Nightmares and Dreamscapes ... the match is coming

“I act like sh*t don't phase me, inside it drives me crazy, my insecurities could eat me alive.”
~Eminem

The match is coming. For all those involved, your emotions are probably all over the place. Your stomach is aching. You can’t sleep. I remember this time like yesterday. I just wanted to close my eyes and sleep until the day after match day. For me, it was like Nightmares and Dreamscapes. Welcome to my mind 2 weeks before the match.

This is the year

where hope fails you

The test subjects run the experiment

And the bastards you know is the hero you hate

But cohesion is possible if we try

There's no reason, there's no lesson, no time like the present

Tell me right now, what have you got to lose?

What have you got to lose, except your soul?

Who's with us?!

Slipknot (Pulse of the Maggots)

Please someone make the pain stop.

Why do we

Crucify ourselves

Every day I crucify myself

lf Nothing I do is good enough for you

Crucify myself Every day

And my heart is sick of being in chains

Tori Amos (Crucify)

Phone rings (RING, RING)

Mother mother can you hear me

I’m just calling to say hello

How’s the weather

how’s my father

am I lonely heavens no

Mother mother are listening

just a phone call to ease your mind

Life is perfect never better

distance making the heart grow blind

When you sent me off

to see the world

where you scared that

I might get hurt

Would I try a little tobacco

would I keep on hiking up my skirt

I’m hungry

I’m dirty

I’m losing my mind

Everything’s fine

I’m freezing

I’m starving

I’m bleeding death

Everything fine

Tracy Bonham (Mother Mother)

There are so many applicants that are better than me .... what if ....

Almost there ...... help ... make it stop

My end It justifies my means

All I have to do is delay

I'm given time to evade

The end of the road is my end

It justifies my means

All I have to do is delay

I haven't time to evade

THE END OF THE ROAD!

Slipknot (Before I forget)

...... Is that my name, my eyes .... I can't focus .... WHAT DOES IT SAY .....

May be your 2 weeks will be better than mine. Sleep well .....

“If you want a happy ending, that depends, of course, on where you stop your story.”

~Orson Welles

There is no crying in orthopaedics ... Do women really belong in orthopaedics?

"If you wait to do everything until you're sure it's right, you'll probably never do much of anything."
~Win Borden

Orthopaedics is such a male dominated sub-specialty. You walk into the orthopaedic resident's area, and you are likely to smell the testosterone. The adolescent jokes are endless. Gas and scratching is always funny. It is almost a fraternity atmosphere. So in comes the new era; in medical schools, the percentage of men to women is about equal . Women are making a move in high powered fields across business and medicine. So I ask, do women belong in orthopaedics.

When you look at the typical applicant to orthopaedic residencies, HE fits a mold. Usually, the applicant is a white, dark haired, about 5'8" to 6'2", male with a type A personality. He usually has had some involvement in sports, "an athlete." He is driven, some may say competitive. If you look at most residencies, they have a "type." And most of their residents fit it.

So, how can women make this specialty better? What do they bring? They are not strong enough. They are prone to crying. They are emotionally fragile. What can the fairer sex bring to this testosterone driven specialty?

Well, in my experience, most woman who choose areas that are not female friendly, tend to be of a little bit different personality type. I have seen it when I was in engineering as well as in medicine. The women who choose the surgical specialties tend to be extremely driven and thick skinned. They are still women mind you but the usually are more tolerant. They have to be or they won't survive.

Admit men and women are different. Woman bring a softer more cerebral side to surgery. They bring emotion sometimes absent in male surgeons. They bring patience and understanding. They bring something different. Most of the woman surgeons that I know fit into one of three basic molds.

1. The b*t*h - This female has very male traits. She is aggressive. She is dominant. She will tell you what to do and what was wrong in a heart beat. Usually disliked by the other woman, i.e. nurses, clerks, etc. who are below her. If she was a male, we probably wouldn't even question this because he is a surgeon, it is expected. But a dominant woman is considered a B*T*H.
2. The star - This is the female that stands above all others, both male and female. When you look her, you notice she is able to tow the line. She is able to control a service and get the respect of all. She understands men and works with our flaws. She never loses he femininity or "womanness." she is able to negotiate the delicate politics between her peers and those under her.
3. The crier - This is the female that cannot understand why the men act like men. They take everything personal. She lets her emotions get the best of her. Frequently, she is questioning herself and why other treat her in a certain way. She forgets the sure fact that boys will be boys.

I could probably categorize the male residents as well. These are just generalizations for those I have seen. There are probably more or mixtures of them all. These are just a few.

So do we need women in orthopaedics. I would argue yes. Regardless of what category they may or may not fit into, we need a change. Orthopaedics needs to be upgraded like a Microsoft© program. Orthopaedics needs less testosterone and the addition of some estrogen. So are we as a specialty ready, I don't know; but, the writing is on the wall and they are coming. So, all you rock star men get ready; bring some tissue and a Hugh Grant movie, and we'll all get along just fine.

"If we're growing, we're always going to be out of our comfort zone."

~John Maxwell

What gives me the right ....

“I have never met a man so ignorant that I couldn't learn something from him.”

~Galileo Galilei

I reread most of my posts several days after I post them. It is usually to check my thoughts and to see how pompous I sound. For the most part, I think the point I am trying to make is made. For me, I say a lot of things in jest and in the role of the devils advocate. As the great lyricist Eminem said, "sometimes the truth is said in jest." What I really want is for people to think about other's and re-examine their positions on certain topics. It is just to begin a dialog between people. I look at myself and ask, "what gives me the right to write about these things?" Well, I don't know. I do have strong opinions about somethings, but for the most part I am someone who is "on another level" as one of my residents put it. My thinking is not in line with the old guard or new guard, it is somewhere between. I try to see things from both sides and I can usually find valid points in both.

My ultimate desire is not to be famous or world renowned; it is not to be rich. My desire is to be a great educator. Someone who inspires others to develop their own thoughts and question other's thought. We tend to be so self involved about what our current positions are that we lack perspective. As a student, we see things as a student looking up; as an educator, we see things looking down. Maybe we should all come to the same level and look eye to eye. Maybe it should be more of a dialog than a lecture. But to do this, both student and educator need to meet half way.

I look at my teaching style now and wonder how to make it better. I draw from some of the great educator physicians in my past; as well as, some of my previous and current students. So those who read this and take offense to a topic or disagree with a point, I have done my job. I am not here to say what is right or wrong. I don't have the ultimate say, it is not a dictatorship. When someone writes a comment agreeing or disagreeing, I just smile; now we have a dialog.

“All truths are easy to understand once they are discovered; the point is to discover them.”

~Galileo Galilei

You are not in training be a resident ...

"Wisdom is not a product of schooling but of the lifelong attempt to acquire it."

~Albert Einstein

In my residency, we had an attending that was particularly hard on the younger residents. He was of the old guard. He was a yeller and a thrower. He struck fear in most of the residents and hatred in others. He was my mentor. My respect for him and understanding of his method developed over time and with some frustration. What I learned from him is that residents need to be pushed a little and encouraged in their development. Not that I agree with his tactics, but I do understand and fear can be a great motivator.

When I was a 3rd year (PGY-4) orthopaedic resident, for 2 weeks I was the acting chief of the service while the chief was on vacation. I still had the fear in me from when I had being yelled at, as a lower level resident, for not placing a spica cast on correctly, or couldn't get the locking cap on the CD instrumentation. He comes to the scrub sink as I scrub for a spine case and he asks me, "When do you start thinking?" I said to him, "I am not sure." I mean what else do you say to that. "I think all day and night, I worry about you yelling at me in front of the nurses and saying how I have no operative skill." In my mind, I am thinking, "When am I not thinking?" As I talked to him more, I began to understand his motives. I began to understand his question. What he wanted to know was, "when do begin to think like an orthopaedic surgeon? When do you stop thinking like a resident, and start treating patients as if you are treating them? When do you develop the skill of evaluating the patient, reviewing the studies, and come up with an exact plan for treatment?" My mentor's way of helping you to develop the necessary skills was to prevent you from making the mistake, mostly by fear. He described it as, "if every time you come around a corner you see a tiger, you stop going around that corner." I disagree with teaching by fear, but I understand its effectiveness.

In July, we will have a new batch of residents. They will come in bright eyed and eager to learn. They will begin their internship with fear of making a mistake. The first call night will be filled with doubt and insecurity. They will aspire to be better, to treat patients well, and to be good physicians. They will complete their internship and make their way to their intended specialties. Ours is orthopaedics, the best of course and most important of all. They will look to their peers and attendings and aspire to be more like or less like them, depending on their experience. Your ultimate goal in coming into orthopaedic residency is to become an orthopaedic surgeon. So why do so many residents act as if they will always be a resident?

Although my mentor taught by fear, he did not discriminate. He treated you according to your year. As a 1st year (PGY-2) orthopaedic year, he was relatively lenient on you. You did the floor work and simple cases. You didn't know enough to be dangerous. It was the 2nd year (PGY-3) that he gave the hardest time. He felt they were a problem. They had enough orthopaedic knowledge to treat most basic things and not enough to know when they were over their head. So, it was that resident that was his "whipping boy." Nothing could be done right. It was a hard year. My ego took a big beating. As a 3rd year (PGY-4), he started to ask you what you thought. What was your plan? And as a 4th year (PGY-5), he treated you more as a peer. He allowed your input in developing a treatment plan and follow-up care, with some guidance. This helps you to develop you thought process. As you developed more skill, he allowed you more freedom.

Today, I still remember that day and they impact that it made on my perception of my own resident education. So to this day, when a resident calls me or presents a patient in clinic, I ask, "so what is the impression and plan?" What I am looking for is a thought process, any thought process. It is better to have a wrong thought than no thought. That is why I am here, to correct that wrong thought. So, when you are speaking with your fellow residents about a case or discussing it with your attending, ask yourself, how are you thinking?

“The greatest barrier to success is the fear of failure.”

~Sven Goran Eriksson

Don't quit in February

“Build me a son, O Lord, who will be strong enough to know when he is weak, and brave enough to face himself when he is afraid, one who will be proud and unbending in honest defeat, and humble and gentle in victory.” ~Douglas MacArthur

I trained prior to the 80 hour work week. I remember my first week of orientation. All of the interns went through all of the initial paper work and getting acquainted with the hospital. It was a great week. We met all the previous year interns. Life was good. I was finally out of medical school; I could finally officially call myself doctor. It was all good until the evening prior to our official first day. We went into a room and the previous years interns came into the room with the new chief surgery residents. We had been all well rested and most of us tanned from our month of relaxing and celebrating our graduation from medical school and matching into our residency program. We watched the previous years interns walk to the front of the room. They were all pale from the lack of sun; black circles were under their eyes. They looked tired. They proceeded to go through what needed to be done, what a normal day was like, how not to get into trouble, some basic survival tactics. But, there was only one thing that stuck out in my mind. It was this one statement, "Don't quit in February." That scared me, as well as many of the other baby faced new medical grads, half to death.

It was a tough year. There were months of every other night call. Times were time I took days of in house call in a row to get a full weekend off. It was hard. We could sleep anywhere. My wife still teases me and my friends about it today. She still tells people about the time my friends and I were all sleeping sitting up in a restaurant; or the time I was answering the alarm clock instead of the phone. At the time, I thought it was awful. When I look back at that period in my life, it was one of the best years in my life. My fellow interns are still some of my best friends to this day. Regardless of our specialty, general surgery, neurosurgery, urology, orthopaedics, ENT, and plastics, we all had gone through the same aches and pains, and it made us closer.

In the military, there are values that instilled into each soldier. These are things that are driven into every soldier in basic training and important ultimately for the development of that soldier into a leader. They are put though grueling tasks made to do many things that most of which seems senseless. But, over time, they develop a sense of:

• Loyalty - a faithful adherence to a person or unit
• Duty - a moral obligation to accomplish all assigned or implied tasks to the fullest of you ability
• Respect - treating other with consideration and honor
  
• Selfless-service - placing your personal duty before your personal desires
• Honor - being honest with one's self and being truthful and sincere in all of our actions
• Integrity - adhering to a code of moral and ethical principles
• Personal Courage - overcoming fears while doing what is right even if unpopular

And this is what my internship was like, boot camp. In the end, I would and will do anything for my classmate and they would for me.

The 80 hour work week has change the attitude of the "New breed" of resident. It has created shift workers. Once their time is up, they are gone. Lost is the sense of loyalty, duty, and selfless-service. Character traits that are I feel are essential when taking care of patients. Getting the work done no matter what it takes and not leaving it up to others. It is your patient, complete the task. Today's resident is more likely to pass over a case that they admitted to go home rather than stay to see the interesting case. It is not their fault; and I am in favor of the work hour restrictions. It is the implementation with which I have a problem. It has helped change the face of American residency as did the insurance companies rules on number of hospitals days allowed. But, remember the back lash from the woman forced out less than 24 hours after delivering their baby?

Residents need time for study. They need rest. They need a life. They need camaraderie. The question I have now is how do we teach them to complete the care of patients and not hand it off? There is no one that scrubs me out of a case. How can we train to have more stamina for the long days? When you are in practice, if you are up all night, will you cancel you next days cases or clinic? These are questions I think many people have. When the 80 hour/weekers graduate and come to your practice, will they leave work left undone because it's "not their shift?" Or, will they step up and do what is best for the team and group? This will be seen in the coming years. For now, I will keep working on trying to instill the values that were given to me in that year of internship and my army training; and I will hope some of that rubs off on our new physicians.

“The trick is in what one emphasizes. We either make ourselves miserable, or we make ourselves happy. The amount of work is the same." ~Carlos Castaneda

Stay off the pedestal because the fall hurts

“The self-confidence of the warrior is not the self-confidence of the average man. The average man seeks certainty in the eyes of the onlooker and calls that self-confidence. The warrior seeks impeccability in his own eyes and calls that humbleness. The average man is hooked to his fellow men, while the warrior is hooked only to infinity.”
~ Carlos Castaneda

One of my favorite things to see is the maturation of young surgeons. Watching the 26 year old intern who is unsure of his/herself, blossom into a confident surgeon is like watching you kids grow up. It almost makes you want to cry. With growth come growing pains. Like teach you teenager how to drive, the temptation to take the wheel is great; and as an educator, there is a fine balance between allowing for the growth of surgical skill and creating more grey hair.

Residency is filled with triumphs and failures. Perfect reduction of a fracture on first attempt or getting the guide pin in just perfect position, these are moments that make you fell like you are the "man" or "woman." With these triumphs, come a lot of failures and disappointments. The humbling experience of your chief resident or attending taking the knife out of your hands because it is just not going your way is probably one of the must ego deflating things in residency. You may hear in the background, "first day with your new hands," or "your hands are moving, but nothing is happening." As the years go on, most residence experience more positive experiences than negative. They begin to develop their own style.

As the residents progress in their years of training, the young surgeons become more and more confident. The trick is not to become over confident and overstep your skill level or skill set. It is important to know your own strengths and weaknesses. This self-awareness will make you over all a better surgeon. In a mostly male dominated specialty, we naturally know how to do it; we don't need help, it is a sign of weakness. Unfortunately, the patient in the end may suffer. It is important to know when to ask for help.

Some people are more self-aware than others. Competing for years in sports and in education, it is hard to let that part of your personality go. We are use to being the best. It is that confidence that has gotten to this point. Who would go to a surgeon who was unsure of him/her self? There is a difference from being confident and cocky. Young surgeons tend to get a little cocky after they have several good experiences. It may have to do with the young male mentality. These are usually residents somewhere between the 2nd and 3rd orthopaedic year. They usually overstep their level or skills set, and are quickly humbled. It is not until they are chiefs do they realize that they won't be perfect every time. Those who have operated over many years understand you will have good days and bad days. Hopefully, you will have more good than bad.

So, I will put out a plea to all those in training currently; stay off of the pedestal, remain teachable / trainable. You will never be the BEST at everything; there will always be someone better at one thing or another. Stay open to new things and opinions; this in the end will make you a better physician and surgeon.

“Intellectual growth should commence at birth and cease only at death”
~Albert Einstein

The selection is hard when it comes to the last 24 ...

When you start getting down to the last few, it gets really hard to pick those last few. Some are it's about untapped talent, others a great voice, and still others there is something special, the it factor. You may disagree with some of that Randy, Simon, and Paula choices, but they do have experience. They see something. Sometimes I disagree and others I have to agree. They have been choosing contestants for years and know what works.

So many residency applicants and even residents what to know what we use to select candidates. Rumors spread from person to person. There are whispers about USMLE cutoffs, AOA, and clinical grades. "TELL ME WHAT SCORE I NEED TO GET INTO ORTHOPAEDIC SURGERY," they scream. Well I can tell you one thing, I don't know. You may say, "well then what good are you, someone has to know." Well, maybe there are programs that do have cutoffs, but for my program, not so much. What I can tell you is that if you have a below average score, the likelihood of you getting into any competitive residency is less than if you have a high score. That's common sense isn't it. So then what is important? EVERYTHING.

Everything is important. We are interviewing people with names, not 240 or 205. So what about these "people" is important. I personally think there are several things we have to look at an applicant.

USMLE
Ok, yes I said it, the F**K*N USMLE. I think this is one of the things we most look at to help us evaluate how you do relative to you peers nationally. But, that being said, I don't feel it should be done by the strict number. I think it should be used like a blood pressure or cholesterol. There are numbers that are low that may put you on a little medication, but won't kill you; and then there are others that make you start pulling out the defibrillator.

Now, how can you salvage a bad score. It is hard to do, but possible. If you have a bad score, you need to take step II early as possible and rock it. This will show us that maybe your lower score was a fluke. Most people tend to score around the same score each time, within 10 points.

CLINICAL GRADES
I think this is more important as a measure of you abilities as a physician. Now you ask, "what do I need do? What grades do I need to get?" The best grades you can get.

Now clinical grades are more like trying to compare college football teams from different conferences. Some are strong conferences (SEC, Big Ten), and others weak (WAC). So it is difficult to interpret their competition. The assumption is made that the stronger conferences get more "quality wins" than the weaker. But, if you are undefeated, maybe you should go to the championship game. So, regardless of were you are, honors is better than pass. If you are in a very competitive school (proven but the %honors and school), a high pass may be just as good. If you are Boise State, maybe you will have your chance.

The most important honors are those in Surgery and Orthopaedics. I can tell you if you DO NOT honor orthopaedics, we will question your application.

MEDICAL SCHOOL
This is your conference. Presumably, you have stronger competition. So you get points for Doing well in undergrad and getting into a good school.


RESEARCH
Research is something that more academic programs look at to see if you have aptitude to do research. The most important research is published or presented research. I see a lot of applications that have research on the application, but it was a project done over several months in their 3 year of medical school. That appears as a desperate effort to pad your application. So that time is better spent working on another area of your application. Research that stands out is done over time (meaning may be a year or two), started early in medical school, that results in a publication, presentation, or poster. But, if you are interested in research please pursue it.

RECOMMENDATIONS
These tend to be more important in the interview. It helps us to see how others view you. If we know the person writing the letter, it is a plus.

AOA
Varies from school to school and is more tied to clinical grades.

LEADERSHIP POSITIONS
Elected leadership positions in college and medical school are helpful at assessing your personality and ability to be like by others. It doe not say if you are a good or bad leader, just that you may have the aptitude and/or the drive to lead. That says a lot about charisma.

THE OTHER (IT FACTOR)
Do you have it? Well, this is something I can't quantify. It may be you had a previous job, or some special volunteer position. May be a pro athlete or actor. May be you organized a mission to Haiti. It is something that makes you different from everyone else, and it's not because you or a family member have an orthopaedic surgery, or because you played sports, or because you are a team player. It is, hmmm, I i don't know, but i know it when I see IT.

IF WE KNOW YOU
This is easy. A known is ALWAYS better than a unknown. That is why people like to have rotators (from inside or out , because it is like a month long interview. It allows us to see your personality, the good and bad traits, your work ethic, and you knowledge base. It also allow us to see if you fit in with the other residents.

So, those are most of the factors. Not one thing is going to get you into a orthopaedic spot. Not one specific number is going to get you in to a program. But, the better you do in all of the categories, the better chance you have.

Simon Cowell is my boy ....

Music is wonderful, wouldn't you say. Songs inspire; bring back past memories. Both tragedy and joy can be tied to one song. The same lyrics can have separate meaning to different people. Change the vocalist and a crowd favorite can become a dud. American Idol is great, watching all of these hopefuls, and some freaks, get up there and sing their hearts out. Sometimes causing pain to my ears. We love watching people on both ends of the spectrum, the highs and the lows. And Simon Cowell is the driving force behind the whole thing. It is his British brashness and true honesty, sometimes may be a little mean, that we thrive on. I like him because he has the balls to say you suck.

In the United States, over the past say 15 years, we have developed an environment where everyone does well. We all get good grades. Score is not kept in some of the kids sports. Everyone gets to play. Everyone gets a trophy. We see it even in college/university today. It is extremely hard to fail someone. If the professor does, then they have to explain themselves and the student will dispute it. You have to have a really good reason to give a failing grade. If you look at grades, B has become the average. It kinda defeats the purpose of the grading system if the average grade is above average. How are we supposed to differentiate people? Who is better? That is why I think America loves American Idol, at least to some extent there is some brutal honesty. "Honey, it just wasn't good."

Tool gives me inspiration and drives me, with the crescendo and decrescendo in the music and the complex arrangement of music and lyrics. They say Maynard is a genius, so much can be implied from his lyrics

"Something has to change.
Un-deniable dilemma.
Boredom's not a burden
Anyone should bear.

Constant over stimu-lation numbs me
and I wouldn't have
It any other way.

It's not enough.
I need more.
Nothing seems to satisfy.
I don't want it.
I just need it.
To feel, to breathe, to know I'm alive."

- TOOL (Stinkfist)

I look at the medical students coming through on service and those coming to interview. Most are of this generation. Most probably played soccer growing up. With their Blackberry's and text pagers, they are linked to the world. They have always been told they were great, like so many idol contestants. They come with their good scores and nice university pedigree. For many years they wee told what grades and scores the needed to get in to college/medical school. Now, they try to apply the same principles to getting into residence. "So, tell me what scores or grades do I need?"

Now, these idol contestants are applying for competitive residencies, like orthopeadics, an they are being evaluated by Simon Cowell. The application is reviewed and contestants are chosen. Some contestants are dismissed as tone deaf, while others given consideration. If everything is the same between one application and another, why one and not the other? Well, probably a majority of the time, after all is said and done, it comes down to a personal preference of the person reviewing the application, like a taste in music. There are things we are drawn to in an application, as we are to a vocalist or group. Personal experience of previous medical students, residents, and physician/surgeon, helps us to find characteristics or traits about an applicant that we like. Sometimes it is all thumbs up and other times is all thumbs down, and sometimes Randy, Paula, and Simon come to a 2 to 3 vote.

In the end, there are some good singers and some bad. Some great singers with a bad look; and some bad singers with a good look. We see good scores with bad applications and visa versa. So when you get rejections, don't take it personal; and when you get the interviews, be thankful. Try not to read into it all. It is not personal, just business.

I watched Greys anatomy .... Let's Operate

With shows like Grey's Anatomy glorifying the life of surgical residents, I have a feeling that the number of students who choose to go into the surgical subspecialties will increase. It will probably be like what ER did for emergency medicine and CSI did for criminalists. Not that surgery has ever needed to be promoted. It has always been seen as a great specialty but a poor life style. With the 80hr work week restrictions, it has been less intimidating from the life style stand point, and with shows like Grey's Anatomy and Dr. 90210, it is becoming more high profile. I predict the numbers of applicants will increase. In orthopaedics, we really don't need an increase in applications.

Now, with our TV knowledge of the surgical residency, an intern may expect to first assist on a complicated cardiac procedure, or in my realm, a complex spine procedure, such as a pedicle subtraction osteotomy. As the intern first assist, when my hands start to tremble, you will take over because you have read the book and looked at the pictures. Au contraire, mon frair. The development of surgical skill can not be learned like the Kreb's cycle. Surgical decision making can not always be fit into an algorithm. It is more complex than that, just because I slept at a Holiday Inn. Becoming a surgeon is a process. It takes time to develop. Your vision gets better, like a running back who can see the holes in the defense. Some develop quicker than others, some are more skilled and some less skilled. Let's talk about surgical skills development.

In an article by one of my mentors, Dr. Robert Hensinger, he describes the development of masters. In his editorial, "The Making of Masters: Some Assembly Required." (SPINE 2003; 28(18): 2046-2048), he describes the different stages of surgical development.

THE NOVICE LEARNER

At this level, the learner is given rules that define the actions. The learner is told precisely how the procedure is to be performed. It is the exact formula to attain a specific goal. Unfortunately, the formula cannot predict all the variables for each instance, patient or procedure. This level requires a great deal of memorization. Because of this, the learner never reaches a level of incorporation of information.

THE ADVANCE BEGINNER

At this level, the learner gains experience in coping with real situations and patients. The person begins to understand the problems that can occur in clinical situations. The learner begins to notice subtle variations in outcomes that occur within the same diagnostic theme. It is at this stage that the learner begins to organize the information within a frame reference. As the student incorporates more principles and rules, the teacher assumes the role as coach, evaluating and providing feedback.

This is a rule-based phase. Because, algorithms become longer and more complex, the learner can become overloaded and experience burnout.

THE COMPETENT

The Competent is the level which we as educators would like to see our learners reach prior to you leaving our supervision.

This is the level when performance and expectations can be overwhelming. In prior levels, when rules didn't work, the learner rationalizes that maybe they have not been given enough or adequate rules. This is when the learner may wonder "how can this be mastered?"

Competence is more than rules based; It is problem solving. It is the ability to manage ambiguity and tolerate uncertainty, making decisions with little information. Competent physicians sort better and can compare patient patterns. They transform knowledge to fit the task. The learner becomes accountable for their actions and begins to take some responsibility for outcomes. They become emotionally invested and begin to develop a sense of remorse for their mistakes.

THE PROFICIENT

At this level, there is an incremental incorporation of technical skills, rules, and principles. As experience is assimilated, the rules become subliminal. Answers become intuitive. Certain findings jump out as important without the learner standing back and going through the tiresome mental process to select a plan.

Due to past experiences, the learner is able to select one of several possible options based on relating the patient's presentation to others. With this "pattern recognition", the learner needs fewer clues to develop a plan. This specific trait of "pattern recognition" is one of the most important trains in determining surgical excellence.

THE EXPERT

This is accomplished performer, the skillful practitioner. The expert sees what to do and has an immediate intuitive response. Envisioning becomes a part of the practitioners’ behavior. The ability to represent mentally the physical environment and the movement to be performed are major determinants of surgical technical performance. Specific strategies associated with this stage include imagery and mental practice. Aristotle noted that we acquire our craft from the master through observation and experience. In problem solving, experts draw on many strategies, while the student uses the same cognitive strategy.

THE MASTER

The master has style. The master is a truly unique individual. The master loves surprises and challenges. There is a danger that the apprentice will merely become a clone of the master. Musicians have learned from this experience that those who follow one master are not as creative of a performer. Professors in the School of Music encourage association with several masters, taking bits of style from each to develop a completely unique performance.

Surgical mastery—the ability to gain knowledge, although necessary—is not sufficient to develop superior operative skill. Pure psychomotor skills and manual dexterity are not the major components that distinguish the outstanding surgical performance from the mediocre. More important are visual–spatial problem-solving abilities, for example, the capacity to rapidly analyze and organize perceptions based on multisensory information. They have the ability to distinguish essential from nonessential detail even when the signal-to-noise ratio is high. This appears to be most crucial to superior technique and correlates better with operative skill than board scores. It is essential that the surgeon manage anxiety and tolerate stress.

So, I guess we are not all trying to be masters, but our development as surgeons does go through various stages. Those who are in training or have completed training know the point where all of the sudden, they began to see clearly. We all remember when the process of seeing patients in clinic and making a plan became easier. The mental work became less. We became quicker or more efficient. Becoming a surgeon is a process, it takes time. It is not innate. Sometimes we want to force the situation before we are ready. Be patient young Padawan, your time will come.

My Rank List

So, interview season has come to an end. Most of you who are in the process of applying for residency are making your rank list. You may have had X number of interviews, liked Y number of programs, and have a list in your head of who you think is the best for you. So, how do you make your rank list? This is very difficult as you probably already know. So, this is my opinion. I think you really need to understand yourself. You need to look at your past and look at what has worked for you. I feel it is more of an introspective process.

Now, I do understand that because orthopaedics is very competitive and so many don't have 20 programs on their list. When you are making your list, you may want to take way all of the bias that you may have based on "rankings", what people have said, and what the different forums have said. You need to try to look at these programs in a vacuum that is influenced only by your own experience.

Things that may become important are : (these are not in any particular order)
location

1. learning environment
2. resident "personality"
3. program "personality"
4. research opportunity
5. faculty / resident relationship
6. operative experience
7. program balance

So, let's look at each of these an how they relate to you and your personality.

LOCATION

I think location is one very important factor. Now, most of the ambitious students always want to go to the best program regardless of location. I am gunner hear me roar.

Well, location does really become important in you underlying happiness. Yes, I said it, your HAPPINESS. Look at what size cities and locations in the country may you happy. Are you small town or big city, east coast or west coast, northern or southern? These things should be taken into consideration. You need to fit into your environment outside of work as well as inside.

LEARNING ENVIRONMENT
When you look at the department, what is the learning environment? Do they have a schedule of lectures? Who gives the lectures? How often are the lectures? Do they teach to the OITE or Boards? What is the board pass rate?

I bring this up because there are some programs that have a great learning environment. There are scheduled lectures, the faculty (all) is involved, the residents give lectures with faculty assistance and the attendance lectures is a requirement. There are other programs that lectures are given mostly by residents (lectures passed from resident to resident), there is very little faculty input, and attendance is sketchy. A lot of programs like to promote the OITE as a marker of how good the programs didactic schedule is. I would beg to differ. In some instances, the program trains its residents for the exam. Be careful, I do feel it is important; but by itself, it means nothing. I do feel the board pass rate is much more important.

RESIDENT PERSONALITY
This is the gut feeling part of the rank list. Will you get along with you peers? I call it the "I could sit down and have a beer with this person" factor. Does the general resident personality fit yours?

PROGRAM PERSONALITY
Every program has a personality, an underlying undercurrent to the program. This is usually dictated by the program chairman/residency director.

Is it a "malignant" program or more "benign"? This is the conversations with other applicants and residents from the program come into play. Can you tolerate the malignant programs? Do you respond to that type of instruction? Can you flourish in a more benign environment, or do you need more encouragement?

RESEARCH OPPORTUNITY
This is something for those who are looking for a future in the academic arena. Are there opportunities for research? How many publications do the residents (not faculty) put out each year? If you want to move up in the academic world and want a high profile fellowship that will set you up for increasing you input in the AAOS etc., then this will be an important factor; if you are going into private practice, probably not.

FACULTY / RESIDENT RELATIONSHIP
This is like the program personality, but I feel it is important to your underlying happiness. How do the faculty and residents interact. Is there supervision with the opportunity for you own growth and input or is it a dictatorship? Do you operate or observe? Do the faculty welcome questions or are not available for questions? As a chief resident, do you have the opportunity to make some decisions with supervision; or as an intern, you make the decisions without supervision?

I feel this is extremely important. There need to be supervision or guidance for the residence growth. If no supervision is given early, you will develop bad habits, like learning golf on your own. The faculty and upper level residents need to help the lower level residents develop good habits to prevent errors. On the other hand, there needs to be a point where you make a decision. This is a process that needs to be fostered within the program helping you mature from a grunt to a chief.

OPERATIVE EXPERIENCE
This is something that most people applying look at an relish. You must beware of programs that operate a lot early. Most applicants love this in a program. But, remember this YOU DON'T COME INTO RESIDENCY KNOWING HOW TO OPERATE. So, operating a lot early is a double edge sword. Yes, you will become more proficient earlier; but, the most important part of the outcomes in operations is proper patient selection. So, operation early is great, but should be offset with a lot of supervision and appropriate clinic experience.

PROGRAM BALANCE
Is the program balanced? Well, most programs are not. They tend to be heavy in some areas and weak in others. So, how do you decide? The question then is, what is the program doing to make the program more balanced? Have they added a rotation at another hospital? Are they adding faculty? These are things to look for in a program.

Another indication of how a program is doing is looking at what fellowships are people doing and why they have chosen that specialty. If they are going into a fellowship because of an interest, this is not a negative and may indicate that this is an area influenced by the faculty (people tend to like areas where they have had a good experience). If they go into an area because they feel weak in that area, this is a negative.

In the end, making your rank list comes down to you gut feeling. But, I think you should look at number of factors that will make you happy in the end. The happier you are, the more likely you will be successful in you chosen field.

The residents and medical students now adays are soft .....

5am this morning .... I am out running ... 8 mile run ... training ... marathon training ... it's been cold outside ... today, cold and a fresh coat of snow ... the numbers of runners are far fewer ... several people walking dogs ... very few footprints in the snow .... I run past a older man (grey mustache and hair) ... I've seen him before ... We are the dedicated few ... continuing our training regardless of the weather ... like the postal service .... rain or shine, we will be there .... we smile at each other with a kind of understanding not understood by those still in bed ....

I look at the young doctors coming into medicine now a days and their perception of what is expected of them and what they are willing to do is less. Will they run in a storm. Will they stay until all the work is done or will they say, " my shift is done" and leave.

Times are changing, but the patients are not. The amount of work that is needed to be done does not. Residency programs are now dealing with how do we adapt to the 80hr work week. It has become difficult for most programs to accommodate the restrictions. A number of things within residencies have changed to adapt to the changing hour restrictions. As programs become more accustom to working within the restrictions, so do the young physicians. They become more likely to schedule those hair appointments during the day (4:30pm or so) etc. The medical students leave without even checking out. I say strange. This is a definite change from when I was a medical student or resident. The expectation is different.

You may say, "Well, it is a different time and place. We don't need to do every other night call or stay in the hospital 2 days straight to be a good physician." And I would say, "You are exactly right." I do not think that you should spend countless hours in the hospital doing nothing. I would agree that more time spent reading and not doing busy work is probably better in the long haul. Andrew Palmer, MD, former president of the American society for Surgery of the Hand, made an opening address several years ago making a plea to many young physicians to find other interests outside of medicine. He felt that after many years dedicating his life to medicine, researching, operating, and teaching, he learned that there is a need to develop other interests. A need to develop yourself without medicine. So, I do feel that this is an important.

The problem we have now is the same problem that you get with unions. Yes, being formed is protective, but a certain mentality develops. The mentality developing now is that of a sense of entitlement. A sense that menial work is beneath them and that they should only do meaningful things. They don't need to prove themselves before we let them make decisions or make incisions.

Some may read this and say, "he is full of it. I am not like that." Well, not now, but there is a changing mentality. We had a visiting lecturer from the UK who gave us a lecture of the system in Britain. He was describing their work hour restrictions and how they have adapted. They are now down to, I think, 48 hrs a week. He says now they have more residents, to cover the time; the number of "hand off" errors have increased; and the operative case number is dropping. He reported to us when the restrictions began, the residents there said, "we will stay, regardless of the restrictions." Now, when time is up they just leave, regardless if they are in the middle of a case or in clinic, time is up and they are gone.

This mentality will creep slowly into the mentality of most as it has done in the auto industry. I fear the development of shift workers. I say that the medical students and residents are weak to incite anger in you. I want you to prove me wrong. Prove to me, yourself, that you have the fortitude to weather the storm, the cold, and the snow. Maybe one day when I am old and grey I will see you and we will smile together with an unspoken understanding.

The rank list - a scientific process?

I sit here in my office thinking about the resident applicants that I am about to interview tomorrow, and I realize that this really is not a very scientific process. We have to go through and interview a number of applicants. Everyone sits down in a room and goes back and forth and tried to remember the people form weeks ago. We go back and forth who we like and who we didn't like. I actually think placing people at the bottom is the easiest part of the whole process. Those people that give you the willies are easy to spot, and it is usually a consensus thumbs down. The middle section is extremely difficult, and the top, sometimes, even more difficult.

At our institution, we review all of the applications to select those who we will interview. We split them into 2 piles, and 2 faculty members review half and the other 2 faculty members review the other half. Then we rank the applicants from 1 to whatever. Unlike some institutions, we actually read the applications first and offer interviews based on what we see. Now that is not very scientific. There is no exact formula; no cutoff by board scores. It comes from a gut feeling. Now understand that we don't have 500 applicants to review. We have a 6 year program, which deters some from applying. Most large programs and programs in more desirable cities have a larger number of applicants and therefore use some way of "screening". For most, the USMLE score is probably use in some way shape or form (e.g. cutoff). Smaller programs, like ours, are more likely to look at other factors like where you are from, the school you attend, your aspirations, where you rotated for AI's. These "other" factors come into play.

I sit here trying to think of what factors I am looking for once we have selected you for an interview. What makes me want to choose you? I guess it comes down to a number of things. We are all shaped by our own experiences. We tend to be drawn to things for different reasons. May be it is your alma mater; or may be we know the person who wrote your recommendation; or may be your personal statement brought to light something that is not evident in you application, something that is unique to you. The interview for most is a snapshot of who you are. I guess for me, I can't speak for anyone else, it is a gut feeling. As an attending, I have to trust you, I need to like you, I need to know that you will be a good representative of me to my patients, as well as, a good representative of our program. So we are shaped by our experiences. Bad previous residents or experiences may cloud our judgment of you (not something you can prepare for). If you come unprepared to the interview (don't know your CV or research, don't know about the program, and don’t have answers to the simple questions like why you are going into orthopaedics), I wonder is this how you will be when you enter the program. So, I guess what I would advise be yourself, know who you are, know your strengths and weaknesses, and some how bring that to the interviewers attention. You need to be able to be your own spin doctor.

So, needless to say the whole rank list comes basically out of some gut feelings. People that make us feel like you will be a good representative of our program. I personally feel that the people that I help train are somewhat a representative of me and our program. When they go onto fellowship, into practice, and present at meetings, I want to be like a proud parent and say that was one of ours.