“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Saturday, March 31, 2007

Training ... hey where is my cheese?

“There is nothing wrong with change, if it is in the right direction.”
~Winston Churchill

Every morning I wake up and I have the same routine. Alarm rings at 430 am, I put on my running shoes; I make my cereal and cup of coffee; I check my email; and then I set off for another run. This is what I do. I am in training. I don't think I am ever not training for something. Every morning I wake up, I wonder why I am doing it. I have nothing to prove. But, something drives me to be better, to run faster.

I find that endurance training is very much like residency training. There is a lot of time placed into doing tasks that seem not to matter. Long shifts and busy work seem to be without use. How will this train you to be a better surgeon? Discharging patients and giving excuses for work and school, these are social work tasks, I am a surgeon, this is below me.

Each week, I have a set mileage goal. It is on my schedule. Short (4-5 mile) runs for speed; medium runs (7-10 mile) at tempo pace; and the long runs (14-22 mile) for endurance. All of these runs serve a purpose in completing the ultimate goal of finishing a race and/or improving on a previous time. There are many different ways of preparing yourself for an endurance race, such as a marathon. There are many books to read and philosophies to follow. There are also different goals that people have. Many years ago, people trained intensely, many running over 100 miles a week. Over time, the training elite have realized that that is not necessarily important and alternate training schedules have come out. Rest and diet have become a key component of optimal training for the endurance athlete. Mileage goals and speed of training has changed; cross training implemented. Most people now believe that depending on you goals, high mileage (total weekly) breaks you down more than builds you up.

Residency is endurance training and the 80 hour work week a philosophy change. The training elites, the attending staff, will have to adjust to the changes in philosophy. There will of course be many who will resist. Of course for many years, high hours where seen as a rite of passage, a test of you character, and necessity for your growth as a surgeon. The truth is that it is probably not necessary for overall growth of a surgeon. The system does need to become more efficient and more streamline. Change is painful.

Many of the old guard in medicine are asking, "who moved my cheese?" Many are like Hem, they do not want to change; and others are like Haw, somewhat resistant to change, but once they can see that change is needed. People like Haw realize that the change is better and that with the change there is growth.

So will the change be a success? I think it will. I think hospitals will become more streamline and efficient. More support staff will be present to assist in some of the busy work. This takes time. It is a large systemic change. Like increasing a patients potassium, we can't just push the medication. It has to be dripped in slowly so that the body can adjust. As the system adjusts, so must the training physician. Like the marathoner, although you don't have to do 100 mile weeks, you still must put in the miles, otherwise you will not complete the race. Consistency is one of the keys to successful training. So every morning, like it or not, the alarm rings; I put on my running shoes; I make my cereal and cup of coffee; I check my email; and then I set off for another run.

“What you leave behind is not what is engraved in stone monuments, but what is woven into the lives of others.”


Tuesday, March 27, 2007

Why do I have to be an @ss&*!# ....

"God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference. "

~The Serenity Prayer

Sometimes this is all I can say to prevent me from being one of those yelling, cursing surgeons. Why are they testing me? Why does it have to be so hard? I fill out the booking sheet. I speak with the family at length about what is going to be done. I speak with the scrub people the week prior. I speak with the equipment rep to make sure all of the equipment is going to be present. So why is everyday like ground hogs day?

I would like to say that this is an uncommon problem, but it is not. At every hospital, in medical school, residency, fellowship, and now in practice, I have encountered the same things. You would think if you do similar cases and the same people are there, they would stop asking you what suture you want. This is why people say, "we do it the same way everytime." I don't, but I wish I could say it.

Everytime I am in the OR, it is like we have never done the case before. Nurse says, "Doctor would you like the thingamodo, or the hickamagig?" I say, "well nurse, I have never used that before, so why would you ask?" "Well that is the way doctor soandso does it." (REDFACE)

I just want to come to work and things to run smoothly. No b!#ching, no complaining, JUST GIVE ME WHAT I ASK FOR D@M!T.

Now I feel better. Thanks for listening.

“Each one has to find his peace from within. And peace to be real must be unaffected by outside circumstances.”

~Mahatma Gandhi

Monday, March 26, 2007

I guess it is all about perspective

“You have your way. I have my way. As for the right way, the correct way, and the only way, it does not exist.”

~ Friedrich Nietzsche

Over the last week or so, I have been getting acquainted with a number of other bloggers. Seeing what topics are being discussed and what comments are being made. The list seemed endless. I realized that there are various other opinions, duh. These other opinions are somewhat skewed based on the person's perspective. Where they are; where they have been; and where they are going. We all have a different perspective, and of course my perspective is more right than yours, because I have more justification.

Today, I had the opportunity to speak with a physician from Uganda. He was a spine surgeon who was here to observe us, to see a few cases, and attend a course. It was a little slow in my clinic, so I asked him how things ran in his country? How was the residency run? How did his practice run? He began to discuss the basics of his hospital and what types of cases he sees. His practice was totally different than your typical American spine surgeon, all trauma and infection (mostly TB). His approach was different, usually delayed because the families had to get money for the instrumentation. He explained that the residency structure was also different. It was set up more like the UK system. After A levels, students went to medical school for 5 years, did a 1 year internship, worked for 2 years or more in local hospital, and then started residency. He explained residency was 4 years, and that there was really no supervision at night. Residents would do cases unsupervised at night, unless it was an extremely complicated case, then a staff surgeon may be called. He is amazed at some of the things we are capable if doing. He thought most of our complaints were; well, let just be thankful for what we have.

As an attending, sometimes I do forget the perils of being a residents. The money issues and abuses from the medical staff, other services, are may times forgotten. As an attending, we are kind of immune to some of the resident issues. We have more power, so we think. We have control over our time (in some respects), we have some control over the patients we will see and the number of cases we do. There is some sense of control. But, then why can't I get the insurance companies to pay? Why do I have more paperwork day in, day out? Why am stressed out over patients, cases, teaching? How can the hospital tell me what medications or instrumentation I can and can't use? Damn, I thought I was in control.

As a resident, the perception is that we are always out to get you. People are always trying to shit on you, take advantage, and abuse you. You get paid little and respected less. No one works harder than th resident, and those other residents are always getting out of work.

As a patient, the perception is that the physician makes a lot of money. "They are always drinking coffee and making me wait. " "Even if the physician is wrong, his colleagues will cover for him/her." "They like to use big words to confuse use, why can't the just use regular lay terms."

As nurse, the physicians always talk down to us. "I have been a nurse for 10 years and that resident graduated last month, what does he know?" "They don't spend anytime with the patients and don't really have the patients interest in mind." "I am the patient protector."

There are so many different perspectives. Is any one perspective more right than the other? Hmm, of course I would tell you that my perspective is ultimately the right perspective to view everything. Truth is that we are all right from our own perspective. The most important thing is that us appreciate that the difference exists. When you are complaining about how bad it may be, remember there is always something or someone worse.

“Everything that irritates us about others can lead us to an understanding of ourselves.”

~Carl Gustav Jung

Wednesday, March 21, 2007

AFI ... So, I started running marathons ....

“Success is not final, failure is not fatal: it is the courage to continue that counts.”
~Winston Churchill

There is a fire inside (AFI) of me that I can not stop. I don't know when it started. Maybe it was when I was little and I was smaller than most of my friends or maybe it was when my dad said I wasn't going to be good at something. I really can put my finger on it. Whatever it was that started it really doesn't matter; what matters is that that fire still exists to this day, and I don't ever think I want it to stop. You may ask, "what is this fire?" AFI is a burning desire inside of you to do SOMETHING. It is to be driven to complete a task or feet, to compete, to improve.

For me, it was definitely there in high school. I was always looking for the next fix. A task to complete. Sports, school events/clubs/committes, and music, I was involved in them all. What My reward, college. In college, I gave up sports for my son, work, and completing school. My reward, medical school. Feed the beast and it grows. You get the picture. I always had an end, a reward, somthing I was working towards. Now, end game, I am an orthopaedic surgeon. How do you stop the fire from burning? Do I want it to stop?

I started to run marathons after a dare to run a half marathon. Now my fire has been satisfied, for now.

"Sacrifice Theory"

I offer grace, I offer blood.
I offer everything till my heart is crystal clear.
I offer grace,I offer blood.
I offer everything till my heart is crystal clear.

Let me taste the life flow.
Do you want to feel the warmth?
To taste the life, to taste the lifeI want to taste the life.
To taste the life, to taste the life flow.
Go, Go, Woah, Go


When I am looking at my residents and resident applicants, I think to myself, do they have a fire burning? What drives them? Do they desire to be better or are they satisfied? I ask you all, what drives you? Do you know? Obviously, if you are in medical school or a resident, you must have the desire. Will it be sustained?

I look back and wonder why I didn't quit. It was a hard and long road. I could have just gotten a job somewhere doing something. But, would I be satisfied? Well, I am not sure. For now the fire still burns, so I run marathons.

“If your actions inspire others to dream more, learn more, do more and become more, you are a leader.”
~John Quincy Adams

Sunday, March 18, 2007

A failure to imagine ...

“Thinking is easy, acting is difficult, and to put one's thoughts into action is the most difficult thing in the world.”
~Johann Wolfgang von Goethe

The other day I was in the faculty lounge and one of our pediatric nephrologists was there. I asked her the basic question you typically ask people from other services, "how's business these days?" We talked about the state of medical care, so forth and so on. You know that "poor me" type of stuff. "I work too hard and get paid too little." Blah Blah Blah. After we got over ourselves, I asked about how call was for her and the state of her subspecialty in our city. She mentioned how reimbursement is bad and there aren't many people going into the subspecialty. I voiced the same concerns with my specialty. Then, she then told me a story that I will share.

At 3pm the day before, she went to complete a consult on a patient that had come in the night prior. This patient had a number of issues, but she was addressing some electrolyte abnormalities. She noticed that a number of labs were out of wack (WBC 40, NA 170 , CXR complete whiteout of left chest). She contacted the resident for the patient and informed her of what she recommended and that some of these labs should be rechecked since it has been greater that 24 hours and nothing had been rechecked and the patient was rather sick. The resident informed her that she was on her way home and to call the resident on call to take care of the patient. This resident had been on call the night before, but her "shift" actually ends at 5 pm. My jaw fell wide open. This was borderline incompetence in my mind. The patient's workup wasn't even complete and the resident left without proper sign out or coverage. Needless to say, the patient ended up in the PICU and in the OR the next day. This brought up a number of other discussions.

Another faculty member came in an we began discussing some of the troubles we are already seeing with the medical students and residents coming through. Many of them have started to develop the mentality of a shift worker. "I work until my shift is over." My colleges brought up the real concern of what are we going to do in 10 years, when people graduating bring that mentality into practices. We all noted that we will need more people to fill in the time voids. The problem is that medicine has taken a major financial hit decreasing the ability to expand practices; and we already have a shortage in many specialties. So what can we do about it?

I previously wrote that I thought that the medical students and residents were "soft". This was said half serious and half in jest. I said it to bring up some issues that we are already seeing. I am sure many took offense to this and a couple of comments were made, which I welcome. When I make a statement like "you all soft," I want you to have a visceral reaction to this statement. I love playing the devils advocate. I like to see how people respond. Truth is there is a real fear for many educators that there is a changing mentality of those who are now training.

There are many things that are changing in medicine. Reimbursement is awful. The hours are still bad. The risks are high. The respect for the profession is down. So, why would you sign up for this bad life. What so many in training fail to realize is that when you begin in practice, depending on the specialty, you will have more than just patient care to think about.

As I speak to my pediatric colleagues, they explain to me how much of their time is spent answering phone calls from patients and doing paperwork. They explained that on call they receive calls from both patients and ER physicians constantly during the night. One of the pediatricians described how his residents have a problem, they have a "failure of imagination." They fail to imagine that even though they are not on the floor, they may have other patient care responsibilities. This failure of imagination is what we fear. There is a belief that when residency is over, life will be much easier.

Unfortunately, the life of a physician is not easy. When you are in your private or academic practice, the patient's care is your responsibility. If something is missed, it falls on your shoulders. The patients don't care that your "shift" is over, you are their doctor. In the end, you will have to stay until the work is done. Some physicians will tell you that they work harder now than they did in residency. Remember, once you graduate, there is no 80 hour work week that will protect you.

“Don’t ask what the world needs. Ask what makes you come alive, and go do it. Because what the world needs is people who have come alive.”

~Howard Thurman

Saturday, March 17, 2007

Oh sir... it's only wafer thin ...

“A man's errors are his portals of discovery.”

~James Joyce

Orthopaedics residency, for me, was a wonderful experience. The
camaraderie between residents and surgical services was wonderful. It almost felt like being in a fraternity. You scratch my back and I'll scratch yours. We looked out for each other. I always felt I could count on my fellow residents to cover my back. On the same note, we always had attending supervision. Therefore, when things became a little more difficult, there was always someone senior to step in and complete the task. During this time, I never felt sick. I never felt a sense of doom.

As an attending, especially in the first couple of years in practice, there are times when you just want someone to take over the case. You may be in a trauma or revision total joint and have planned everything out. You have all of the equipment, etc.. You feel you are well prepared. You even looked in the "books with pictures" and reeducated yourself on the complexities of the procedure at hand. You have looked at all of the bold faced and italic items. You may have even checked with your senior partner to make sure you have not missed anything. Now you are ready.

After the case has begun, you go step by step. Things are going well. Then, something changes. An alteration from what you saw in residency or a change from what you read in the book. Maybe there is a bleeder you can't get or a critical screw that has broken out or you lose motor and/or sensory evoked potentials. This is what separates the men from the boys. At first, you will have a sinking or nauseous feeling. This is the time you need to become very focused and concentrate on what needs to be done. This is not a drill. You have to start thinking clear and concise. You have no one to bail you out. As in a code situation, first stabilize the situation (i.e. for a bleeder, put your finger on it or pack it), then calm yourself down (your adrenals will have been squeezed, and you will be shaky), gather your thoughts, and begin to go stepwise through and fix the procedure. The most important thing to understand, if you have a partner in the OR or close by in the office, REQUEST HELP. This is not the time to be bull headed and feel you can do everything. It is not a sign of weakness. It is smart to get someone who is not involved to look at the situation objectively.

Once the situation is stabilized, and the patient is out of the room, I feel it is important to look critically at the case and understand the errors you may have made in initial assessment, surgical approach and exposure, surgical technique, and emergency management. In the military, this is known as an After Action Review (AAR). I feel this is an important step in the growth of a surgeon / physician. The ultimate AAR is M&M (morbidity and mortality) or D&C (deaths and complications). In M&M, we can learn from others mistakes or misfortunes and hopefully apply that experience to our own practice.

This situation does not only apply to the OR. It can also happen in clinic. You may be in clinic and have a patient that comes with the same complaint and you realize they have a different problem than you initially thought, or maybe a fracture reduction has lost it's position, or a wound looks infected, or your surgery has fallen apart. You will get the same sense of impending doom. It is important that you act on these appropriately. You may ask a partner what he or she thinks. This is an objective view and takes away our biased view of the situation. It is always easier to see someone else's error. DO NOT neglect the situation. If you think there is a problem, prove it is not. When I was a junior resident, one of my chiefs said to me, "If you think it is infected, it is infected until proven otherwise." These words stuck with me.

In the end, remember we are all human. It is important to know your limitations. These limitations become more evident with experience. When you get to the extents of your knowledge base, experience level, or comfort level, ask for help. We go in this specialty to help not harm patients. It is not time to have an ego. If you do what is right and are honest with yourself, you will gain the respect of both you peers and patients.

“Good judgment comes from experience. Experience comes from bad judgment.”

~Bob Packwood

Wednesday, March 14, 2007

Good night moon ..... Good night stars

“Do not spoil what you have by desiring what you have not; remember that what you now have was once among the things you only hoped for.”

~ Epicurus

Match day is tomorrow. I feel like it is Christmas and I can't wait to open my gifts. We get a new group of bight eyed new residents egar to save the world, or may be a limb. It excites me.

Unfortunately, all of those who are waiting to find out where they are going to go will probably not sleep tonight or drink themself to sleep. Those who have matched will be should be excited as I am ready to start their new life. I am almost giddy.

I say to you all, welcome. Welcome to the specialty that inspires me and I hope you are also inspired. Do your best to keep that youth and egarness in you. Remember this day. Eventhough you may not get your first choice, you are IN. Make the most of what you have. You will be an orthopaedic surgeon. (Smiley face) So, good night moon and good night star because you are about to find out where the wild things are.

“Limitations live only in our minds. But if we use our imaginations, our possibilities become limitless.”

~Jamie Paolinetti

Saturday, March 10, 2007

How to train the next generation of orthopaedic surgeons ...

“Every generation thinks it has the answers, and every generation is humbled by nature” ~Phillip Lubin

"I hate Generation X," one of my mentors used to say. Generation X was a term given to my generation and most of those who are in residency now. This term was given to us based on a book by Douglas Coupland titled Generation X. In this pivotal book that defined my generation, there are three strangers who decide to distance themselves from society to get a better sense of who they are. He describes the characters as "underemployed, overeducated, intensely private and unpredictable." I don't know if that defines me, but it does point out some important characteristics of my generation (born between ~1965-1980). Why did my mentor have a distaste for us? We never wronged him in anyway. But, what we did is challenge him to teach in a different way. We did not respond to some of the teaching styles of the past. We required him to change, and who likes to change?

Looking at training today, many of those so hated Gen Xers are now in the positions of educators. Many of those from the Silent Generation are gone or are Emeritus Professors; and those of the Baby Boom generation are making their way up the ladder of academia and in their business and practice. The next generation, my generation, is being groomed to fill in for those from the previous generations. Now, what are we going to do with the next generation that will be making it's way into residency and eventually into practice? This is the generation known as Mellenials, Echo Boomers, or Generation Y. I have a feeling I am going to hate this generation. (grin and wink)

How do we train the next generation of orthopaedic surgeons? As I was taught in public speaking, one of the most important things in preparing a lecture/talk is to know your audience. Even though my mentor made the statement of distaste for my generation, I know for a fact that he did take the time to understand us. So, who is this coming generation? Well first lets us travel back in time to understand some of the previous generations and the basic characteristics (generalizations) that are common to those generations.

First, let's discuss the Silent Generation. This was the name given to the generation that came of age in ~1925-45 this generation in a Time cover story of Time referring to a generation described as "withdrawn, cautious, unimaginative, indifferent, unadventurous and silent." They looked for job security offered by big corporations (2% where self employed). Because they were born around the time of the great depression and WWII, many of this generation felt they were a generation without a cause. Silent Generation knew hardship and knew how to struggle through tough times. This was the earliest marrying group in American history with Men marring at an average age of 23 and women at 20. Ninety four percent of women became mothers and stayed at home raising an average of 3.3 children. This generation started the "divorce epidemic" as men and women born between 1930s and 1940s showed the biggest age bracket jump in divorce rate (No fault divorce laws jumped from zero to forty-five). Training the silents was like being in boot camp. Residencies were true residencies and the match was just coming into effect in the 1950's, so many went through the period of being coerced into a residency. This was the generation that worked hard and complained little.

The next generation is the Baby Boom Generation. The Baby Boomers, of course, are the product of post-war enthusiasm by returning GI's. This generation, from its infancy, was granted oppo
rtunities which were absolutely unprecedented in the history of the nation. New schools were built all over the land, suburbs allowed for a non-urban development of children, new technology paved the way for much higher standards of living (domestically, industrially, and medically), and overall economic windfalls from the war effort gave this generation a starting platform which all but ensured success and equality for all future generations of Americans. A great many of this generation, particularly those raised near large or major cities, not only went to college but began to see where the basic faults of the social contract became glaring problems. There should be no poverty in a nation which possesses such a strong economy and thriving industry. There should be no hunger for anyone when there is more than enough food to feed everyone. The government, in essence, was seen by these young adults as a vehicle by which every member of society could turn to for assistance when needed. The big problem for this generation was, of course, the war in Vietnam. Without delving into the military reasons for the war's failure, or even the government's justification for going to war, it is essential to focus on the social impact that it had on this generation. This was without a doubt the first social hiccup that the Baby Boomer's had ever faced. The Utopian ideal, which had so carefully been planned and administered by their parents (through education, modest upbringing, and technological advancements), was finally coming unraveled. The greatest impact the war had was that it shattered the illusion that had so carefully been designed for them by their parents. Crime did exist, racism is all too real, and corruption and greed are powerful forms of coercion which exist even in the sacred halls of Congress and the White House. The protest movements of the 1960's and early 1970's were an acknowledgment by this generation that the cat was out of the bag; Santa Clause, the Tooth Fairy, and the Easter Bunny do not actually exist. Most of the physician Boomers were sent to Vietnam, if they were of age, and where trained in the days of the screamers and throwers. Some of them have that more aggressive type of teaching. By many in my generation, it was termed malignant.

Now let's talk about the best generation, Generation X.
We were brought up on television, Atari 2600s and the first personal computers. Our generation was raised in the 1970s and 1980s, and saw this country undergo a selfish phase that we do not want to repeat, so well depicted in the novel by Bret Easton Ellis, American Psycho. Born between~ 1965 and 1980, we grew up in a very different world than previous generations. Divorce and working moms created "latchkey" kids out of many in this generation. This independence led to traits of independence, resilience and adaptability. Because we were never accustom to it, the was a general sense that "I don't need someone looking over my shoulder." At the same time, we expect immediate and ongoing feedback, and are equally comfortable giving feedback to others, something that frustrated my mentor. Many saw their parents get laid off or face job insecurity, and at the same time many entered into the workforce in the 80's when the economy was in a downturn, causing them to redefined their loyalty. That being said, many of us do take our employability seriously; looking at our career as more of a lattice than a ladder. We move laterally, stop and start, their career is more fluid. Even more so than Baby Boomers, Gen xers dislike authority and rigid work requirements. They preferred a mentorship that was more hands-off, but at the same time wanted their mentors to provide feedback on their performance. They also desired that feedback to be encouraging of their creativity and initiative. There was a desire to work with the mentor and not for the mentor. Gen Xers work best when they're given the desired outcome and then turned loose to figure out how to achieve it.

Now we have arrived at today's generation. Some have referred to them as Generation X on steroids. They are known as the Millennial Generation, these are those born ~1980 and 1998.
This generation has been raised at the most child-centric time in our history. I personally refer to them as the BABY ON BOARD or soccer mom generation. Perhaps it's because of the showers of attention and high expectations from parents that they display a great deal of self-confidence to the point of appearing cocky. Technology has always been part of their lives, whether it's computers and the Internet or cell phones and text pagers. Because of their upbringing they are typically team-oriented, banding together to date and socialize rather than pairing off. They work well in groups, preferring this to individual endeavors. Multitasking is almost an inborn trait, having juggled sports, school, and social interests as children. Because of this experience, they seem to expect structure in the workplace. They acknowledge and respect positions and titles, and want a relationship with their boss. This is actually at odds with Generation X's love of independence and hands-off style. They tend to respond well to the personal attention. Because they appreciate structure and stability, educating and mentoring them needs to be more formal. There needs to be a set structure and a more authoritative attitude on the educator 's/mentor's part. A mentor must provide lots of challenges as well as provide a structure to back it up. Millenials have been asked their opinions their whole lives; may mistake silence for disapproval.

So, now that we understand some of the differences, let's get to the point of understanding some things that will help us to get along in the work environment. Let's break it down:

What do we want?
  • Silent Generation: want to be a part of the company’s future
  • Baby Boomers: want to move up within the company (have huge personal and financial responsibilities)
  • Generation X: want to know exactly what they’ll be doing, are they on the right career path
  • Millenials: help them see the future/what role they will play

  • Silent Generation: “I learned it the hard way, you can, too”
  • Baby Boomers: “Teach ‘em too much and they’ll leave”
  • Generation X: “The more they learn the more they stay”
  • Millenials: “Continuous learning is a way of life”

Feedback (Needs to travel up the ladder as well as down)
  • Silent Generation: “No news is good news”
  • Baby Boomers: “Feedback once a year, with lots of documentation”
  • Generation X: “Sorry to interrupt, but how am I doing?” Generation Xers can be very blunt.
  • Millenials: “Feedback whenever I want it at the push of a button”
Both Gen X and Millenials need training in how to give feedback that is polite, respectful, non-threatening and non-confrontational.

  • Silent Generation: satisfaction of a job well done
  • Baby Boomers: money, title, recognition, the corner office
  • Generation X: freedom is the ultimate reward
  • Millenials: work that has meaning for me

What motivates them? What do they want?
  • Silent Generation: Money, Public recognition, Desire to lead, Organizational loyalty, Responsibility, Accomplishment, and Control
  • Baby Boomers: More money, Public recognition, Desire for subordinates, Loyalty to self, Promotion, Peer recognition, Control
  • Generation X: Do well by doing good, Meeting organizational goals, Recognition from boss, Time off , Meeting own goals, Skills training, Mentoring
Now, having some background on my audience, I hope that I can somehow look at those medical students and residents, and figure out what teaching style will they likely respond to. At the same time, I hope that incoming medical students and residents will also look at this information and have some understanding of their educators. In the end we are in this together; we are striving for the same results. So, in the words of a great wise man named Rodney King, "can't we all get along?"

"If you want happiness for a lifetime - help the next generation.”
~a Chinese Proverb

What is the difference between intelligence and wisdom .... Age

I received this in an email and I thought I would share it with you all. These are word of wisdom from a woman for whom I have great respect.

Maya Angelou said th

"I've learned that no matter what happens, or how bad it seems today, life does go on, and it will be better tomorrow."

"I've learned that you can tell a lot about a person by the way he/she handles these three things: a rainy day, lost luggage, and tangled Christmas tree lights."

"I've learned that reg
ardless of your relationship with your parents, you'll miss them when they're gone from your life."

"I've learned that making a 'living' is not the same thing as 'making a life'."

"I've learned that life sometimes gives you a second chance."

"I've learned that you shouldn't go through life with a catcher's mitt on both hands; you need to be able to throw some things back."

"I've learned that whenever I decide something with an open heart, I usually make the right decision."

"I've learned that even when I have pains, I don't have to be one."

"I've learned that every day you should reach out and touch someone. People love a warm hug, or just a friendly pat on the

"I've learned that I still have a lot to learn."

"I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel."

Friday, March 9, 2007

Adult Swim ....

Nothing that is worth knowing can be taught.”
~Oscar Wilde

When I was interviewing for fellowship, one of the fellowship chairman said to me, "in conference we have resident speak, and then there is fellow speak." I was PGY-4 at the time and I really had no idea what he was talking about, but I nodded like I did, of course. It wasn't until I was a fellow that I understood what he was talking about. It is kind of like learning a new language. As you become more experienced, you don't need to think as hard to do the translation. This was extremely obvious to me the other week when I was at a spinal deformity meeting sponsored by an implant company and there was a 2nd year resident (1st year orthopaedic) who was there brought by one of his reps. I looked at him and thought to myself, "does he have any idea what is being said or the complexity of this problem?" I talked to him for a little bit. Then lecture started and the lecturer started using so many acronyms even I had a hard time keeping up with him. I felt that the experience for the young man was probably lost. But, I think he had a good time and meet some important people in the field. What this gentleman and many young surgeons failed to realize is that this is what I would call an "adult swim" area of orthopaedics.

"So, what is this adult swim you speak of?"

What I refer to as adult swim are surgical topics and procedures that require a high level of understanding than you can get from an orthopaedic or a anatomy text book. This refers to an understanding that can only come from experience. It comes from already being there and understanding the difficulties of the particulars of the specific problem. It humors me to hear medical students and young residents discuss a surgeon’s technical ability when they have no true understanding of surgical techniques and complexities of a case or procedure. An artist's rendition of a procedure NEVER does it justice and makes it always seem simpler than it may be. You know adult swim when the surgeon says, "let me show this to some people." Then when it is shown, the response is, "yeah, let me know how that goes." These are not resident cases.

So for me, there are cases that I feel are cases that a resident an X level should be able to do with adult (STAFF) supervision. Then there are other cases when I look at the resident across from me and say, "time to get out of the pool, this is adult swim, only."

“I know what I have given you. I do not know what you have received”
~Antonio Porchia

Wednesday, March 7, 2007

The match is coming .... the match is coming ....

“"But I don't want to go among mad people," said Alice.”Oh, you can't help that," said the cat. "We're all mad here."”
~Lewis Carrol
For all of those waiting for that magic envelope that will becoming next week, you are probably filled with angst and apprehension. For those of you who match into my chosen specialty, I welcome you; and for those who don't, I wish you well. Regardless of your outcome, remember this is only the beginning of a long journey of learning. Your education has not stopped, it has just begun. You will realize in the coming years that with more understanding come more questions; and more questions lead to reassessing you knowledge. Once you reassess that knowledge, you will realize you don't know as much as you think you do or should.

Young padawan, everyday is a school day. I ask you to aspire to learn at least one new thing a day, always question your reasons why you do things or why others do things, and continue to reevaluate yourself and your knowledge. Although you may have made it through you first level of education, you have a long road ahead of you. Remember, everything in medical school is in the past; you must again prove yourself and show your worth. You have arrived with a clean slate; do with it what you will.
“You know more than you think you know, just as you know less than you want to know.” ~Oscar Wilde

Saturday, March 3, 2007

I want your DOR ... MAY-O-NNAISE

“Continuous effort - not strength or intelligence - is the key to unlocking our potential”

~Winston Churchill

Through all of my training, I always felt there was someone better. In my mind, I was not the "ideal." As for many, I never felt I was good enough. (tear) In medical school and residency, there was always someone who was rather hard on me. I never understood why. Someone, once told me I have great potential. In my fellowship, I received a lot of praise from those above me which I could not understand. One day, I said to my mother, "I don't see what they see." Well, what I have realized is that you can not see your own potential, only others can. So much of the old style of teaching has been lost in the rules and regulations. How do we now draw out the potential you can't see? How can I challenge you to be better?

The most common way that I have seen greatness brought out of a person who is falling short of his / her potential is to be challenged. My greatest educators were, what I would call, assholes. They expected so much out of me.

"Get of my back, I am doing the best I can," I say.

"Well, may be your best isn't good enough," he says.

It was experiences like this that allowed me to push passed myself. I was the limiting factor in my improving. Those assholes saw in me what I could not see in myself. They forced me to be better; they expected me to be better. Slowly, I began expecting this of myself. I began improving passed my self imposed ceiling.

You all will have experiences that will shape you as a physician and surgeon. The things that come easy mean nothing; the information that was given does not stick. That which is earned means everything and will be everlasting.

“There are no failures - just experiences and your reactions to them.”

~Tom Krause

My residency is better than yours ....

“My education was interrupted only by my schooling”
~Winston Churchill

In the search for residency, many people want to know what are the best residencies. The tendency is to look at rankings in the US NEWS AND WORLD REPORT to evaluate the quality of a residency. We look at the programs that are associated with highly ranked universities and expect that they are quality programs. Most people who graduate from residency would probably tell you that their program is the best or is at least a quality residency. We all have the tendency to have a special place in their heart for our own training program. Let me give you a few things to look at when you are evaluating a residency and you can judge for yourself its quality.

When many people are looking at programs, they look at who is there and who has been there. We look for people whose name we recognize. Most of us do not know everyone across the county, we tend to recognize people who are published, or who we see giving lots of lectures. The expectation is that if you write about it or speak about it, you must be good. If there are more of these people in a residency program, then the residency is good right? This is not always the case. Remember, ~5% of orthopaedic surgeons produce ~95% of the literature. Being a great researcher does not correlate with being a good educator. So how do we assess a program's ability to produce quality orthopaedic surgeons? There are probably more than a few more good orthopaedic programs with a large number of very good to excellent surgeon educators. So what makes a quality program?

I think you first need to look at who is there. Yes, I said it. "Who" is there is important. You don't need a laundry list of people that have been presidents of the academy or their specialty organizations, but you need a good stable core group of surgeons who are established in their area locally. It is nice to see people of varying ages. You need a grey hair, practicing 15+ years, who can impart wisdom of past history, both failures and successes. There should be those in their prime practicing 10 or more years, well established practice and with their own personal flare. You would like to see the mid level people, those practicing for more than 5 years; these are in the process of establishing themselves. And you need the young surgeon, someone who may seem like a maverick but usually are very current on the newer techniques and less set in their ways. This core group will provide you with varied opinions and approaches to different things. This will give you a better breadth of experience based on experience.

The next thing you want to look for is what specialties are covered. You want to get an experience in all of the areas in orthopaedics. It is even better if you do not have to travel to cover those specialties. But, a lot of hospitals can not provide all areas of care. Usually, there are a couple of areas that programs farm out. The most common are tumor, trauma, and pediatrics. This usually requires you to spend time away from your home and family. But, it is usually at a very quality institution. So, it is not necessarily a down side, just something to consider.

Also, when looking at a program, do you get both an academic (sub-specialty) training and a private experience? Face it, not everyone is going to publish a 100 papers or make a million dollars, but you need to get a feeling for what both practices are like. Now, there are some private / community programs that are very academic, Rush, Carolinas Medical Center, Union Memorial. So, some of the basic differences are (now these are generalizations):

Now, when looking at the quality of training, you should spend some time investigating what previous residency have done. Understand that we tend to emulate people who are big influences in our training. So, many community programs will have people do general or private practice and visa versa. The one thing that raises questions in my mind about a programs training or the comfort of the residents with their training is the number of people doing fellowships. If a small number do fellowships, it is a good sign that you get very good overall training. If 80-90% of the residents do fellowships, it makes me wonder. Please keep in mind that we do emulate our mentors; so in many academic programs, there are more residents going into fellowships. Something that may also be telling about a program is if there is a known weakness in the program and everyone is doing that fellowship, your eyebrow should raise.

Operative experience is another important factor when evaluating residencies. Many resident applicants have noted that early operative experience is an important factor when choosing a residency. My opinion is that the operative experience should be level appropriate. For example, a 1st year orthopeadic resident first assisting or being primary on a complex acetabular or spine reconstruction is level inappropriate; on the other hand, a the same resident performing, I&D's, simple fractures, and basic arthroscopy, is level appropriate. I also believe that it is important for a resident to be both learner, one on one attending to resident, and teacher, resident to resident with attending supervision. When the resident is in the learner role, he/she will gain knowledge from the more experienced attending. This is active learning, read about the surgery and then do. In the role of teacher, this is were the most growth will occur. In this role, you must be prepared for the case from beginning to end. This require more understanding than just the technical aspects of the procedure. It includes running the OR, what is needed for the case, where the C-arm should be positioned, what type of anesthesia is needed, how to perform the exposure from the opposite side of the table, and lead someone else through the case. This takes a higher level of thinking. This is what separates the men from the boys. Both of these aspects are important to have in a program, because it give you a more rounded surgical experience.

Lastly, what is the academic set up? Is there a curriculum? It is important to see is that there is a structure to guide you in your reading. Who gives lectures? Both faculty and residents should give lectures. The resident lectures should have faculty supervision and not be passed from resident to resident. What are the OITE scores for the last 5 years? Shows stability in the didactic set up. Be wary of the programs that brag about their OITE stats. You can teach to the OITE, which a number of programs do. Do the faculty go to lectures and / or journal club? This is a barometer of the faculty's involvement and dedication to resident education. So, these are some questions that you may use to evaluate a programs "academics."

So, what are some red flags? Well there are several.
1. Program on probation: there are several things that will cause the RRC to place a program on probation that are required, loss of program director, etc.
2. High resident and faculty turnover: I feel this is an extremely telling statistic. it usually means that there is something wrong with the inner workings of the program, chairman, hospital, resident morale, etc. This is a extremely bad omen.
3. Pink flag - High percentage of fellowships: this may be a sign of residents not being comfortable with certain areas because of lack of experience. But, as stated before, we are influenced by our training. So academic programs tend to send more of their residents into fellowships.
4. A hospital, or medical school in financial trouble: for example DMC and Wayne State, need I say more?
5. High ABOS part 1 failure rate: Enough said

So, what is the best orthopaedic residency? I feel I received great training in my residency and I can name countless other orthopaedic surgeons who will tell you the same about theirs. Well, when you are looking at residencies to apply to and those to place on your rank list, use some of those things listed above to help you in your decision. Ultimately, the most important thing is that you matched into an orthopaedic residency. So don't be disappointed if you don't get that residency so highly touted. I truly believe everything happens for a reason.

"Really great people make you feel that you, too, can become great.”
~Mark Twain

Friday, March 2, 2007

Hey Adam Currey .... BRUMSKI

Hey did you know podshow has less than 12,000 downloads per day. Well, that's the word on the street. I tink KATG has more. I'm juss sayin'.

Dig http://www.digg.com/podcasts/Keith_and_The_Girl/290588


That's for you Keith. Y'all rock.


P.S. No brumski

Thursday, March 1, 2007

Calls, Lies, and Letters ....

“The truth is rarely pure and never simple.”
~ Oscar Wilde

I was speaking with one of my residents yesterday about match day. We shared our experience. How it was during the interview process. What we were told. We both had expectations based on what we were told by many people during the process. In our own mind, we had expectations based on information given to us from people in positions of importance. Therefore, on match day, we were both surprised at where we ended up. And we both had an ego deflating sensation based on where other people matched, etc. When I submitted my rank list, I submitted it as I saw it. I placed the 12 programs in the order that I like them, not based on the likelihood of me matching there.

I am a purist. I feel that the match should be done the way it was intended. I like these applicants and I rank them as I see them; you like these programs and you rank them as you see them. So, it kind of bothers me when there are people who make calls and send letters saying that you are in a ranked to match or in a position that has matched in previous years. When information is sent out about being ranked to match, it only benefits the program. The more applicants that have ranked you high, the more likely it is that you can report that you program always gets its top applicants. That is an ego thing. Truth is, we all can manipulate our list so that we get our top applicants. Making calls and misleading applicants can be done as long as there are no “verbal or written agreements”. That is why many letters give ambiguous information.

So, what is my point? The point of the match was to prevent programs from influencing/forcing your decision. I say, "stick to your guns." Rank them as you see them, what are they going to do, say “but you promised.”(sad face) Were all big boys and girls, we’ll get over it.

“Integrity is the essence of everything successful.”
~Richard Buckminster Fuller