“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

Monday, January 28, 2008

We are all in this together ....

"We have two ears and one mouth so that we can listen twice as much as we speak.”

I haven't been a resident for a little while now and I think it has been long enough that I have truly forgotten some of the fear and anxiety I had as a resident. In the past, many attendings taught by pure fear. I have been there. I remember doing things not because I knew it was the right thing to do, but because it kept me out of trouble. I watch the residents come and go on my service. I see them do the same things in the OR and in the clinic. They do them because it has been beaten into them on another service. It was their way of staying "out of trouble." I question them on why and they can not give me a "good" answer. I looked back on my own experience. I tried to put myself back into the resident's perspective, but it is difficult.

From my current perspective, an attending interested in education, I am not here to have you be afraid of me or for you to do things without a reason. I am here to help train orthopaedic surgeons. The resident is here to learn how to be an orthopaedic surgeon. This is an unwritten agreement that we have made. We are in this together.

Sometimes, I feel that residents view the attending/resident relationship as an us versus them battle. Is it really us versus them? I think we, residents and faculty, need to realize that we are in this journey together. The communication about education needs to occur both ways. The attending needs to be clear with his/her expectations; and the resident needs to speak up when s/he has questions. It is a relationship that needs feedback from both participating parties.

During this next year, I will plan to improve the out national economy, get our troops out of Iraq, decrease our national debt, and improve our relationship with the rest of the world. Oh, sorry I was watching the state of the union address. During this next year, I pledge to communicate my objectives to my residents, to give more feedback about their performance, and to ask appropriate questions. I will be responsive to resident questions and concerns. I hope this will improve in our symbiotic relationship.

“The single biggest problem in communication is the illusion that it has taken place.”
~George Bernard Shaw

Thursday, January 24, 2008

More Interviews ...

“Sometimes questions are more important than answers.”
~Nancy Willard

It is our interview season. We had our first interviews a couple of weeks ago and I posted that I would ask the question, "tell me about yourself?" Well, I did ask the question, but I did modify it a little. The actual question I asked was, "in one sentence, tell me who you are outside of medicine?"

I also asked 4 other questions:
  • What is your favorite book?
  • Who is your favorite author?
  • What is your favorite song?
  • Who is your favorite music group, singer, or artist?
So, I ask you, my readers:
  1. Do you think these are reasonable questions?
  2. How would you answer them?
Thanks in advance,


“Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning.”
~Albert Einstein

Sunday, January 20, 2008

Orthopaedic Surgery: Back to Basics

I have started another blog called Orthopaedic Surgery: Back to Basics. It is a blog that takes an objective look at orthopaedics. I plan on going over basic things concerning orthopaedic surgery. It will include physical examination, coding, surgical procedures, and orthopaedic diseases. Please come visit and give me any recommendations that you may have.



To be a good surgeon, you must first be a good first assistant ...

“You cannot teach a man anything; you can only help him discover it in himself.”
~Galileo Galilei

One of the first questions resident applicants ask is, "when will I get to operate?" For the most part, operating is the reason most people go into a surgical specialty. We understand that clinic is a necessary evil. Clinic is where the surgical decision making begins and the final outcomes are determined. It is a key element in surgical education, and for the most part, is hated by most residents.

So, when should a resident be the primary surgeon operating surgeon? Well, I truly believe that you must first be a good first assistant. Many may disagree with this statement. I hated when an attending would make the same statement to me. My response, in my head of course, would be, "I have prepared for it and I am ready." I will concede that holding a retractor in a 10 hour case is not a great learning experience; but like the unpopular clinic, first assisting is a vital tool in developing surgical skills.

Surgery is about pattern recognition. For a more experienced surgeon, watching another surgeon operate is like watching film to prepare for a game. S/he is looking for better or different ways of attacking a problem. When we see a certain pattern or obstacle, how should we approach it? The basic pattern is understood. Like Tom Brady reading a defense and changing the play to exploit a weakness, an experienced surgeon may change his/her techniques based on a recognized pattern. A young surgeon uses all his/her senses to orient themselves to a procedure. The anatomy never looks like the Netter drawings. Like a child experiencing the world, they need to feel, see, and taste everything. It is more information into the computer to be stored for future pattern recognition. In assisting, unknowingly the surgeon is increasing the data bank of patterns. Pattern recognition is what helps surgeons move effortlessly thorough procedures. "I have seen that before .... this is what worked before." It allows for almost reflexive responses to challenges and obstacles during a procedure.

Learning through observation, passive learning, is different than the learning through direct participation, active learning. As primary surgeon, the surgeon can "feel" the education occurring. The active learning is through brute force and improvements are almost palpable. For the experienced surgeon, observation, passive learning, is a vital tool in improving surgical skill and improving their currently used techniques. For the less experienced surgeon, the subtleties of the surgeon's techniques may be lost because so much energy is used to understand the basics of the procedure. Because the learning is more passive, it does not feel like learning has occurred. Fortunately, it increases the surgeon's data bank of patterns.

What is it about assisting that improves surgical skill? Being a good first assistant requires you to understand the case. It would be like the caddy's relationship to the golfer; the assistants role is to anticipate. It starts with room set up and patient positioning. You must be able to think steps ahead and obtain whatever is needed help the procedure run smooth with less delays. The assistant must know the instruments and have an understanding of how they are used. Although these little things seem unnecessary, they are all extremely important.

As a novice surgeon, the OR can be very overwhelming. Sometimes just remembering the approach is stressful enough. As an assistant, you don't have to think about the how and why during the procedure. Your role is to pay attention, to anticipate the next move, and to help his/her exposure and/or vision. To be a good first assist, you actually must understand the procedure and think steps ahead. For the novice surgeon, the assistant role allows them to absorb the information. Although you are thinking ahead in the case, you are not required to make critical decisions and therefore, it is less stressful.

With each case and surgeon, you will experience different ways of accomplishing the same goals. Some will use different instruments to perform similar tasks. You will begin to develop your own style or flare. You find what works for you. There will be instruments that you like and dislike. I am partial to the cobb. My residents have heard me say more than once that I could win Survivor with 2 good sharp cobbs. With each case, the young surgeon's repertoire of surgical approaches, positions, instruments, and retractors, increases. Their understanding of OR management from set up to time management improves.

The goal of residency is to create a complete surgeon. Technical skill is only one component. Like the decision making skills gained from clinic, assisting helps in rounding off the surgeon. Although many other specialties view orthopaedic surgeons as technicians, there is a lot more thought that goes into the treatment of musculoskeletal disorders. The easiest part of what we do is the technical part. The decisions are the hard part. So, when should a resident become primary surgeon? Well, my view is not until they are chiefs and almost ready to graduate. In my mind, the primary surgeon is not the one who is making the incisions; the primary surgeon is making the decisions. The primary surgeon has to decide who is an appropriate surgical candidate, what surgery is appropriate, and what techniques are to be used. The primary surgeon must think about OR setup (lights, bed position, c-arm position), patient positioning (supine, lateral), surgical approach, instrumentation type, surgical closure, and postoperative management. The primary surgeon must be complete.

As the attending surgeon, it is difficult to perform both roles, surgeon and first assistant. There are many days when I wish I had a first assistant instead of a resident. Someone who would concentrate on assisting and not trying to move into the role as primary surgeon. The assistant's role is to keep the surgery moving forward. As a resident, I remember finishing a case and believing I did a great job on it. In hindsight, I realized that is was my fist assistant (the attending) who made the case go so smoothly. The attending surgeon moved me through the case like a puppet. So what do I do today when I need an expert assistant, I ask one of my partners to assist.

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

Thursday, January 17, 2008

Congrats AM.......

“Promise me you'll always remember: You're braver than you believe, and stronger than you seem, and smarter than you think." Christopher Robin speaking to Pooh
~A. A. Milne

There are some days I ask myself the question, "why do I do this?" The OR is a struggle. In clinic, patients are unappreciative. Insurances deny a study or questions your rationale for treatment. Referring physicians get upset because they did not receive a patient's consult note. At the end of the day, there is a stack of paperwork to be completed, school excuses, gym excuse, PT referrals, etc. It can be exhausting. So, why do it?

The other day I walked into my office. As I passed my secretary's desk, I asked, 'is the anything for me?" She said, "yes. AM called. She wanted you to know that she received her schools award for courage." I smiled.

That is why I keep coming back.

Congratulations AM. You ROCK.

“Courage doesn't always roar. Sometimes courage is the quiet voice at the end of the day saying, 'I will try again tomorrow.'”
~Mary Anne Radmacher

Wednesday, January 16, 2008

When in doubt, examine the patient ..

“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

As orthopaedic surgeons, we are not known for examining patients. A common orthopaedic joke is "the patient looked good from the door." Another common joke is the orthopaedic triple point, located in the center of the thorax at about the xyphoid, where you can listen to the heart, both lungs, and the abdomen. We all laugh and joke about it. The truth is we do examine our patients. We are more focused on our organ system, the musculoskeletal system, and that is considered less important than the heart, lung, and abdomen examination. When push comes to shove, most of us can examine the heart, lungs, and abdomen better than many physicians can examine the musculoskeletal system.

(Here is a case. Not picking on any service)

Several days ago, we were called to examine a child for possible compartment syndrome, an orthopaedic emergency. It was a child that had a boil on his knee, it burst, and now he has cellulitis with leg swelling. Because the leg was swollen, or as my patients like to say "swolt", we were consulted for compartment syndrome. So, I go up with one of my residents, and we examine the patient. When we get to the room, the patient is lying in his crib eating a cracker and smiling. The leg was swollen, but the patient was comfortable. Pain out of proportion to the injury is one of the hallmark signs. But, we understand, they probably didn't know the signs. We fill out a consult note, speak to the covering resident, and advise on getting an MRI to evaluate for osteomyelitis if doesn't improve.

Next day, my team visits the patient. He was on Vancomycin for a skin culture of MRSA. The leg was significantly better, and we moved along. Later in the day, my residents get a frantic call from the patient's resident. We were informed that we need to see the patient right away because they had necrotizing fasciitis. ?????????? Ok, sometimes I am slow, but usually necrotizing fasciitis is caused by Strep. and tends to progress very rapidly. This child got significantly better with only antibiotics and cultured Staph. We again see the patient. The patient is still getting better. The calls continue. The patients attending then calls my partner to ask why isn't this necrotizing fasciitis being treated. We again look at the patient. Patient is stable. So, were did this confusion come from? Our friendly radiologist mentioned a differential of cellulitis vs necrotizing fasciitis. It is not their fault, they haven't seen the patient. They are just reading in isolation. The patients physicians were asking us to treat this reading.

So, how do we rectify this situation? When in doubt, you should examine the patient.

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

Friday, January 11, 2008

Did you see my xray?

“Whoever undertakes to set himself up as a judge of Truth and Knowledge is shipwrecked by the laughter of the gods.”
~Albert Einstein

The reason I went into medical school was because I wanted to go into orthopaedic surgery. With an undergraduate degree in engineering, orthopaedics was a natural progression. One of the major draws to orthopaedics is the surgical side. A common orthopaedic joke is, "bone broke; me fix." We do multiple complex procedures to help individuals stand straight, walk better, and live without pain. We have instrumentation that costs more than most people's car. We gaze at our xrays as if it was a work of art. We show them to patients and other surgeons as if saying "look what I can do."

We are very xray driven. We like to see fractures AFT with plates and screws, or a rod placed perfectly. Residents get caught up in this superficial, self-aggrandizing look at patients. We see xrays not faces. We remember fracture patterns not names. We hear drills and not voices. But, these are people, human beings with families and friends.

I do a number of larger cases on children with multiple medical issues. Because of the chronic nature of their diseases, I become almost like a primary care doctor. I see them multiple times during the year. I know many of the family's stories and the triumphs and trials of their lives. I treat the patient like family. I would not recommend a surgery that I do not feel is needed and I involve the family in making the decisions.

For most of my complex surgeries, we have a preoperative conference. I recommend that everyone involved in the child's life come to the visit. I ask them to right their questions down prior to the visit so that they don't forget any. We go through the risks and benefits. I give them numbers on some of the risks. Regardless of what we do, there is always a risk of a major complication that can result from unforeseeable events.

When I was a resident, we would salivate over big cases. Beg to do major surgeries to xrays, because we knew that we could "make it look better." We knew exactly what instrumentation would make this perfect. It was always the wise, grey-haired attendings that would make you rethink your decisions and look at the potential harmful risks to the "patient". Because regardless of what we do, there are always risks. As much as we talk about the xrays and our surgical prowess, they don't necessarily matter. In the end, what really matters is that you did what was right for the patient based on what was needed and not based on making a pretty xray.

“We learn more by looking for the answer to a question and not finding it than we do from learning the answer itself.”
~Lloyd Alexander

Wednesday, January 9, 2008

Why would you go into medicine when you can make millions working for youself

A number of students have asked me about going into medicine. My answers is usually that you have to really want it. Don't get me wrong, I love my job, but the road is long and hard. Unlike many years ago, the respect, autonomy, income, and security is no longer what it was. So, why go into it. I cam across this article in the New York Times on Sunday. Now, it does talk about lawyers, but I still think it is an interesting article.

Orthopaedic Surgery Interview

“Whatever course you decide upon, there is always someone to tell you that you are wrong. There are always difficulties arising which tempt you to believe that your critics are right. To map out a course of action and follow it to an end requires courage.”
~Ralph Waldo Emerson
Twice a year, we have mock oral boards. You may say oral boards sound like it's malignant, but it's not. It is just another assessment tool. Like the real orthopaedic mock boards, it always us to assess your understanding of orthopaedic knowledge in a dynamic setting. It does cause many residents a great amount of anxiety, but it is helpful. As the years progress, you can see a increase understanding of orthopaedic surgery. The residents feel that it is a mega pimp session. I guess, by definition, it is a question and answer session done without a #2 pencil and multiple choices. The purpose is not to make the resident uncomfortable and sweat; the purpose is the assess your application of what you learned.

Today, we had oral boards. It got me thinking. When we give the examination, the resident brings a known case and a is given an unknown case. Why don't we give the resident applicants a known question?

Our interview season is beginning this month. For those who are interviewing at out program (St. Louis University orthopaedic surgery), here is your question when you come into my room: "Tell me about yourself." Please keep your answers short and don't recite your resume. You can take a hint from a previous comment I make on the "tell me about yourself" question and answer.

Good luck all

“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

Sunday, January 6, 2008

Are we too nice?

“High achievement always takes place in the framework of high expectation.”
~Charles F. Kettering

When I went through all of our applications, it was hard to separate one application from another. The white pages and black lettering blended together after the about 15th application. For a majority of the applications, all I had was a name, school, and their basic statistics.
John Doe
  • Medical School: State University of X or X University
  • USMLE step 1: 235
  • Clinical Rotations: 1/2 clinical honors
  • Orthopaedic Rotations: honors
  • LOR's: good to excellent with some stating he is in the top 10% of students rotating this year
  • Personal Statement: "... Since I injured my knee playing football, I have always wanted to be an orthopaedic surgeon. ... I have played sports all of my life ..."
I can't count the number of times that I have read this type or similar application. The names of the applicants are sometimes interchangeable. What aspect of their application tells me that this is going to be a stud or a dud? I have received a number of emails and have read plenty of forums that ask the same question, "what do I need to get into orthopaedics?" If I could tell you the exact recipe, I would, but I don't think there is one. In truth, we all know the recipe, good grades, good scores, good rotations, and a little luck. I think what is more important is the special ingredient or special sauce you bring to make you different.

Many applicants get caught up in the numbers of the game. Time and time again the question is asked, "what score do I need to get into orthopaedics" or "what grades do I need" or "how much research do I need"? I can give numbers of the typical solid application, as I have listed some above, but does that guarantee a spot? Not so much. The quoted figures on scores, grades, research, and AOA are just guidelines, not a guarantee. Every year there are applicants with strong numbers that don't get into a residency. So, why didn't they match? Typically, when I have reviewed these non-match applicants, the reason was either glaringly obvious (USMLE score 205, bad letters, failing a subject in medical school) and on other occasions, it was not. When there was no glaring flaw, the applicant looks like every other applicant. There is nothing in their application that makes him/her stand out.

I have asked myself why is it that that most of the applicants so similar. Is it because they have all used performance enhancing drugs to make them all academic superstars? All jokes aside, I think it may have more to do with the way we grade. I blame it on kids soccer, where everyone gets to play and in the and they all get a trophy. Many parents display their honor role student sticker on the rear window of their SUV. All the children are A and B students. Many go to a 4 year university and expect the same. They argue for a better grade and petition for grade changes when it doesn't meet their expectations. The professors that grade on a true Bell Curve are not liked or considered "hard" because they give out fewer A's and B's. Over the past 10 years, I have noticed this trend and I have wondered if we (educators) are too kind in our evaluations?

With a student's application, we receive a copy of the grade distribution for that medical school. When comparing applicants from one school to another, there are definite differences in grading philosophies. I don't know if this is a problem with the grading set up or that we are "too nice." In my experience of clinical grading, unless the student does something drastically wrong (like never show up or cursing out a patient), the student will at least receive a pass. The question is who receives the highly coveted Honors. Each School varies in their grading system. The grades can range from pass/fail only to honors/pass/fail to honors/high pass/fail to honors/high pass/marginal pass/fail and the always popular A/B/C/D/F (with +/-). What puzzles me about all of these systems is that the average tends to be a B or high pass. There are schools with greater that 50% honors in some subjects. You may say, well are these the "lesser schools"? Not so fast young patawan. In my limited research (okay not really research but observation), it is more common for the "very competitive schools" to have more of a top heavy grade distribution and the "less competitive schools" to have a more even grade distribution. It is not uncommon for a school to have grading distribution (in the clinical years) with greater than 50% honors and less that 30% passes. How does this allow for us to assess these applicants? If you score only gives out 20% honors and you received a high pass, should you be penalized? On the other hand, if you went to a school that gave greater that 50% honors, should you be given bonus?

With competitive specialties' concentrating on USMLE scores, students have been crushing this test. The USMLE is one of the only tools we have to compare applicants from different schools and areas of the country. Because the USMLE "powers that be" don't want the test to be used in the manner we use it, they do not provide us with the distribution of scores. In the old days, the mean was in the low 200's (205 when I took it) with a standard deviation of 20. Today, the mean is in the mid 210's. Therefore, a score in the 90's of 225 is equivalent to a score of about 235 in today's scoring (I am guessing). Most of the applicants I have reviewed have an average of a 230 (just a guess, again no true data). Again, when trying to create separation like Randy Moss from a corner back, it doesn't happen. The applicant's are all bunched together like 6 year old children playing soccer.

You may say, "then look at the letters of recommendation (LORs)." This is less helpful than the grading. Most folks have the prerequisite letter from their program chair that says he or she is a supernova or has star like qualities. There are usually 1-2 letters from surgeons that are not known by most interviewers and 1 from a well known surgeon. Although the letters are helpful when pointing out top end and lower end, they to not create the needed separation to differentiate one applicant from another. There have been occasions where I have read the same recommendation on 2 or 3 applicants from the same physician. Although we think we know the code words, I think we kid ourselves at thinking we can read into another's recommendation like it is Morse Code. Usually the true meaning is missed, except when comments are blatant like, "we recommended that he look into other specialties ... "

What is the answer? I have recently begun to reevaluate my own grading system. How is my grading? Am I too nice? The answer is yes. I believe that many of us don't want to be the bad guy. Who wants to be the professor who fails most of his/her students? I don't think that there are many who would answer yes. I believe we do need to re-center. In the clinical setting, the average grade should be a pass. The excellent grades should be give to those who truly stand out for the rest of the students. As an educators, we must communicate our expectations are and explain what passing grade means. Is this a student problem, I would propose it is not. It is a educator problem. We have evaluate honestly. No more just checking the 4 out of 5 box. If they have met expectations, then they should get a pass. You may read this and think I am arguing for more strict grading, but I am not. I think that our grading should be fair. Lumping the average around above average is not fair to those who are truly above average.

“Success is simple. Do what's right, the right way, at the right time.”
~Arnold H. Glasgow

Saturday, January 5, 2008

Goodbye my friend ....

“Somebody should tell us, right at the start of our lives, that we are dying. Then we might live life to the limit, every minute of every day. Do it! I say. Whatever you want to do, do it now! There are only so many tomorrows.”
~Pope Paul VI

Sometimes, the days feel long; but in reality, life is short. We complain every day about meaningless things that, in the end, lead to nothing. How will I leave this world? Will I leave the world a better place or will I be just another complainer?

Death of friends and family changes you. It makes you reflect on your life. What legacy do I want to leave? What will be said in my eulogy? How will my children remember me? When it is time to go, I hope I am ready. I hope I do not feel as if I have left unfinished business or work to be done.

Have a safe trip my friend. We will not forget you. Please continue to watch over the babies in death as you did in life. You will be missed.
dying is fine)but Death


wouldn't like

Death if Death

when(instead of stopping to think)you

begin to feel of it,dying
's miraculous

cause dying is

perfectly natural;perfectly
it mildly lively(but


is strictly
& artificial &

evil & legal)

we thank thee
almighty for dying
(forgive us,o life!the sin of Death

E.E. Cummings
“Live as if you were to die tomorrow. Learn as if you were to live forever.”
~Mahatma Gandhi