Aarrrggghhh .... July

"Courage - the first of human qualities ... because it guarantees all the others."
~ Winston Churchill

The academic year is coming to an end. There is both happiness and uncertainty in the air. The chief residents are packed up and saying their goodbyes. The newly graduated interns are finding housing and readying themselves for a new venture. It is an exciting time for all involved. At this time of the year, everyone is changing their position in the hierarchy. The rising chiefs have to assume the role of leader and the new interns will be a "doctor" for the first time. Some are up to the task and others, well, take a little bit of coaching. For everyone, July is eventful.

On July 1, there will be a new set of faces here. There will be those who have acquired the skill set needed to assume their new role and there will be others who have not. Some will have the confidence without the skills to back it up; and others will have no confidence but have good skills. In the end, there are very few who are not salvageable. Not everyone was born knowing how to do everything. That guy sitting next to you who acts like he has it all under control is probably just as scared as you are. We are all human and you WILL make mistakes.

Here are a few points that I found helped me put some things into perspective.

When you start getting anxious about a situation, remember start your thought process by taking your own pulse.

Never run to a intense situation (like a code), but walk briskly and come up with a plan of action.

Ask questions if you don't know how. It is not a sign of weakness, it is a sign of strength.

Know your own limitations.

There are probably many more. Good luck to you all on your new adventures. We are all getting ready for a little bit of a roller coaster ride.

“The key to change... is to let go of fear.”

~ Rosanne Cash

All good things have to come to an end ...

“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

When I was in medical school, one of the key issues that discussed at the time was the increasing need for primary care providers and the over abundance of sub-specialists. There was a push by multiple institutions to increase medical students interest in the primary care areas and a deemphasis of the sub-specialties. Over recent years that prediction was found to be off target. Unfortunately, the opposite was found to be true. One of the causes for the miscalculation was an aging population and a predicted increasing need for care including sub-specialty care. Along with the general population, the orthopaedic workforce is also aging. There are a number of the elders who will be retiring in the near future with no one to fill their position or role. No where in orthopaedics is the particularly true than in my subspecialty, pediatric orthopaedics.

As we go through our medical education and resident training, there are a few individuals who have a lasting impact on those with whom they have interacted. These are the individuals that many years later are still quoted and mimicked. In many instances, these individuals have dedicated their lives to the education of the young physician and the advancement of medical knowledge. Not all of the memories may be good memories, but they have effected you none the less. If you close your eyes and visualize your education, these are the people you see. The more time a person is associated with a program; the more they become a part of that program. They are fixtures at that program, an "institution".

As is the nature of life and careers, they all have to come to an end. Recently, I heard that one of my mentors has cut back his practice. He has not retired, but he has decrease his case volume and stopped performing major procedures. This past week I was reminiscing with some former residents from my program. As you do, we talked about our current practices, how many kids, new relationships, new cities, etc. After we finished with the formal updating of our lives, we reminisced about residency. We laughed about the good and bad. We all had a lot to say about my former mentor. It was very interesting that everyone had very similar stories. While I was still in residency, I remembered having other former residents tell these same stories to me. As we talked about him, I found out that he had cut down his practice. We all had a feeling of sadness about it. It seemed like the end of an era.

When a program loses someone who was influential, part of that program dies. As with many tribes, they depend on the elders to impart wisdom and insight. It is with this wisdom we are able to stay away from mistakes of the past. They remind us of previous successes and failures. Because of their years of experience, they are able to quickly reference the patient catalog and give advise base on previous experience. In their mind, it intuitively "makes sense." It is true their techniques make have fallen behind the current en vogue treatments and/or techniques, but it is their experience that is vital to the education of both medical students, residents, and young attending staff.

In my specialty where 60% of the Pediatric Orthopaedic Society of North America members are over the age of 50, the era is coming to an end in multiple institutions. Unfortunately with the current generation of attendings and residents (GEN X) choosing sexier and more lucrative specialties such as sport medicine and spine surgery, the number of specialists in the other specialties has decreased. For a number of reasons (malpractice, case volume, lower salaries, interest), residents have shied away from some of the other specialties. Pediatrics has be hit particularly hard. We know the mentors and sub-specialty exposure influences resident selection of sub-specialty. With many of the great educators reaching retirement age, who will assume the role?

I look back at my own education and remember how much I was influenced by my faculty. Both in my fellowship and residency, it was the wisdom of my elders which particularly influenced me. As I look to the future, I hope these voids will be filled. This is an unknown. In the end, all I can do is hope and pray that this is only a cycle and we are on the bottom end of that cycle. If not, may be at the beginning of an ice age.

“Wise men speak because they have something to say;
Fools speak because they have to say something.”
~Plato

Are we there yet?

“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

Education is a wonderful thing. I learn something new everyday. Everyone from my patients, students, residents, nurses, and even the cleaning ladies, teaches me something. I truly believe that when I stop learning or wanting to learn, I should retire. While I love to learn, I also have the same passion for teaching. This is a double edged sword. The more you teach; the more you must know; the more you know; the more you realize you know nothing. This is a vicious cycle. How can you teach when you don't know?

Teaching in the medical field is tiresome. Sometimes I just want to do things myself, because it is easier and I don't have to think so hard or try to keep bad things from happening. I do realize that I have to allow the residents to grow and have to give the medical students some sort of education because they are paying for it. The whole process is taxing. Leading a service with medical students and residents is like being the lead car taking a caravan of cars through downtown Detroit. When you are leading, you have to drive slower than you usually do. If you see a stoplight turning yellow, you'd better slow down because not everyone will make it through the stop light. You'd better rethink passing that car because not everyone will be able to pass. Signal early so that everyone will know when you are turning. Don't forget about those potholes. For everyone in the caravan, it is stressful; but for the lead car, you have to anticipate what the needs are for the other drivers as well as try to predict how they will react.

It is my favorite time of the year, the end of the educational year, April-June. Everyone has a sense of confidence about them. From the medical students to the chief residents, everyone is spreading their wings and ready for the next level. It is when I have to lead less. My chiefs are leading the service without much need for our input; the mid levels are showing that they have advanced in both their knowledge and surgical skill; the juniors are making fewer errors and gaining confidence; and the medical students, well they just are nowhere to be found (just jokes). My least favorite time of the year comes right after this, July-September. It is like groundhog's day all over again. I feel like I am repeating myself. "I swear we just lectured on that." Or "I do it like I always do." I do realize that they don't necessarily know how I do it and others may do the same procedure differently. It can be a little frustrating. Usually I am whining, "Why can't we just do it like we did last time." It is probably more dramatic because it was so good a month or two before. We go from freshly paved highways to unpaved roads.

In my view, this is what keeps me on my toes and keeps me learning. The changes in residents and differences in experience help to enrich my experience. Yes, it is painful when I have to re-explain when and when not to brace scoliosis; or when I have to go over the different types of in-toeing for the millionth time. At the same time, those same residents and medical students question what I do and why I do it. It forces me to constantly re-evaluate what I do and why I do things the way I do. As much as many resident and medical students complain about attending pimping, all those questions you ask are like reverse pimping. Sometimes I want to shout out like a parent, "Just because that's the way I do it." As much I (attendings) am there to help in their (medical student and resident) education, they prevent me from getting stale and set in my ways. It makes almost everyday interesting; every case a little different; and every patient special. To those who are graduating, thank you and lead well; and to those who are entering, welcome and watch for the break lights.

“For everything you have missed, you have gained something else, and for everything you gain, you lose something else.”
~Ralph Waldo Emerson

My thoughts go out to you and your families....

To the family members of the University Michigan Transplant team who were lost in the tragic plane crash,

my thoughts are with you and your loved ones during this difficult time of loss.

RIP
Dr. David Ashburn
Dr. Martinus "Martin" Spoor
Richard Chenault II
Richard Lapensee