S04E81 - From Columbia General Surgery to Robotics: Journey to Cardiac Surgery - Dr. Joseph DeRose

Revisit the demanding yet rewarding world of surgical training with us as we sit down with Dr. Joseph DeRose, Professor and Chief of the Division of Cardiothoracic Surgery at Montefiore Einstein Medical Center. We share memories from our surgical residency days at Columbia University Medical Center, reflecting on the camaraderie, jokes, and resilience that shaped our careers. Dr. DeRose's journey from those formative years to his current leadership role underscores the importance of teamwork, hard work, and precision in the OR.

Explore the evolution of surgical training and practice, where high expectations and competitive environments meet innovative advancements like minimally invasive procedures and robotic surgeries. Dr. DeRose offers insights into his pioneering work in robotic cardiac surgery, shedding light on how these technologies are transforming the field. The episode also touches on his mentoring relationships, particularly with Dr. George Todd, and explores the balance between clinical practice and leadership roles.

Balancing the high stakes of surgery with personal passions takes center stage as we discuss the parallels between the precision required in both heart surgery and sports. Join us for this nostalgic and motivational episode, perfect for current and aspiring surgeons, as we journey from residency to becoming leaders in cardiothoracic surgery.

#CardiacSurgery #SurgicalResidency #MedicalPodcast #SurgeryLife #SurgeonTalk #MedicalMentorship #SurgicalTraining #DoctorLife #HeartSurgery #MinimallyInvasiveSurgery #RoboticSurgery #MedicalCareer #SurgicalStories #MedicalProfession #SurgicalEducation #CardiothoracicSurgery #MedicalLeadership #Mentorship #SurgicalInnovation

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S04E81 - From Columbia General Surgery to Robotics: Journey to Cardiac Surgery - Dr. Joseph DeRose

TRANSCRIPT

[00:00:04] Dr. Sam Rhee: So I just finished the podcast recording with Dr. Joseph DeRose, who you are about to hear, and it was so great to talk to him. As you'll hear, we haven't talked since we were in residency, and that was twenty, like, six, seven years ago. Uh, And after the podcast, we just sat for like another 15, 20 minutes talking about all the people that we knew in residency.

And there were so many characters, so many personalities, uh, so many great. people. Uh, and from my perspective as a plastic surgery resident, I only did three years of general surgery there. So I, I was on the outskirts. I wasn't a regular general surgery resident. I, uh, I didn't stay. Um, but the people that I trained with were some of the most impactful people in terms of their work ethic, how they approached life, um, their dedication to their craft.

And, uh, And also just, like, how to have fun when things were really terrible and horrible, and you had, like, a crushing amount of responsibility. And they took it all very seriously, but they also enjoyed life. And so we just ran through a bunch of names, and also, uh, a couple stories that I We can't discuss on the podcast because it wouldn't be appropriate, but, but they were just so reminiscent of some of the great things that were so special about surgical residency training.

And I know if you've ever watched like a surge, like a show, like Grey's Anatomy or ER, or some of these shows, like they try to capture a little bit of what that camaraderie is, you know, how people interact, uh, in the hospital under stressful situations. Uh, And maybe it's just like the fog of time, but when I look back at it, it was horrible.

It was difficult. Um, I definitely was An average resident at best at that time, but that team and those people around me tried, you know, they really tried to lift me up and make me the best person that I could be most of them. And I would say I, I really respect that. And Joe was one of those people. And, um, And as I mentioned in the podcast, he enjoyed life to the fullest then, and he continues to enjoy everything that he does now, regardless of how accomplished, how many accomplishments he's had, how, um, big he's become in terms of leadership, in terms of, uh, you know, what an expert cardiac surgeon he is.

So I hope you listen to this and realize that, you know, for me, it was very special talking to Joe, and I think, um, Very inspirational to see what he's done, uh, over his life. So I hope you enjoy the episode. Uh, it really meant a lot to me. Thank you.

All right, welcome to another episode of Botox and Burpees, the surgical series. I have with me a very, very special guest. This is Dr. Joseph DeRose, and Dr. Joseph DeRose is the professor and chief of the division of cardiothoracic surgery at Montefiore Einstein Medical Center. He's also the co director of the trans catheter aortic valve replacement program at I know Joe and this is actually literally the first first time we've talked in almost 26 years because he was my senior resident in general surgery when I was doing the general surgery portion of my training at Columbia.

University Medical Center. Um, now, and, uh, and though, and everyone that were my senior residents, including Joe and many other people we could name were, were really people I looked up to. They were amazing, amazing people, but a little bit about Joe's background. He graduated, uh, with a BS in biology from Georgetown University.

And, uh, you won the summa cum laude Chapman medal for the most outstanding student, which is a. And then you also went to Columbia University Vagelos College of Physicians and Surgeons, and you won the Whipple Award for the Most Outstanding Student in Surgery, which is a real award, that's pretty prestigious.

Um, and then you finished your full general surgery residency at New York Presbyterian Columbia University Medical Center, where I met you, and then you stayed on to do your cardiothoracic surgery fellowship. Uh, at Columbia and, um, also did a postgraduate fellowship in robotic and minimally invasive surgery there and your, um, specialty or your interests include robotic cardiac surgery, arrhythmia surgery, atrial fib, uh, fibrillation surgery, thoracic aortic surgery, um, I mentioned the trans, uh, trans, uh, Catheter aortic valve replacement, the minimally invasive stuff.

This is a, this is a far cry from the stuff you used to do in, in, in as a fellow, probably like you've, you've gone into the next gen of cardiac surgery at this point, isn't it?

[00:05:10] Dr. Joseph Derose: Yeah. I mean, it was super exciting though, because all those things, including and most closest to me being minimally invasive cardiac surgery and robotic surgery were in their infancies. They didn't even exist when I was a fellow. And then when I was a super fellow stuff was just starting to be developed.

So I was involved at the front end of this, developing these operations, trying to figure out how to do it. It was super exciting. I was lucky that I had those experiences to be able to get in at the ground floor. I'm at the early part of my career because of Columbia, honestly. So that's all been great.

It's one of my passions. Um, it's funny, my practice is weird. I'll do the smallest operations, which are like robotic surgery. And then I'm also the director of the aortic surgery program, which are massive operations, arch replacements and aortic operations. So it runs the gamut and it's really a great practice that I have.

[00:06:01] Dr. Sam Rhee: Yeah. I remember when I was training with you guys, like we did a lot of laparoscopic gallbladder surgeries, and I remember you guys as seniors taking the juniors, us through it and, uh, Everyone was super facile at it. And it's so amazing to see where all of that minimally invasive stuff has gone. And, and the fact that you guys have developed so much of that.

Um, so when you think back on your training, what do you remember as particularly memorable or something that was very impactful for you during your training, uh, that sort of led you to become where you are right now?

[00:06:38] Dr. Joseph Derose: Yeah. I think, you know, you, you sort of alluded to it when we were getting started and, Looking back now and having the relationships I have had over the last 30 years, Columbia General Surgery Training was a brotherhood and sisterhood and a family and there were very specific expectations and requirements, but there was such a camaraderie and that was something that was brought down from generation to generation.

I mean, I was, you know, I'm really honored that you said you looked up to me and some of my other co fellows, but You got to realize that I had those same aspirations of the residents that came ahead of me, and they were the people that I wanted to model myself after from the time I was a medical student or intern.

And uh, there was a certain way that we decided that we were going to conduct ourselves as a general surgery team. It stayed with me forever. You know, and when we, we, you may or may not realize this, but there was always this dynamic, not just on the general surgery end, but also on the cardiac surgery end.

This sort of, this sort of competition between Columbia, Cornell, NYU and, and Cornell and NYU had a certain way of doing things and at Columbia we were gonna do it differently. We were gonna be sort of the team, the kinder, gentler group of surgeons. But we were expecting, um, 150 percent from everybody at every level.

And, uh, you know, a lot of these people that I looked up to, who I trained with or trained under me, I'm still very close with, and I still stay in contact with, and as the, I also am the head of the residency program here, uh, for the I 6 program and the fellowship. And I've tried to inculcate that into our trainees.

You know, the trainees train each other, but everyone does that with respect. There are expectations and we do expect you to, to, to work hard. But, but that respect in the OR, I think it was, it was always translated to me. And I, and, and the memories that I have

[00:08:42] Dr. Sam Rhee: have

[00:08:43] Dr. Joseph Derose: are with some of the guys that you already mentioned and girls of spending, you know, countless nights in the ER or on the floor.

[00:08:52] Dr. Sam Rhee: what to

[00:08:53] Dr. Joseph Derose: doing what we do every third night or every other night and loving it and having so much fun. Now, some of the experiences I can't recount on this podcast, but, um, Argenziano and Laboudi and I and Chen do recount them frequently offline. And, uh, it was a lot of fun. It really was. The jokes we play on each other, the jokes we play on the attendings, the stories we'd have.

Uh, some of the stories have actually become so legendary. That, for example, I would tell one of the stories to one of my fellows, who would then do like a super fellowship, or have a, we have an exchange program at Columbia with Pete, and they'd run into Argenziano, and he would tell them exactly the same story.

So, you know, I have other co fellows who are with me, like Evan Lipsitz, he's the Chief of Asculi here. And when my I 6 residents rotate through Vascular, they believe that the stories I told them were true because he's telling them the same story. So it was lot of fun.

[00:09:56] Dr. Sam Rhee: was such shared, um, experiences for sure, and I think of you guys, and I think that the reason why I admired you guys, and you know, being a Plastics guy, I was sort of off to the side, and you guys treated me with kindness and, and love. A lot of tolerance in patients, uh, but obviously at Columbia, there was a huge general surgery tradition, as you mentioned, but also, uh, cardiothoracic surgery, all of the bright, best and brightest in general surgery seemed to Want to do cardiothoracic and, and many of you guys stayed there and, um, yeah, to see Argenziano, to see Raj, to see you, to see, um, Nader, Mozami, and all these guys, like, just, you know, who, who handled a tremendous workload, like, there's no doubt at that time the workload was insane.

The, the tasks that were expected of, of all of us. Everyone, especially the seniors, was insane. But you guys had a sense of humor. You had a sense of being able to accomplish these things with grace. There was no, um, uh, you know, there was no hate or malice, uh, sent downhill. It felt like a team. Everyone contributed.

Um. You know, I remember just very vividly, like, Bobby Dable was my two. I was the intern. Like, you, you know, you were like my four and Moza you know, it was, it was hierarchical, but in such a good way. And it was that team aspect of it is something that I have taken away in terms of a lesson, a life lesson, and also how to treat your juniors and the people that you work with, with respect and, and, um, Um, expect a lot, but you're also giving a lot at the same time.

[00:11:46] Dr. Joseph Derose: that's so true. And we loved, we loved being there though. That was the thing that I'm looking back at. Like, I mean, we were there a lot. I mean, I guess by the time you were at two, I think we had eliminated some of it, but most of us who went through was every other night or every third. We went to that every third.

It was like Monday, Friday, Sunday, and that was hard. And it wasn't that like the juniors and the seniors, they wouldn't leave if they were not on call and you'd, you stay there and take care of whatever you had to take care of. I mean, there's a loads of stories. One story I remember, um, I, I forget that some of the things that I've told the juniors, right, like they took to heart, they remember it.

So like Dave D'Alessandro was, uh, I think, was he in your class?

[00:12:32] Dr. Sam Rhee: he was one year down. Yeah. So he was a two.

[00:12:35] Dr. Joseph Derose: I was a chief. He ended up going into cardiac surgery and actually ended up joining us here at Montefiore Einstein. And he comes to me the first day that he's here and he's like, Hey, I just want to let you know it's one piece of advice you gave me when I was an intern that I've kept with me forever.

And I'm like, Oh God, what's this? He said to me once I came to you and said, Oh, I think there's a consult over in area A and you stopped me. You said, Whoa, Whoa, Whoa, Whoa, Whoa. I'm going to give you two pieces of advice. Never swim upstream. And if you get called about a consult, don't ask anything but the medical record number and go take care of it.

I was like, oh, yeah, I'm glad I was able to affect you so much. The other thing that was fascinating was that, like, we had this hierarchy, we did. And I remember Libutti saying to me when I was a 2, Joey, listen, you are a 2. You don't speak to me directly as the five. The one speaks to the two, who speaks to the three, who passes up to the four, and then maybe the five gets involved.

And, uh, that was true, but it was as a joke. And, but eventually you'd go up this ladder, and, and when we were chiefs, we didn't have, the attending didn't come in, right? I mean, we did the cases at night. And they were on the phone. That changed thereafter. And so you were like an attendant, you had your own service.

[00:13:55] Dr. Sam Rhee: Hmm.

[00:13:56] Dr. Joseph Derose: All right, fast forward one month, right, to cardiac surgery fellowship. And it's a complete reset. And I knew that, I mean, but you start day one and you're like, Oh my God, I know nothing. I was just, I thought I was attending and now I know nothing. And I think that understanding of that, knowing that you have to reinvent yourself and relearn something again is really important.

And maybe sometimes I'll see that in my fellows who just get started is that it takes them a little while to realize. Whoa, we gotta stop, reset, and learn again. So, um, but all those things were ingrained in me. I still love it. And I gotta tell you, every time I speak to Libutti or Argenziano we're gonna tell the same ridiculous stories about whether it was Benvenisty or Ford, start imitating other attendings.

I mean, probably inappropriate, but, but still very funny.

[00:14:51] Dr. Sam Rhee: They were, they, it was so memorable. I mean, I remember so much of it, like it was yesterday and, uh, I was just thinking the fives were like attendings. I remember there was a ruptured, uh, AAA up at Allen Pavilion, and I was the two on, and I think it was Goldstein who came up and handled it until the attending eventually came up, but we were like halfway up.

You know, in surgery, like a solid hour and a half or two. And I remember holding the distal part, like squeezing that, like a mofo, like, like just don't move, like in the middle of the OR. And like, it was just it. And, and that type of leadership, uh. I mean, I've talked to other surgeons about like, you know, patient care versus teaching and all sorts of other debates about like what kind of responsibility residents should have.

But at that time, there's no doubt the amount of responsibility that we had was Tremendous, especially as, as seniors and that leadership experience. I don't know. Um, it just, it gets kicked down so much farther, I think, in residency

[00:15:58] Dr. Joseph Derose: It does, you know what, I mean that's the one thing, so in cardiac surgery there is this whole dichotomy between I6 residency just like plastics, I5 matching right out of medical school and then the traditional pathway of general surgery and doing a fellowship and you know there are pros and cons of both but the big argument for doing the conventional pathway and then the fellowship is exactly what you said, slowly getting not just the knowledge but the ability to lead and have independence.

And then learn how to teach those below you. I think it happens in the I 6. My I 6 residents are phenomenal, but it happens in a different way. Uh, but that, that, that maturation is so critical. And, and also I think the other part of it is that, and I'm hoping that residents today still have this. I try to have my I 6 residents do this.

And I think they do, but it's to enjoy it, to share it as a team, make sure that you have responsibilities as a three for the two for the one and the four for the three, et cetera. But enjoy it, want to be there, right? It's not about getting out as quickly as possible. It's about trying to be there as long as possible.

And uh, and that was true. I mean, even though I was exhausted, I never wanted to be anywhere else. All

[00:17:13] Dr. Sam Rhee: and he's a great guy. And I remember cause I, I rotated over at Overlook and it was actually not him, but back in the day, I don't know if you remember at Overlook, you took power weekends. So you were on call from Friday through Monday and you took everything that came in and, um, and.

The laundry was not open on Monday morning, by the time you got to, uh, to the OR at 7. 30, so you usually, like, took your scrubs, had them in the call room, uh, took your power weekend, uh, You know, and then you change or whatever. And, um, I remember coming in on Monday and Jim Burks had been on, uh, for the weekend and he took, yeah, I know.

Right. So he took my scrubs that I had and he had left the ones he had worn all weekend. And I had to go to the OR. In his, his foreday, and for knowing Jim, it might have been like a week old scrubs that he had worn. And that was, that was a very, very, very memorable, memorable experience for me at that time.

[00:18:19] Dr. Joseph Derose: right, here's a story which, which some people might think is a little bit depressing, but sort of mirrors how much, how hard we did work. So in general surgery, I thought we worked really hard. And then when I got to cardiac surgery, And at Columbia, it was hard. We were on call, same kind of rotation schedule, but we were there all the time.

And then my co fellow ended up leaving, which left me with

[00:18:42] Dr. Sam Rhee: oh my God.

[00:18:43] Dr. Joseph Derose: double the call. I remember being called into the office and, uh, Sam Weinstein. Brings me into the office with, uh, Craig Smith. Sammy goes, Joey, uh, I got some really good news for you. I said, what's that, Sammy? What is it for, Craig? He goes, I think you're going to be able to do a lot more cases early on in your career.

I said, why's that? He said, well, so and so is going to be leaving, which means you're the only intern, so you're going to be able to take double the amount of call. And I think that's going to be really good for you. And now I didn't say like, you know, Oh my God, that's horrible. It's all great, Sammy. Thanks so much.

Thanks. So I don't know if you ever read this. There was this book called life and death and life and death was written in right before I started as an intern. It was a book written about Columbia Presbyterian, the old Columbia Presbyterian. And all the different characters in Columbia. Each chapter was one.

Alcan, who was the ward clerk in the ER, was one. He used to call me number one, and my wife, who was a resident, number two. Everyone had a name. Eyeball on the phone, you know. You know, whatever, that was ophthalmology. And it would go down the ladder. I remember there was one chapter, and I read this book before I started residency, and it was about the, uh, the cardiac fellow.

So the cardiac fellow is in the call room, and, uh, And he's exhausted. And, uh, we did those power weekends also, but we were up constantly. And frequently your wife would bring, you know, if you had a kid or whatever in just to have lunch or something so they could see you. So, um, the guy, the, the, the, the wife knocks on the call room door with her little son and says, Hey, go say hello to daddy.

They open the door. The girl runs right to the phone, even though dad's sleeping in the bed, says, hello, daddy. So I tell my wife, who is also, uh, was a medical resident at Columbia and is an internist in Englewood. I tell her at the time, I said, listen, that's never going to happen to us. I said, I'm going to be there for everything, it's never going to happen. So my wife used to bring my son in, even when I was, uh, at the Allen Pavilion as the ghost and then as a fellow and, uh, he was like one or two, he would come in, we'd have lunch, we'd play a little bit.

So it just so happened that one day. I must have gotten home after a call night on a Saturday or something, and I was home early, and I was passed out in bed. And, uh, for cardiac surgery on 7 Garden South, there was a blue door, and behind that was the Cardiac Surgery Fellow's office. We were in there constantly. So my wife goes, my son's running around, screaming and all. She goes, shh, be quiet, you're gonna wake up Daddy. And he's like, what are you talking about? She's like, Daddy's sleeping in bed. He's like, well, daddy doesn't live here. He lives behind that blue door. I said, I definitely did not do what I was supposed

[00:21:31] Dr. Sam Rhee: That's so funny.

[00:21:32] Dr. Joseph Derose: big deal.

Those things were big

[00:21:33] Dr. Sam Rhee: Yeah, you, I remember Sam Weinstein crashed on a Monday, I think coming back post-call, like going home like that was serious. Yeah, yeah, it was

[00:21:44] Dr. Joseph Derose: good story. Uh, this is a cardiac surgery story. So every night before, uh, we used to have rounds on Thursdays. Okay. So every night, like Wednesday night, every fellow would be in the office trying to get their presentations together till like midnight. So I come into the office and our Genziano is out, is on the couch lying flat with an EKG machine on.

And I said, what the hell are you doing? Because I think I'm an SVT. So I go, look at the EKG. I go, yeah, you're an A 5th. I said, you got to go home. He said, no, no, no, no, hurry up. Go out to the nursing station and get some loprezo. I have a visit tomorrow. So I go out to the nursing, I try to give him a karate massage, it doesn't work.

I go out to the nursing station, I give him a bolus of low pressure, he converts, he gets back up, gets the presentation ready, and goes home at midnight. I mean, you know, I'm not getting that from his residents and fellows of today, so. And that is a very true story,

[00:22:40] Dr. Sam Rhee: he would flip into SVT in the OR Yeah, and he would like sit there and Valsalva in the case to try to flip himself back Into sinus like he would he would do that like you'd see him. He's like getting all red and sweaty like what the What are you doing? And, and, uh, it was nuts. Uh, I mean, and trying to get that guy up in the morning to round was effing impossible, like as

[00:23:07] Dr. Joseph Derose: When we were, when we were, when he was a, when he was an intern, when he was a two, when I was an intern, he used to tape his beeper to the top of his head, like this, like a band, like a headband, so that when it went off and vibrated, he'd wake up. He had sleep apnea, so.

[00:23:26] Dr. Sam Rhee: Uh, so I know you had so many mentors, uh, that sort of helped form you to be who you are, but if you had to name just someone. off the top of your head and, you know, who would that be? And what was it that they did for you to sort of get you to where you are?

[00:23:44] Dr. Joseph Derose: I mean, for me, that was an easy one. I mean, like, a lot of people knew who my mentor was when I was going through residency hall, and that was George Todd. I mean, George Todd was the chief of vascular surgery. When I was a medical student there and he'd been there forever. He was a resident there and then had been the chief there early on.

And I got close with him when I was a medical student. And even at that time, you know, I wasn't one of these people that was all in to do heart surgery. I love the heart and everything. And I did do some research, but I just wasn't sure because you know, the rap on heart surgery was always, Oh, there's only two cases that you do a valve and a cabbage.

Oh, you don't take care of patients. You just operate and that's it. And you know, in hindsight, I found out that none of that was true, but. My early experiences with Dr. Todd were that he was like a master surgeon. He set up every case like the heart surgeons did. It was very specific and he did every case the same way, but he also was a really good doctor.

I mean, he took care of every part of his patient, and his patients loved him. And it was this combination of being a good doctor and being a good surgeon. And then also we just had a great relationship from, uh, we just, we hit it off early on and understood each other well, and he understood what made me tick.

And, uh, and we used to laugh a lot together. So, um, he was the reason that I stayed at Columbia. I mean, I was looking at going to Brigham and I remember exactly what he said to us, like I never asked him for too much advice, but I'd be like, yeah, you know, these are the places I'm looking at. And he's like, Brigham.

What do you, what do you, Brigham? I said, you need to stay here. I said, Brigham, they all wear bow ties. You don't want to be up there all the time wearing surgeons. You've got to be here in Columbia. I said, oh, okay, that makes sense, Columbia. Um, and then as I moved on in residency, um, he was always kind of there for me, you know, and he was there for a lot of the residents and he always gave really like good, smart advice.

And I came very close to going into vascular surgery. Um, But at the end of the day, I did love the heart and cardiac surgery. I tried to be the kind of surgeon and leader that he was, uh, heart surgeon. Uh, he, uh, I still, I still speak to him. He's retired now, but I still speak to him and he's exactly the same.

Um, and it's great. And there was, you know, loads of other surgeons, but, um, the heart surgeons were obviously mentors to me too, but in a different way, you know, I tried to take little things from each one of them.

[00:26:10] Dr. Sam Rhee: Mm hmm.

[00:26:11] Dr. Joseph Derose: George, I tried to be. I tried to be the doctor that he was and uh, you know, I've told him that and now it's later on in life And I I think i'm I think i've done some of that I mean, I don't know if i'm good as he was but I think i've done some of that.

So

[00:26:26] Dr. Sam Rhee: hmm. I remember him well. I never really operated with him because he, you know, obviously the case is he's, as you said, he's very meticulous and he was really particular about who he operated with. And you could tell he only, you know, he operated with the seniors. Uh, he did very meticulous carotid endarterectomies.

That's the, the, the surgery that I think of him the most with. He was so particular about how the case went and he was a man of few words when I saw him like he was a pretty like I wouldn't say grumpy but he just was not very like if you're a junior and you know he just wasn't going to really talk to you he was focused on what he was doing and the one thing I do remember is he didn't play a lot of albums but the one he really liked in the OR was Dire and I've Must have sat there, like, hearing that CD about fi You know, cause it wasn't like the days of the iPod.

You just had like a CD player, and sometimes you'd ask the nurse to like change the CD or whatever. And that one just, you know, he liked that one. He just kept playing that one over and over and over and over and over again.

[00:27:34] Dr. Joseph Derose: It's funny, I think, you know, he, he took me under his wing when I was a medical student, and he brought me in sort of to the inner circle with some of the other great residents that were ahead of me, like Galanowicz and Auteri, and these were guys that I looked up to that I thought were the greatest. But it wasn't until Loubouti, Argenziano, and myself, I think, started getting to be more senior that we broke them down.

Then we broke them down. And he realized What you would call us, you know, the morons, right? I mean, Incredible compliment and I think it was really good for all of us and for him and then he started loosening up and then my first job that I ever took out of fellowship was with him He left and became the chairman at St.

Luke's Roosevelt and he brought me there and hired me for my first job as a cardiac surgeon in St. Luke's and Probably the mentoring that I got there from him was even more important than I got moving on early in my career. He brought me in very early in leadership positions. He brought me into the whole process of recruiting the whole department of surgery and all of it from the residency program to research.

He really gave me a lot of responsibility early on and, and I think a lot of the leadership skills I have are from him. He only gave me one other piece of advice when I started. I remember first day I started my first day As attending, he said, listen, I can give you a lot of advice. One thing. I said, what?

He said, and he usually would joke around with me all the time, but this was serious. He said, when you're first starting, every case looks like a good case. He said, don't, he said, do not get sucked into that. He said, you will be a good surgeon when you decide who the patients are that should not have surgery.

And there's going to be a lot of them. And he was totally right. You're running around. You want to get cases. Every case looks like a good case. And a lot of times you have to not operate, right? So, I'm sure he doesn't remember any of this, but I did. I did take some of these things to heart.

[00:29:25] Dr. Sam Rhee: very true, very true word of advice. So over the years, what do you do to become a better surgeon? You're a better surgeon now than you were last year, the year before that, 10 years ago, what are you doing to constantly better yourself as a surgeon at this point?

[00:29:51] Dr. Joseph Derose: going to do? And I think that learning, especially when you're first starting early on as a resident, you don't understand, you think that the learning is the technical parts of it, right?

So, there's this classic. There's this classic maturation that my fellows go through. They're all panicked the first month that they're not going to be able to take the mammary down. I tell them, you got to trust the process. There's not a single person I've graduated who can't take the mammary down. Okay.

I said, but to learn an operation, you have to learn the entire operation from both sides of the table. So, what I used to do, no matter what, where I was, I would focus so much on the left side of the table at what was happening on the right side of the table, focusing on my moves, but looking at what's going on the right side of the table and saying, let me put myself in that situation.

And I learned a lot of this with Dr. Quagavare, who was the, uh, the congenital cardiac surgeon at Columbia, who was very difficult, but one of the best surgeons I've ever scrubbed with. I mean, he would exhaust you. So, but, um, trying to watch every little move and step he made. And then, you know, when I got out, I said to myself, there's a lot of things in heart surgery that we do that make no sense to me.

Like why is everyone, why do we have to stop the heart and make a sternotomy and go on bypass? We're just sewing some blood vessels together. I mean, the plastic surgeons do this all the time with 10 0 and on a microscope. Why are we making it such a big deal? And constantly putting myself to learn more.

And I did that mostly by reading and watching and going and watching other people. So I did not get a lot of training in aortic surgery when I was at Columbia. They hated it. They really didn't do a lot of it. But when I came to St. Luke's, I was in charge of minimally invasive surgery, but there was a guy there named Dr.

Agnostopoulos who had a huge aortic practice and I had just absorbed it. And I said, okay, I got to get really good at this. So I found all the best aortic surgeons in the area. And that time there weren't that many. And I went and visited all of them. I watched all of them operate. And I just took little pieces of each of it and made it my own.

And I continue to do that. You know, you have to always see what other people do, but you also can't be afraid to push the envelope, which is hard because, you know, when you're pushing the envelope, there's, there's a target on your back, right? People don't want you necessarily to succeed at something that's a little bit different than what they do.

So. Today what I try to do is, um, always look for what the next thing is that I'm not doing as well or could be doing and absorb it either into my practice or into the group's practice. Because there's constantly new things, but you gotta get involved in that early, so. Um, and that's been what I've done my whole career and I, and that's what I love about it.

I mean, otherwise you just come into work doing the same thing a thousand times over.

[00:32:31] Dr. Sam Rhee: Yeah, especially in your field. There's so much change over the past 10 years. It's insane. Like you said, with robotics and, and I, I can only imagine what's going to be coming next, especially I've talked to some surgeons about AI and, and sort of starting to integrate that. And I've seen the ortho guys with their, um, You know, sort of assisted, guided type surgery, um, and I'm sure you guys are developing even better and improved, you know, safety techniques and other things to make it more foolproof for people.

Do you think that these things are going to hurt surgeons? Skill because like, for example, the, the Mako system for ortho, like it almost prevents you from making a bad cut for your knee replacement. Like, it's like, Oh, you can't do that. That's not good. Like it sort of stops you and helps guide you to make the right one.

And, and, and is that, are those kinds of training wheels good overall? Or is that something that a surgeon Shouldn't necessarily rely on.

[00:33:33] Dr. Joseph Derose: A lot of great questions. I mean, look, look at, look at, uh, general surgery and, uh, colon and asthmosis, right? From hand sewn to mechanical, right? I mean, they're going to be done better probably at some point with new tools and those new tools have to be learned. I think for cardiac surgery, what's happening is that a lot of things are moving away from these big types of operations because we have less invasive ways to do it, whether it be, um, Transcatheter valve or, or other structural heart interventions, um, but, or, and same with aortic surgery with stent grafting, but there are scenarios that will occur and will continue to occur where you have to do a third time redo aortic arch, where you have to do the third time redo operation.

And part of the problem in, in heart surgery is that people are just not having, they don't have that experience because those aren't common operations. And so You're developing this cadre of older surgeons that are the only ones that are trained to do these big operations. I think something similar has happened in vascular where, you know, 90 percent of it has gone to, to, you know, endo.

And so when you have to do a complicated open aortic aneurysm or a complicated open bypass, it sometimes isn't as easy for the more junior people. So there are trade offs. There's no question that we've pushed the field so far, um, on the minimally invasive end, and that's all good. You are, you are, you know, giving a trade off there because people do need big open operations sometimes and at some point there's not going to be anyone available to do them.

[00:35:07] Dr. Sam Rhee: What is your favorite operation now? What do you really like doing at this point?

[00:35:11] Dr. Joseph Derose: Um, so my favorite operation is a robotic cabbage. So robotic cabbage is an awesome operation. The DaVinci system, most people don't know this, but the DaVinci system was originally owned, the, the, the copyrights and all of the, all of the, um, all the hardware was owned by DARPA, the Department of Defense.

You Um, that as well as the, um, trademarks for using the robot for surgery were bought by Intuitive Surgical in the mid to late 90s with the sole purpose of doing totally endoscopic bypass. That was the reason for it. It wasn't to do urology surgery, it wasn't to do prostatectomy, it wasn't to do gynecology, none of it.

And, um, you know, what their ideas were for it haven't really come to fruition, but what has come to fruition Is doing, uh, the robotic cabbage, the way we describe it today. And that's using the robot to take down the lima or the Rema. Um, opening the pericardium, identifying your targets, and then doing a hand.

So anastomosis with an endoscopic stabilizer through a tiny incision to put Lima to LAD or Lima to the diagonal RLAD. If people with Multivessel disease, they're treated with that plus stents and the reason being is that LIMA to LED improves your survival, the stents are a way to treat the other vessels with, um, quick recovery.

Now the reason the other stuff took off is because I don't think people had the understanding that robotics is for two reasons. You apply robotics to minimally invasive surgery for two reasons. One, it'll allow you to do a minimally invasive operation better. than you could do if you just did it laparoscopically or thoroscopically.

Or two, robotics should be applied if you can't do that operation minimally invasively and the robot's the only way you can do it. So, so let's step back now in time to the late 80s and 90s where general surgeons were amazing at doing laparoscopic everything. So they didn't need a robot, right? But the urologists, they're only a handful of people.

And some of them are guys we trained with who were doing laparoscopic prostatectomy. Very few other people were because urology wasn't a field where you were getting such in depth laparoscopic training. Put a robot in a urologist's hands, now they're milling with a surgeon. Same with gynecology. The same idea occurred.

And so that's how those things took off. In heart surgery, it's very difficult. I mean, I have done, but it's very difficult to do a robotic cabbage without the robot, do it thoracoscopically. But people do use the robot to do like minimally invasive mitral valve surgery. I typically do that thoracoscopically because I'm good at it.

But other people that don't do a lot of that, you put a robot on their hands and then they can do it minimally invasively. So I love the robotic cabbage because it's, it's quick. It's simple. The patients get discharged in three days. Okay. And it's, and it's, and it's reproducible. Um, and, uh, I think I also love it cause it's an operation that I was involved in from the, you know, inception of the first case.

A lot of these cases that are being done today, I was involved at Columbia with the first cases done ever. So, you know, it's exciting for me to see it and evolve and see that it's like routine. So,

[00:38:19] Dr. Sam Rhee: What does that do? Just stabilize the surgical site so you don't have to move?

[00:38:25] Dr. Joseph Derose: used to take down the mammary, which is not easy to do that laparoscopically or thoracoscopically because there's no space there. So you have to insufflate the chest. It drops the heart out of the way. You take the mammary down. Then you open the pericardium, identify where you're gonna go.

Now what you do is you say all right there's the LAD and you find a spot right on the chest wall where you make a tiny incision right on that and you can use what's called a soft tissue retractor or a regular retractor and then you take a stabilizer that's put in endoscopically through a port that stabilizes the area so it doesn't move and then you just sew it by hand.

You have to snare the vessel but

[00:38:58] Dr. Sam Rhee: Mm hmm.

[00:38:59] Dr. Joseph Derose: it sounds simple. There are parts of it that do require additional training for sure because most heart surgeons are just, you know, Used to opening the incision and going on bypass and stopping the heart and taking some veins out, but um, I love it. I love the operation.

There's lots of operations I like, but that's my favorite one.

[00:39:15] Dr. Sam Rhee: That's very cool. Um, so. When you set up for these cases, now that you've been in practice for so long and you've been operating, uh, I remember, like you said, Dr. Todd being so meticulous about every step of his case, of his cases. What is it that you do now that is the same for every case or is there anything that, or do you just kind of do everything freestyle different?

[00:39:41] Dr. Joseph Derose: So, you know, it's fascinating. You have to have the structure and the orientation of the operation and the operating table the same. You need to repeat that over and over from where the towels go to where the stitches go. But every operation is completely different. And uh, something I think Dr. Todd told me about this was something I did from my first day in practice.

You know, every operation is a conglomeration of thousands of steps, literally. Now, you're not verbalizing those steps to the person you're operating with, but you're going through them in your mind, whether it's from putting ports in or making the incision, all of it down to the most nitty gritty, right?

And so what I do every night or on my way into work is I think about the operation that I'm doing today, the very specific operation, and every steps of that operation I go through in my mind, I go through, uh, exactly how each part of it is going to be done, contingency plans on whether, you know, this vessel is not graftable or this looks like this, all the way through to the end.

And then what I also do and always have done, is I also think in my mind, what is going to be the roles of everyone in the room, because I'm an academic medical center with a training program. And to me, that's really important. And, and, you know, The way you train residents well is to manage expectations.

So upfront, you need to know in your mind what's going to happen. You have to discuss with the team who's doing what today. All right. So today we're doing this cabbage. I also have a case to follow. It might be a long day today. You're going to open the chest. You're going to get everything set up. Then maybe I'm going to take both mammaries down and cannulate.

Cause that might take me, you know, five minutes and it might take the fellow three hours. And then. You know, I'm going to cannulate and then we're going to switch sides. And then you're going to do the cabbage from the right side of the table. And I'm going to help you from the left. Oh, okay. That's the plan.

Right. Or whatever it is. I realized that that takes a lot of energy. It takes a lot of energy on the attending side, right? To think about not only teaching somebody, but then to think about what everyone's going to do. Imagine if you just walked in and said, I'm doing this case today. This is the way it's going to go.

It's going to go fast. But the amount of, the amount of value that comes from that, is tremendous both in both directions from the fellow to the attending and the attending to the fellow. And that's the way you build trust. And that's the way you build dedication from your fellows. And that's the way everyone feels like they're working on a team to save this patient's life.

So those are the things that I go through every morning or every night before an operation.

[00:42:14] Dr. Sam Rhee: I cannot,

[00:42:15] Dr. Joseph Derose: a simulation.

[00:42:16] Dr. Sam Rhee: like a what?

[00:42:18] Dr. Joseph Derose: You're simulating the operation, right? Like this was a big deal, simulating hours they need. I've been doing simulation, you know, since 1989 when I'm thinking about everything, but it is true.

[00:42:28] Dr. Sam Rhee: I have to say every surgeon I've talked to so far does some sort of pre visualization prior to surgery. I think it's universal. There's no one who never doesn't think about every step of the surgery before they do it. And I think probably if you are a resident fellow, even a medical student, like going through your own pre vis, I Before you do something or even watch will help you get into that role.

And, uh, someone told me that a long time ago, even as a medical student, like you should imagine yourself as the attending. What would you be doing? What, what should this case go as

[00:43:06] Dr. Joseph Derose: Yeah. I think, you know, the one thing about that, that I really, I tried to work on a little bit, and we even, I was involved with, uh, one of the, one of the plastic surgeons here, Evan Garfine, and I tried to work on this a little bit in an application, and, and the, in an application directed towards learning, and the issue is that.

You're going through all these things and little things are happening in your mind, but you're not verbalizing them so no one is learning them. This was, this isn't an original thought. This comes from a book called Peak by Anders Erikson. That's the original source for, I'm sure most of the, maybe a little listeners know about, you know, Malcolm Gladwell's book about 10, 000 hours.

It's a little bit more involved than that. It's not 10, 000 hours of doing something. It's 10, 000 hours of focused practice. And then also the 10, 000 hours of learning need to be important. And there's all these, there's all these, um, uh, opportunities for learning that just go by us every day, especially in technical things, whether it be surgery or music or how to swing a golf club, right?

There may be things going through my mind that are happening, but I'm not telling someone about it because I think it's important. It's routine and mundane, but it's not. So what we did was, we made a bunch of videos of simple things, whether the, I don't know, making an incision, doing an exposure, cannulating, at different fields, in plastics, in cardiac, and, and on the, on top of the video, the surgeon is describing every single thought that's going through his mind.

From, this is how I find the midline, and this is where I buzz here, you know, silly things that you think everyone knows, But by articulating them, you're articulating to the learner, what are the steps? What should you should be thinking about? And that was that that's highlighted in this book. So

[00:44:54] Dr. Sam Rhee: That's huge. So, I know what Dr. Todd liked listening to in the OR. What do you like, what do you like listening to in

[00:45:02] Dr. Joseph Derose: know, I love listening to music, especially when I'm doing work I really do but in the operating room for cardiac surgery, I guess I didn't do this in general surgery I realized that I cannot have music, not because it distracts me, but for me cardiac surgery, it's a flow and there's a lot of communication that's going on between me and the perfusionist and me and the anesthesiologist and the nurses and back and forth.

And that flow and that tempo has to occur at a certain pace. And if someone can't hear me or is listening to something else or is not focused on that tempo and that cadence. Things can go slower. Things can go in a direction that I don't want them to go. And I want to establish in the operating room that this is kind of like a This is, this is a, you know, a holy place that we're in.

We are going to do the same thing, and all of us are going to be on the page about what that is, and everyone's going to know exactly what everyone else's moves are, and if anything is happening, that communication is going to be instantaneous. So I don't play any music in the OR, even though I used to play music all the time when I was a resident, but in cardiac surgery, I don't.

Um, and I'm probably in the minority with that. Most of my partners do.

[00:46:19] Dr. Sam Rhee: I would say probably, so far, a third don't listen to anything, and for the same reasons that you mentioned, and then another two thirds play lots of different things. So it is interesting to sort of hear what people's, Thoughts are about that for, um, so at this point, your head of cardiothoracic surgery, you are running your residency program.

You, you have, you're, you're holding your, uh, you're wearing a lot of hats. Um, what goals do you have as a surgeon at this point for the future? You've already probably achieved many of the goals you aspire to when you were a resident or a young attending at this point.

[00:47:02] Dr. Joseph Derose: I guess. I mean, I don't think of myself as old. I'm 56, but I think Goldstein, who also, Danny Goldstein, you mentioned, who also works with me, uh, referred to both he and I during a conference recently in public as on the, at the twilight of our career. And I was like, well, speak for yourself, but, um, but it's funny how I think that your goals change over time, right?

When you're first starting, your goals are. Geez, I just want to do a lot of surgery and I want to be really expert at this. I want to be a great doctor and I want to be a professor and I want to publish this many papers and those are all good goals and there's pathways to get to that. But now my goals are like less concrete.

You know, they're more about I want to be the best leader that I can be. I want to be the best mentor that I can be. And you know, you're not, that doesn't always happen every day. There are days where, you know, things that you do when you say, I could have done that better. I could have spoken to that person better.

I could have trained that person better, right? And so those are the kind of things that I think about getting better leadership skills. I've had a lot of experience and luck to be able to have a lot of exposure to the finances of medicine and hospital systems, and I do like that a lot.

[00:48:20] Dr. Sam Rhee: myself. Um,

[00:48:21] Dr. Joseph Derose: And I've really tried to learn about that by putting myself in positions Um, next to people who are expert at it.

Um, so I think if anything in my career, that's sort of an area that I would like to continue to get involved in, maybe even at a much higher level. It's just that I'm not quite ready to give up clinical medicine yet. I do love it. I think it's such a, it's such a, it's such a privilege to be able to do what we do.

I mean, I get it. It's hard. It is, but the privilege to be able to operate on someone's heart is crazy, you know? And, I really think my dad's, my dad passed away about a year ago. He was like a big time internist, loved medicine, lived for medicine and he told me when I was a kid and I used to laugh at him, but he's right.

You know, medicine is the noblest of all professions. There's nothing more noble that you can do than to try to cure somebody and these kind of things come back to me as I get older and I'm like, you know what? Those are the kind of things that you have to aspire to and you have to try to give that to those that are behind you and coming up.

So, I don't have concrete goals. I don't want to be president of the world. I don't want to, you know, I don't necessarily want to, you know, be chairman at a particular place. I just want to be a better leader.

[00:49:35] Dr. Sam Rhee: Why did you enter more leadership roles? Because I know a lot of the surgeons that we trained with at Columbia, and they were only happy, or they seemed like they were the happiest in the OR. You look at, um, the vascular guys, Benveniste, I think Todd, Noegrad, like, you know, They were only happy, or the happiest, if they were in the OR doing something, and then when you start taking on other administrative roles or leadership roles, it's, like you said, it's pulling you away, we, as surgeons, ostensibly love the most.

[00:50:08] Dr. Joseph Derose: I think it's because early in my career. So when George left Columbia and went to St. Luke's Roosevelt, now you're right. He didn't love a lot of that stuff at Columbia. He really didn't. And he used to make fun of everybody who was involved in that. Now, all of a sudden he's the chairman of surgery. Like a three campus system and you know, he really learned how to be good at it, but while he was learning to do it He, he allowed me a glimpse and, and some responsibility into some of his responsibilities.

Like no matter what he was doing, I was like, his secondhand man, we gotta get this guy for va. I mean, I was a heart surgeon trying to make my way and just, you know, learn things at that point. But whether it was the residency recruiting people or had to get people together, he always had me as part of that.

It was almost like I was learning at his side. So when I went to, to, to Montefiore to work with Dr. Mitchler, um. I got a lot of leadership roles right from the get go, too, and I felt like so equipped for it based on what I had learned. Now I learned a lot more from the way we organized things at Montefiore and the way we really put together a team because there really wasn't one here and we built a big team.

Um, I don't want to do that as as my only thing, but I understand the impacts that it has when you're leaders are, are part of the battle, right? You got to be in the battle and then people will respect and follow and they'll understand that the things that you're doing hopefully are for everyone's benefit.

Um, and that's unbelievable. There's two things to me that are unbelievably satisfying. One having a resident call me back and talk to me to tell me about, you know, how well they're doing and the fact that their training has made them a good surgeon. And two, to see that I've built something that's helped other people grow, there's nothing more fulfilling than that.

Those are all things that reflect back on you. You don't need to say, hey, I'm the person that did this, but the gratification of that is amazing. So, trying to marry those two things and being like super busy heart surgeon, I mean, I'm still the busiest heart surgeon at Montefiore despite all these hats.

But I do like that. I do. Otherwise, I think life would be boring. So,

[00:52:18] Dr. Sam Rhee: So if someone was to say, and I'm sure you get this, one of your integrated residents in cardiothoracic or even just a younger resident or a medical student, they're like, I want to become Dr.

Joe DeRose someday. Like, what do I need to do to accomplish that? What do you tell them?

[00:52:37] Dr. Joseph Derose: well, I can only hope, Sam. Um, no. No, I mean, I don't want anyone to say that. I always tell people, like, it's good to have role models, but take things from everybody and make them your own. I think, you know, it is important to have a bit of a path ahead of you to sort of think about what are the things that you're aspiring to.

And they don't necessarily have to be super concrete. Like I need to have 30 papers by the time I'm 30. You know what I mean? It can be like, Hey, I want to be the best clinical heart surgeon that I can be. Right? So then what's the pathway for that? You know, or I want to be a truly academic surgeon. Okay.

What's the pathway for that? Cause there are pathways for all of it. The end of the day though. You can forget about all of that. You have to absolutely love what you're doing. And you know, I think in heart surgery, heart surgery has changed over the years. It was definitely not, you don't, it's not necessarily the most, you know, reimbursed field or plenty of other fields you can be in.

It has remained like a big commitment of time, effort, and mental energy. Cause it is taxing when people live and die. Um, so, so, so people that want to do this. They have to say, Hey, listen, there is not a single thing in surgery or medicine that I could do except heart surgery. Because if there is, you got to do that.

I mean, there's too much sacrifice. Once people get to that and they love it and they want to be here and do it all the time. It's an easy pathway and it's, it's awesome. It really is awesome. I mean, I still love it today. I love every day that I work. I really do. I

[00:54:12] Dr. Sam Rhee: I can tell.

[00:54:15] Dr. Joseph Derose: there's only one thing that I love more, Sam, and I think you had a question there about what would you do if you're not a surgeon, and I'm working towards that right now, and that would be on the senior tour, the golf senior tour. I've been playing golf since I was about five, as you're growing up, you know, it's hard to, you know, I can play, but it's hard to play a lot because you're busy. As you get older, then you can start playing. So I've started playing much more competitively and I am qualifying for some of these events.

So I just don't know if my job is, is going to get in the way, but, uh, we'll see,

[00:54:47] Dr. Sam Rhee: I mean, that makes sense. I think, uh, there's a lot of, um, like, a golf swing, course management, all of that is probably amenable to sort of the approach that, A cardiac surgeon would take in terms of perfecting their procedure. I would say, um, there is an obsessiveness about it. Um, I would say I see a lot of pro athletes and that's sort of their, you know, you look at a Steph Curry, you look at a Michael Jordan, like it, it also scratches a competitive itch there.

I think most cardiac guys I know are. They are, they're sort of competitive in a lot of ways, like they didn't get to where they were by just rolling over and letting someone else sort of take their lunch. So I feel like that, that makes sense. How, you know, do you like your golf swing? Do you feel like, uh, you know,

[00:55:37] Dr. Joseph Derose: you know, I've only, I haven't taken loads of lessons over my life. Cause I've been playing for so long, a handful of lessons here and there. And just like I told you in peak, you have to practice, but practicing something is important. So you have to have a coach or somebody give you something to practice, but at the same time.

You don't, especially, you know, I'm like a two handicap. You don't want someone, um, reinventing your swing. You want them to change it and help it, right? Um, so that is important. But, but the thing about golf that I've always loved is I played other sports growing up competitively. Golf I only played for fun.

And as I moved up in my life golf has always been My escape right being on the golf course like going out at 5 30 at night after a horrible day and just walking and focusing on your surroundings and then like you said the strategy of where to hit a ball Is absolutely liberating to me. I am in another place when I do that And you know when you're really playing well You'll you'll hear it's a little different when you're goofing around and playing golf when you're playing competitive golf It's a totally different story because every single shot has to take your utmost concentration.

You're actually exhausted when you're done. But, um, you know, giving that focus to every single shot is, is an unbelievable challenge. And, uh, it's also a great challenge because you'll never do it perfectly every time. I don't care what you shoot, you can shoot well and every shot wasn't perfect. And that's why it's this continuous challenge.

So I like it. I've always liked it for the Relaxation portion of it. I do love it. And I like goofing around playing with my buddies, too. That's fun. Um, but I like the focus part of it the, you know, Really trying to be perfect on every shot on every putt, you know, you play

[00:57:22] Dr. Sam Rhee: Uh, some I've been playing more lately. Uh, I have joined uh, fantasy camp that, uh, where it is competitive for four or five days, and I've done that for the fa past couple years, and I hate being the. weak link, let's say on my team. And so I've been working on it, even though it is time consuming.

Let's just put it that way. When you really play a lot of golf, it is time consuming, but I will say this. Uh, I, I was just thinking about you 26 years ago and you now, and a lot hasn't changed, you enjoy life to the so much back then, and you still enjoy life. Like to the max now, it's really crazy to see, uh, how much.

You take pleasure in everything that you do. I think, uh, that would be like your piece of advice about enjoying what you do. Like you enjoy everything that you do. It's so obvious how much you love that. And I think when I was a junior, I could see that in, in terms of what you did, no matter how onerous or, or challenging the task is.

And I could see that now, um, you know, in the upper echelons of management or The most complicated case you do, like, you just love it. Like, you, you, you, uh, take so much out of it, and, uh, I hope everyone else around you, uh, continues to see that as well, because that's pretty cool.

[00:58:48] Dr. Joseph Derose: I appreciate that yeah, no, I mean I do I do have a lot of enthusiasm for things I do and that's the way You know life is fun for sure Hey, there's one other, uh, uh, one other story I'll tell you about sort of sports and, and surgery. So, you know, I remember, I remember this happening once, like I'm, I'm at some tournament or something.

And someone is like a five foot putt or someone's like, Hey, this is a lot of pressure. And I say to myself, you have no idea what pressure is, right? But there is something to it because when Tiger Woods used to step up to a 10 foot putt, He'd seen it go in a thousand times, right? When you and I go to the operating room, and we've done it a zillion times, there's no pressure.

We know what we're going to do, right? And if something happens, we know what we're gonna do next. And so that's where the top athletes are like surgeons in that they understand what the outcome is gonna be, and so there is no pressure, right? But for us, you don't necessarily know what the outcome may be in athletics.

Nonetheless, You always put it in perspective. That is not heart surgery. That's golf, right? Hey,

[00:59:58] Dr. Sam Rhee: a critical shot at a certain time is like me trying to do heart surgery every, I don't think that's really going to work out. Anyway, thank you so much, Joe. It's been awesome, and I wish you continued success. I really appreciate everything you shared today. It was so cool.

[01:00:20] Dr. Joseph Derose: thanks so much and good luck with the podcast. This is all great stuff. I'm going to listen to all of them and listen to the kind of things you're doing. It's great.

[01:00:26] Dr. Sam Rhee: Thank you so much, Joe.