distract you and put you off.

00:19:12: So instead of both sitting behind the desk, he had like pulled his chair to the other corner of the room.

00:19:18: So now you had like two places in the room that you were trying to make eye contact with.

00:19:23: And then he purposely didn't close the door behind you when he brought you and he left it, you know, a meter to open.

00:19:29: And so you're just a little bit thrown.

00:19:31: And I think, you know, it was just kind of a game to see like how you react when something unexpected is going on.

00:19:37: So there were some, I suppose, subtle things like that.

00:19:40: But mostly it was straightforward conversation.

00:19:42: In one room I was asked, you know, would you if you didn't match, would you consider coming and doing research?

00:19:51: because that's a pathway a lot of international medical graduates follow?

00:19:55: you know what would your thoughts be about that?

00:19:57: so it's I think it's about kind of having thought of an answer for that and what you really feel about it.

00:20:03: you don't want to say you'll do something if it's not what you want to do.

00:20:08: A couple of times I was asked you know why would you want to come to the US?

00:20:12: why would you leave your country?

00:20:14: and I think you have to again have just planned out an answer to that.

00:20:18: you don't ever want to be derogatory about.

00:20:20: where you're leaving, you want to explain your motivations.

00:20:25: And sometimes they were genuinely curious.

00:20:28: They didn't know anything about different systems.

00:20:30: So they wanted to know what the training system was in Ireland and the differences.

00:20:34: And yeah, so most of the rooms were like that, two surgeons.

00:20:38: And then there was one room where it was kind of intimidating.

00:20:41: It was the chairman of each of the four hospitals.

00:20:43: So the Harvard program involves four main hospitals.

00:20:46: So you have Mass General, the Brigham Children's Hospital, Boston and the Beth Israel.

00:20:51: And so each of those has an orthopedic department and a chairman.

00:20:55: And then you have a program director as well.

00:20:56: So you have the four chairs and the program director.

00:20:59: And they're all these kind of intimidating at that time kind of older guys who've been around a long time have achieved a lot.

00:21:09: And you see it at a big long boardroom table and they fire questions at you.

00:21:13: And so I think you just have to kind of keep hold of your nerves in that room.

00:21:18: And then they also had residents interview you.

00:21:21: And that's easy to underestimate.

00:21:23: You know, you do your preparation for the chairman or the attendings and what their specialty is and what you're going to try to talk about from your CV in each room.

00:21:31: And then you have a room with residents, which is more relaxed, their chief residents.

00:21:37: But they actually get quite a say.

00:21:40: And I think it's probably still the same way at Harvard.

00:21:41: And at most programs, I think that The selection committee listens quite a lot to the residents and the residents opinion of the applicants.

00:21:50: And you hear stories about applicants doing stupid things that really hurt their chances, you know.

00:21:57: Like if you're just rude to other applicants or there's something, you know, on a personal level that you just don't show good character.

00:22:08: that will end up being more important than how great your USMLE scores are, how much research you have on your CV.

00:22:15: You know, I think you just have to really be conscious of how you conduct yourself.

00:22:18: You want people to feel above all that you will be a good colleague and a reliable resident.

00:22:24: And do you feel like that showed in the team when you were then working at these four different hospitals that the team was very close together, that everyone was very nice to each other and work well together?

00:22:37: more than maybe in other places?

00:22:40: Yeah, maybe.

00:22:41: I mean, I think you always still have a mixture of personalities.

00:22:44: And of course, everybody can put on a performance on interview day as well.

00:22:48: So, you know, you have your ups and downs, it's a stressful environment during training.

00:22:54: And so it's not always sunshine and rainbows, that would be a lie to pretend that.

00:22:58: But I think, you know, It does work pretty well.

00:23:03: and the teams you know?

00:23:04: usually you're with residents from different years because a team will have you know junior and senior residents.

00:23:09: so a lot of the time you're not.

00:23:10: On the same team as someone in your own year you're kind of ending up getting to know people.

00:23:16: Probably ending up closer to people who are.

00:23:19: Head of you behind you in the program because you end up spending your days with with these people.

00:23:24: they also had a good program.

00:23:27: kind of a mentorship program, like they would assign each first year resident to a third year resident.

00:23:32: And that would be like your big sibling, your big brother, your big sister.

00:23:35: And so you could use that as much as little as you wanted.

00:23:37: I made an effort to make contact with the guy who was assigned to me the third year when I was a first year Daniel Gus, who's now a foot and ankle surgeon at Mass General.

00:23:46: Because I didn't really know anybody.

00:23:47: And I was in a new country.

00:23:49: And so I got in touch when they assigned us, we met for coffee.

00:23:53: And then, you know, we became good friends.

00:23:55: And then when he was the fourth year and as a second year we rotated together on trauma.

00:24:00: so we spent you know quite a bit of time then um and so you end up making friendships kind of up and down the program by just those circumstances either of rotation or where they try to make it a little bit more um official with these mentorship things.

00:24:13: some people didn't use that program that much.

00:24:16: they maybe didn't kind of need it you know but there were those opportunities there to connect with with other people which i think was important.

00:24:24: um how How common were the, I mean, roughly speaking, in terms of percentage, how common were the non-Americans, the residents, there would be a residency program.

00:24:38: What's your feeling and where did they come from, usually from Europe or from which parts?

00:24:46: That's pretty rare at that time.

00:24:48: Harvard did have a history of having previous residents from Germany.

00:24:53: They had had two German residents quite a number of years before that.

00:24:57: They had done really well and actually stayed on as attendings at hospitals within the Harvard system.

00:25:02: And so that sets a good precedent, but it had been quite a long time since they had had an IMG.

00:25:10: When I matched, I was the only one.

00:25:14: And then in the few years after that, there were a couple of more people who applied and ultimately did get in.

00:25:21: There was a guy from Germany again, Arvind von Keudel.

00:25:27: There was a guy from Slovakia, Michael Kozonek.

00:25:31: Both of them had spent time doing research in the labs.

00:25:35: Neither of them got in like their first time applying.

00:25:37: So it really, you know, it was a process where they had to really be tenacious and stick with it.

00:25:44: and then i believe you know after that there have been a few more.

00:25:48: so in recent years there's been a few more but it's definitely much less common you know to have an international medical graduate.

00:25:55: the majority will be american graduates.

00:25:58: some of them will have interesting backgrounds and may not have grown up in the u.s may have come to the u.s later you know with their family during high school or even you know come over for college.

00:26:07: but i think um there is a big difference in terms of the application process as to whether you are coming from an American medical school versus from outside.

00:26:17: It's easier for a program to understand your grades and to feel comfortable that they're not taking a risk on you if you come from a medical school.

00:26:25: that's within their system.

00:26:27: So I think you probably have a bit more to prove if you're applying as an international graduate, you know, to prove that you're kind of up to the standard that they can rely on and You kind of feel a responsibility as well.

00:26:39: like if I perform poorly as an IMG resident that's going to make them not want to take another IMG or be more hesitant to consider another IMG.

00:26:49: So I think when you do go there as a foreign graduate you have a responsibility for the next generation coming behind you that you lay a good foundation or continue to build on the foundation that people before you have put there.

00:27:04: So your residency ran from two thousand eight to two thousand thirteen and since you have returned to Ireland, I think you returned in two thousand fourteen to work in Dublin.

00:27:14: Looking back, what would you say is maybe the key or what are the key differences in either residency residency programs in Ireland and the US?

00:27:27: And in general, working in Ireland and in the US in the orthopedic field of surgery field.

00:27:36: Yeah, I think, you know, they're quite different systems.

00:27:40: In the US, the residency programs are set up so that, you know, you're in the same city usually for your whole.

00:27:48: five years.

00:27:49: Some programs may have one or two away rotations to cover some of the less common specialties like orthopedic oncology or something like that.

00:27:57: Obviously at Harvard we were lucky.

00:27:58: everything was kind of within the Harvard system so I got to live in the same little apartment the whole time.

00:28:04: In Ireland it's a small country and it's one national training program so the residents usually have to move around the country and work in different cities often sort of move house every year every six months.

00:28:19: The training in Ireland takes longer.

00:28:21: It's a bit more fragmented and not kind of one cohesive program, although they have started to try to change that.

00:28:29: I don't know exactly now, you know, how far they've gotten with their idea of like a run through training program, but it certainly takes longer.

00:28:38: One of the things and one of the reasons I gave an interviews for sort of being attracted to the US programs was The fact that in Ireland, the population is small, so it's hard to get exposed to every subspecialty orthopedics during your training.

00:28:52: And there's also a huge need for trauma coverage and service provision.

00:28:58: And so the residents often spend a lot of time doing general trauma and maybe miss out on certain subspecialties.

00:29:07: Whereas in the US, the program has to give you a certain amount of every subspecialty.

00:29:12: The flip side is that the Irish trainees end up really very good at trauma usually because they have a lot of independence and a lot of exposure to it.

00:29:20: I think the subspecialty mix and the balance of subspecialties and the duration of training are probably the biggest differences.

00:29:27: Most people then obviously will go away and do a fellowship.

00:29:31: So that's the way that in the Irish system people will counteract the fact that they may not have gotten a lot of exposure to the subspecialty.

00:29:38: They're really interested in during training.

00:29:40: Usually as they become more senior in the last year or two of training, they can indicate preference and they can sort of gravitate towards their chosen subspecialty.

00:29:48: But I think it's hard to have been exposed to every subspecialty.

00:29:52: But most people will then, you know, go overseas to really get exposed in depth to what they want to do.

00:29:59: And that's simpler in the US.

00:30:00: I mean, obviously, most people in the US will do fellowship within the US.

00:30:03: It's rare.

00:30:05: for Americans to be, you know, open minded and look at the rest of the world.

00:30:08: I think in shoulder, it's probably a bit more common because the French have had such an influence that it's been impossible for the US and the rest of the world to ignore Europe, thanks to, you know, Gilles Valle, Pascal Boulot, La Ralefoss, before them, Paul Grammel, you know, you couldn't ignore the fact that there were things happening in Europe.

00:30:27: So I think in shoulder, you know, there's probably more Americans who will think about fellowship overseas.

00:30:34: And then starting practice, there are things in common that are going to be stressful your first year in practice no matter where in the world you're trying to set up your practice.

00:30:44: But there were certainly big differences in the systems.

00:30:48: coming back to Ireland.

00:30:50: I started full-time private for a number of different reasons.

00:30:55: The government contracts had changed in twenty twelve to be a lot more restrictive and you have a lot less freedom.

00:31:01: To do elective work and private work.

00:31:03: if you took a public job which was sort of the traditional route to take a job in our public system and then gradually build your private practice on the side it was more difficult to do that because.

00:31:12: post-twenty twelve, you didn't really have as many options to work outside of your public job.

00:31:18: And so I didn't want to get sucked into a job where I was doing a lot of general orthopedics, a lot of trauma and didn't have time to really be a shoulder surgeon and put to use what I'd learned during fellowship and potentially maybe even lose some of those skills and become a bit de-skilled over time in the beginning.

00:31:33: So I was starting a private practice.

00:31:36: I was really fortunate because The first guy who really was a shoulder specialist in Ireland, Jimmy Colville, was sort of looking to wind down and there was going to be a lot of shoulder work.

00:31:53: And he and Hanan Mullet, who was the well-established shoulder surgeon in Ireland, were very supportive and Hanan was already really, really busy, so he wasn't going to be able to absorb what was coming.

00:32:06: once Mr.

00:32:07: Calville kind of stepped back.

00:32:09: And so it was really good timing to try to be setting up a shoulder practice in twenty fourteen.

00:32:15: But it was still kind of scary, you know, you're setting up a business, it's full time private practice.

00:32:20: So if patients don't come and you don't do work, then you don't have any money to pay the bills.

00:32:25: The private hospitals help a little bit because they want you to get off the ground and be successful because that then is good for them if your practice is flourishing and you're doing surgeries in their hospital.

00:32:37: But the biggest difference I found between that and the US was just the lack of infrastructure around you.

00:32:43: You come from a big institution like Mass General and suddenly you're setting up your practice.

00:32:49: You have to literally buy the computers for your office, buy the software system that's going to run your practice.

00:32:54: that doesn't talk to the rest of the hospital system because the hospital only has computer systems for its kind of inpatient functions and the consultants, the attendings are left completely separate and independent and you have to hire people, you hire your admin staff now, you're an employer as well as a business owner.

00:33:13: but actually you've spent the last, you know, ten years focusing on trying to learn to be an orthopedic surgeon and a shoulder surgeon.

00:33:20: so you don't necessarily know what you're doing and dealing with insurance companies and procedure codes and that system is quite different to the US.

00:33:29: But I think in some ways the US system probably prepared me pretty well for private practice because obviously it's all privatized there in the vast majority of situations.

00:33:38: And JP Warner, you know, was a really good mentor, not just for shoulder surgery, but also for practice management and business side of things.

00:33:48: So while the systems are quite different, I could take some of the things I had learned in that sense, some of those softer skills and transfer them to Ireland, particularly the kind of American, you know, approach to what I would kind of sometimes think of as customer service.

00:34:04: It was a little bit of a pain when you're a fellow like, you know, calling back patients and making sure you got back to all of their little questions every day.

00:34:12: And, you know, Warner had two or three fellows at any given time.

00:34:15: And, you know, they would mostly do that, or a lot of the American surgeons will have nurse practitioners or physician assistants.

00:34:22: And You know when i started off it was just me and the secretary.

00:34:26: so i worked really hard on that side of things as well and i think that contributed to.

00:34:31: Being able to build my practice and get busy because that stuff matters to patients as well.

00:34:36: and i think i learned a lot about that in the u.s without necessarily realizing i was learning it.

00:34:42: um but yeah it was a big kind of culture shock to come back and you don't expect that.

00:34:47: you know you think you're going back to your home country.

00:34:49: you should just get off the plane and it should be straightforward and easy.

00:34:52: um but you know you forget that you're setting up practice your first year in practice first two years in practice is going to be hard no matter whether you stay in the same system that you trained in or you move systems and no matter whether you're in your home country or you're somewhere else.

00:35:05: you know it's going to be stresses and challenges in that first year or two and some would be the same if I stayed in the US and some were unique to the fact that I had moved back to a different system.

00:35:16: So you mentioned opening the private practice.

00:35:21: How long did it take you to run it properly?

00:35:26: Like that you were satisfied with it?

00:35:29: I was speaking about a time period of months or is it years?

00:35:35: I think it's years.

00:35:37: I mean, I think like I'm never completely Satisfied with that.

00:35:41: I'm always thinking of how can we do things better?

00:35:44: How can we do things more efficiently?

00:35:47: You know We're lucky.

00:35:49: like most of the challenges that we have my team and I my practice now are to do with handling the volume, you know and And managing to keep up with things.

00:35:59: of course in the beginning you're stressed out that you're not going to have enough volume not gonna have enough patience.

00:36:04: so Each situation kind of brings its own challenges and I think it's probably typical of surgeons that we never sort of sit back and say, okay, now I'm completely satisfied.

00:36:17: Everything's, you know, everything's how I want it to be.

00:36:20: You're always kind of thinking, is there a better way?

00:36:22: So I think in the beginning, it probably took about eighteen months to kind of feel like, okay, I'm settled in.

00:36:29: I'm happy with how things are set up and I'm comfortable.

00:36:32: But, you know, I look back like now, you know, ten years, almost ten years in, i do things differently kind of from an administrative and practice point of view than i did when i was eighteen months in.

00:36:44: you know some of that's enforced like.

00:36:46: you know practical situations.

00:36:47: you end up having to move office find different office space administrative staff leave you have a new staff.

00:36:52: you know some things are changes that you didn't choose and then some things are changes that you thought about and made a conscious decision to change what you were doing or how you were doing it.

00:37:02: and i think it's important not to be afraid to make changes not to get stuck in a certain routine and be afraid to change things up.

00:37:11: and even that can sometimes mean changing hospitals.

00:37:14: i never changed my main hospital.

00:37:16: that's always been sport surgery clinic in dublin and that's a really amazing efficient orthopedic hospital.

00:37:24: it's pretty much all orthopedics there.

00:37:26: so the one downside is that There's no ICU.

00:37:32: There are some covering medical physicians and a cardiologist who come, but generally if you have a patient who's complicated medically, it's a little bit harder to manage them there because there's less backup.

00:37:41: So it was important to.

00:37:44: have, you know, another bigger hospital to do some of the older patients, the medically complex patients or the bigger cases or something where maybe you need backup, like you're doing a sternoclavicular joint and you want a thoracic surgeon to be around, then you don't want to do it at an isolated orthopedic hospital.

00:37:59: So that part did change and evolve over time.

00:38:03: as to which hospital was my kind of secondary hospital and different factors kind of influenced that, you know, The hospital I started out doing that.

00:38:13: that was very very old-fashioned.

00:38:15: They had only really ever seen one shoulder surgeon and how he did things and the staff that were there at the time Didn't want to entertain any other ways of doing things and so it was a huge struggle.

00:38:26: and then after about eighteen months I realized you know I don't need to deal with this you know I can do this somewhere else and another hospital had approached me and had a much more kind of modern open-minded take on things and had a couple different shoulder surgeons and so I moved the part of my practice that needed a full service hospital to another hospital.

00:38:46: and so i think you have to be you know willing to be a little bit flexible and agile as things change and then sometimes things come full circle.

00:38:54: you know the first hospital.

00:38:56: i still now do some things there again because the second hospital that i went to politically things changed about how they allocate their operating room time and I used to have more time there and now I have less time.

00:39:07: so you do what you need to do for your practice.

00:39:10: and meanwhile at the first hospital things had progressed.

00:39:13: a lot of the older staff had gone some other shoulder surgeons had come along and probably benefited from some of the initial kind of like ice breaking I had done in terms of getting equipment and getting the you know, table, the arm holder, all that stuff.

00:39:31: So it was probably a bit easier for them there because I had been there trying to kind of do things that were different for them.

00:39:38: And so now that hospital has evolved to be a bit easier to work in.

00:39:42: And so I think you always need to have an open mind and not burn any bridges, but you know, be willing to make changes as your practice evolves so you can do the best things for you and for your patients and have the best situation.

00:39:57: for you to do your best for your patients.

00:40:02: So when you set up a financial plan at the very beginning, how quickly did you assume that your practice would be profitable?

00:40:11: So how quickly did you assume that you would have a positive business balance?

00:40:17: And did you realize this as planned?

00:40:22: Yeah, I think, you know, I didn't know what to expect.

00:40:26: I didn't know what was Realistic or reasonable.

00:40:29: i didn't have a lot of business knowledge.

00:40:31: i did keep up my massachusetts license for like four years because i was always thinking maybe i'll go back and but after about eighteen months i think i was settled in.

00:40:40: things were going really well.

00:40:42: business-wise and financially very early, in fact.

00:40:46: And again, I think that was the set of circumstances, the support in the beginning.

00:40:51: It wasn't that I took over anybody else's practice, but when Mr.

00:40:55: Calvo kind of stopped operating, which was only about six weeks after I got off the plane, he sent me patients who were, you know, kind of ready for surgery.

00:41:04: And then his referral base kind of thought, Okay, well, if he thinks she's okay, then I guess we can trust her.

00:41:09: and they started sending me patients.

00:41:11: So I was really lucky that way with the support from Jimmy Colville and Helen Mullet that, you know, my practice had kind of an instant head start.

00:41:20: And in the first year, I would do a small bit of trauma call at one of the hospitals.

00:41:27: And people would kind of think still that I was an upper extremity surgeon because that was still the model at the time.

00:41:34: I think that's evolving and going away.

00:41:36: But at the time the model was that you were an upper extremity surgeon from clavicle to fingertips and during fellowship I had just done all shoulders.

00:41:46: We had the choice if we wanted to get more exposure to elbow during fellowship that we could do the elective time at the Mayo Clinic or you could choose to go to Europe.

00:41:55: and that was a big reason I had chosen that fellowship.

00:41:57: Number one because I hadn't worked with Dr.

00:41:59: Warner that much as a resident clinically I just done research with him.

00:42:01: but number two because he had these amazing connections to Europe where you could go and spend two months in France or Switzerland, you know, so I chose to spend time with Gilles Volsch and Laurent Le Fosse rather than go and do elbows because I wasn't as interested in elbow and because I wanted the European influence as well in my training, especially if I was going to come back to Ireland.

00:42:23: So I really didn't have any fellowship training in elbow or hand and wrist, but you know, I could do an unlearned nerve decompression, a distal biceps repair, a carpal tunnel, you know, and I would get sent these patients.

00:42:34: And so during the first year, I would take them and then do those operations.

00:42:38: and then i realized that by the end of one year there were so many shoulder patients that i didn't need to keep taking anything that wasn't shoulder.

00:42:47: and so within a year the practice was one hundred percent shoulder and so that was you know really quick i think to be able to get focused down on your subspecialty and that probably also went along with kind of the business sign.

00:43:03: the financial things like the hospitals and I think they still do this like sports surgery clinic was supportive and the costs are really high at the beginning like your malpractice insurance.

00:43:12: your medical indemnity is expensive in this country um and you don't have the resources to come up with that money at the beginning.

00:43:19: so the hospitals will do sort of a deal where they support that for the first two years if you need it.

00:43:25: the first one year if you're above certain targets they'll give you a salary guarantee.

00:43:32: I didn't want one hospital to own me, so I actually split it between two hospitals each guaranteed half.

00:43:36: But as soon as you start making more than that yourself, then they don't need to support you.

00:43:41: So they'll top up your earnings to a certain amount.

00:43:44: And I think it was only the first two or three months that I used that sort of top up because I was lucky.

00:43:49: I got very busy very quickly.

00:43:51: So it did become financially viable.

00:43:53: quite early.

00:43:55: but i think also i was used to living like a resident or a fellow.

00:43:58: so i didn't really spend any money in the first year.

00:44:00: because you don't you know you don't know what's gonna happen.

00:44:03: and i lived really cheaply.

00:44:04: i rented a friend's apartment that she was getting ready to like refurbish to then rent out properly.

00:44:10: so i just lived there for cheap.

00:44:12: it wasn't very nice.

00:44:13: it was fine it was functional.

00:44:15: it's not like this glamorous lifestyle that you think you know.

00:44:19: Okay, I'm finished fellowship and practice.

00:44:20: I'm gonna like suddenly, you know, just have this amazing life.

00:44:24: It takes time to build that up.

00:44:27: And that's probably a good thing, you know, that you just gradually like work your way into a more comfortable lifestyle.

00:44:32: So yeah, in the beginning, when you don't have the guarantee of say a steady salary from like a public job, you're a little bit cautious.

00:44:41: But I would say after about eighteen months, you know, I was able to, you know, move into a new apartment and stabilize life and feel that the practice was up and running and really doing well.

00:44:58: You already mentioned your fellowship which you spend partly in France.

00:45:03: Can you tell us a little bit more about your time in France?

00:45:06: How much time did you spend there?

00:45:08: What maybe were the biggest differences to the yes and how did you manage with the language barrier?

00:45:15: Yeah, the time in France was amazing.

00:45:17: I spent one month in Assi with Laurent Lafoss and one month in Lyon with Gilles Vache.

00:45:23: And in Assi, Laurent had, you know, a number of fellows.

00:45:27: It's a really sought after fellowship program.

00:45:29: He gets fellows from all over the world and various different kind of fellowship programs and funding models and people spending, you know, three months there or six months or a year and then the Harvard fellows rotating for a month.

00:45:44: So it was great because there were other young surgeons there.

00:45:47: The language barrier wasn't too much of an issue because in the OR everybody was speaking English because there was such a mix of nationalities.

00:45:56: It was like the common denominator was English.

00:45:59: I had learned some French in school.

00:46:01: I was much better at German, but I could understand French and that helped.

00:46:06: I could speak a little bit.

00:46:08: And clinic obviously it's harder.

00:46:10: because you have to speak with the patients in French.

00:46:13: And typically, when we were just the one month visitors, we weren't really on our own in clinic very much.

00:46:18: But I think it was helpful to be able to understand what was going on.

00:46:21: I think the people who went and had no French at all, they missed out a little bit because there isn't always time for people to translate for you.

00:46:30: Systems were different.

00:46:32: I mean, in France, it was funny.

00:46:34: They didn't really need any paperwork from us.

00:46:36: Nobody even really like checked if we were doctors.

00:46:39: it just you showed up and you know the fox was like okay wash your hands go whereas when any of his fellows came to visit us at mass general there was you know of course all kinds of paperwork to allow them to come in and they weren't allowed to touch the patient and they weren't allowed to scrub and they just had to observe.

00:46:52: so i think you know moving between different countries.

00:46:56: one of the big advantages can be that you know sometimes you have more access or the system isn't as restrictive.

00:47:02: um There were differences in technique that were really interesting.

00:47:07: There were differences in setup in anesthesia.

00:47:10: La Fosse, you know, was really good at having hypotensive anesthesia and a monitor on the patient's head for sort of intracranial cerebral perfusion, you know, so that he could really try and create optimum conditions for complex arthroscopic cases.

00:47:27: There was, of course, the famous arthroscopic latter J compared to the more traditional open one we were doing in the US.

00:47:33: And then, you know, to go from that and to go to Leon and see the master of the latter day doing the open letter J, which should probably the modern one should probably be called the vault procedure, you know, it really he's kind of brought it to where it is today.

00:47:48: So there were still contrasts even between Anthony and Leon.

00:47:53: And in Leon, Jill didn't have fellows as much.

00:47:58: He had the visiting Harvard fellow that was me, and then he had a visiting resident from Italy at the time who was spending three months with him.

00:48:09: So I got to spend probably a bit more one-on-one time with him, particularly in clinic.

00:48:14: And again, it was really helpful to be able to understand what went on in the consultation between him and the patient.

00:48:19: So then afterwards, we could just discuss about his diagnosis, his decision making, his management strategy rather than him having to take time to translate what had just happened.

00:48:29: But yeah, he always spoke English with me or ninety percent of the time.

00:48:34: So that was much easier.

00:48:36: And the really fantastic thing about that month in Leon was that, you know, all I had to do was focus on learning.

00:48:42: I didn't have the other responsibilities that you normally have when you're training, like being on call, rounding on patients, having to run the service.

00:48:53: I would offer to do things because it felt strange and he would say, no, no, no, you don't need to do that.

00:48:58: So you just come at this time and all I had to do my only job was to learn as much as I could and pay attention to what he was doing and listen to what he was explaining to me.

00:49:10: And that was a really perfect environment for learning and something that JP Warner created for us.

00:49:16: We were still funded from our Harvard salary and then they had funding to cover our food and accommodation.

00:49:22: So you don't have to worry about anything and you could keep your apartment in Boston and you just showed up over there and it was the most unique scenario where your only responsibility was to learn as much as possible and I think that really created a situation where it was possible to absorb a lot.

00:49:42: I also have to mention that just recently you also got a diploma in business and leadership skills for healthcare at the university college in Dublin.

00:49:52: Now you spoke that you opened your private practice, so could you tell us?

00:49:57: how important is it for an orthopedic surgeon to know the business side as well and how much do you think you gained with this diploma?

00:50:08: because you are experienced in private practice, you open it up, you're earning it successfully.

00:50:15: How much did it improve your knowledge?

00:50:20: Yeah, I think it's relevant these days for the PXHR just depending on what system you work in.

00:50:25: It is relevant to understand the business aspects.

00:50:29: I think the most interesting part of the course for that diploma was kind of the psychological stuff and the, you know, softer things that go with business and how to deal with other people and handle that because a lot of those things can translate also to dealing with patients and, you know, human interaction in general.

00:50:52: I think it's important not to let the business stuff take over though, like fundamentally, we're still here to take care of patients and to do the best you can by treating them be that with surgery or without surgery.

00:51:06: And so I think you know, it's important not to get too focused on the business side and lose your real focus.

00:51:14: But I think it's good to exercise your brain in different areas and to understand some of the aspects and the knowledge that come from that world.

00:51:26: So yeah, I think it's a balance.

00:51:29: Probably realistically, my practice is so busy that I didn't devote as much time during that diploma as i could have and maybe you know would have gone deeper into some things if i'd had more time.

00:51:41: but i think just even having an awareness of what factors are out there and what plays into how we run our practices and our businesses and how we interact with other people is very helpful.

00:51:53: So unfortunately we are almost running out of time but at the end of these episodes we usually really like to ask our guests.

00:52:02: if they have any particular advice for young surgeons and residents.

00:52:07: And in your cases, you are actually in our very young podcast, the first woman that we interview.

00:52:13: I wanted to ask if you have maybe some special advice for female young orthopedic and trauma surgeons.

00:52:21: Sure.

00:52:21: Yeah, I think a lot of the advice applies across the board, like to male and female trainees, you know, I think.

00:52:29: be open-minded.

00:52:32: try to talk to people as much as possible and it's hard you know if you're not naturally outgoing or if there are language barriers.

00:52:38: you have to push yourself a bit to make connections with people.

00:52:41: go to meetings like the CESAC Congress is a great opportunity to, you know, meet people in person and see that actually people that you think are big names are actually very human and approachable mostly.

00:52:54: When I was a third-year resident, I got to go to the International Congress for Shoulder Elbow Surgery in two thousand ten.

00:52:59: That was in Edinburgh.

00:53:01: I went there with Dr.

00:53:02: Warner because I had a paper in the meeting and It was amazing to see the shoulder community and how close it is and how friendly people are.

00:53:15: Don't be afraid to network and take advantage of that.

00:53:19: If you know that you're interested in the area of shoulder and elbow surgery, and I was someone who knew that pretty early on.

00:53:26: you don't want to close your mind off to other specialties and you have to do all your other rotations and they'll help you be a better shoulder surgeon too, but don't be afraid to really go for it and seek out mentors.

00:53:37: And I think, you know, on the side of kind of the female surgeons, you know, I think mostly put that out of your head and don't sort of use it as something to think that you're disadvantaged or to stress out about.

00:53:54: Yes, there are certain challenges for females but there are more and more women now in orthopedics so it's easier to have women role models as well.

00:54:03: but your mentors don't have to be female.

00:54:04: all of my mentors were male and they were great.

00:54:06: so there are a lot of guys out there that are very supportive of female surgeons and I think you know.

00:54:14: talking to people and understanding how different people balance things in life, whether that's having family or whatever else, you know, I think you can learn from a lot of people around.

00:54:24: So yeah, for female surgeons, I would say, you know, just don't think that you're any, any different or any less good than the guys, you know, be, be confident and get out there and make connections with people.

00:54:40: Excellent.

00:54:42: Thank you very much, Ruth.

00:54:43: for the time that you took out of your very busy schedule.

00:54:48: I'm really happy we had the opportunity to speak with you.

00:54:51: It was really a fascinating conversation and I'm sure that our listeners will enjoy it as well.

00:54:58: I would also like to thank to everyone who tuned in and listened to this podcast.

00:55:06: Yes, thank you so much again after from me.

00:55:08: Thank you.

00:55:08: Thank you Ruth.

00:55:09: It was really really fascinating and interesting.

00:55:11: Thank you to everyone listening and see you next time.

00:55:15: Thank you very much.