“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

Sunday, March 16, 2008

March madness ...

“Luck is what happens when preparation meets opportunity.”

I love the NCAA tournament. Every year there is a team who goes further than predicted. I join a poll every year and every year I am high on a team that gets knocked out early. When the brackets come out, all of the analysts put in their 2 cents. Dicky V always has an opinion. "It's march madness baby."

Every year there are teams on the bubble. The "at large" bids are the big question. Which bubble team should be in the tournament? Each year there is a team that has an argument. This year it is Arizona State who missed out while the team they beat twice, Arizona, made it. Dayton may have an argument as well. For the tournament committee, it can't be easy.

Tomorrow is known as Black Monday. The day that all resident applicants find out if they matched or did not match. I remember this day well. I previously posted about how the process had affected me. Black Monday reminds me of tournament Sunday. Teams on the bubble sit waiting to hear if they are in the tournament.

To all of you in the match, good luck.

“Serendipity. Look for something, find something else, and realize that what you've found is more suited to your needs than what you thought you were looking for.”
~Lawrence Block

Wednesday, March 5, 2008

I wish I had this much courage ....

“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

I was catching up on my blog reading and I ran across a note on Over My Med Body. It congratulated Cheri Blauwet for winning the LA Marathon. So, I check out her site. All I could say was WOW. She is a superstar amongst stars and a inspiration to all. Cheri good luck in Beijing.

"Only as a warrior can one withstand the path of knowledge. A warrior cannot complain or regret anything. His life is an endless challenge, and challenges cannot possibly be good or bad. Challenges are simply challenges."
~Carlos Castaneda

Tuesday, March 4, 2008

There'll be no shelter here ...

"They who have put out the people's eyes, reproach them of their blindness."
~ John Milton

I need to watch things die
From a good safe distance
Vicariously, I
Live while the whole world dies
You all feel the same so
Why can't we just admit it?

I remember when it began. At the time, it was a novel thought. I don't know if MTV knew it at the time, but The Real World was ground breaking. It opened a whole new genre, entertaining through others' fortunes or misfortunes. For Generation Y, this has always been a part of their lives. Caricatured lives placed in the open for all to see. Computers and the Internet have perpetuated our desire to create worlds for make believe lives. Avatars are created; caricatures of our inner selves. Social networking sites explode. We don't call any more, just text. In this make believe world, we can live our fantasy lives and project our opinions in a forum with little anxiety, fear, or regulation. For those who felt they had something worth being heard, they took to blogging.

When I began blogging, I wasn't sure what to expect. What I found was that it was a wonderful community of people with different opinions on any number of topics. For many of the anonymous posters, it is a world where their voices could be heard. Like the wild west, it is an unstructured platform where opinions can be made, discussed, and debated without fear of repercussion. This community has its own set of rules. For many of the medical students and residents, it is their venue. They grew up here. From Myspace to Facebook to Twitter, their lives and ideas have been free form on the Internet. In this brave new world, I am a learner.

Hospitals not profit full
The market bull's got pockets full
To advertise some hip disguise
View the world from American eyes
Tha poor adore keep feeding for more
Tha thin line between entertainment and war
fix the need, develop the taste
Buy their products or get laid to waste
Coca-Cola was back in our veins in Saigon
And Rambo too, we got a dope pair of Nikes on
Godzilla pure m@#*&fu%@n' filler
Get your eyes off the real killer

Cinema, simulated life, ill drama
Fourth reich culture, Americana
Chained to the dream they got you searchin for
Tha thin line between entertainment and war

There'll Be No Shelter Here
~Rage Against The Machine
In terms of technology and popular information, the medical community is generally behind the times. Caught up in our world of IV's and Ambu bags, we lose perspective on the real world. We teach the youth of America, yet we have no perspective on what is important in their world. Our eyes open only when topics are discussed in the media or cause a direct effect on us (the medical community). We are naive on many issues and undereducated outside of our world.

Change and the unknown create fear. Blogging and social networking is an uncontrolled medium. A venue where opinions can be voiced anonymously open forum. The paranoid mind says this medium will be used to slander the institution or organization and must be regulated. Although universities claim to welcome differences, there are policies that prevent true open discussion of all opposing views. In the Ivory Towers of academic medicine, popular ideas flourish. We feign tolerance. Unpopular thoughts are discounted and discarded. Hierarchy and politics rule. In this atmosphere, subordinates believe they lack the power to question. In an open forum, would I voice my opinions to a superior? As a subordinate, where is my platform?

Born with insight and a raised fist
A witness to the slit wrist, thats with
As we move into 92
Still in a room without a view
Ya got to know
Ya got to know
That when I say go, go, go
Amp up and amplify
I'm a brother with a furious mind
Action must be taken
We don't need the key
Well break in

Something must be done
About vengeance, a badge and a gun
cause I'll rip the mike, rip the stage, rip the system
I was born to rage against 'em

Fist in ya face, in the place
And I'll drop the style clearly
Know your enemy...know your enemy!


Hey yo, and d!$k with this...uggh!
Word is born
Fight the war, f@!k the norm
Now I got no patience
So sick of complacence
With the d the e the f the I the a the n the c the e
Mind of a revolutionary
So clear the lane
The finger to the land of the chains
What? the land of the free?
Whoever told you that is your enemy?

Know You Enemy
~Rage Against The Machine
Like the Real World, the blogging community was ground breaking. A whole new media outlet for millions of people. In this world, they feel empowered. Blogs, forums, and social networking sites give people a place where their anonymous (or non anonymous) voice can be heard. But like reality shows, they have become too popular. People push the limits and step over boundaries forcing regulation. Medical blogs will be tested. Under the guise of HIPPA and professionalism, there will be regulation. The rules will become formalized as policy in a handbook somewhere. Watch what you say and who you challenge because they will be watching. Will this affect the rawness of the ideas, emotion, and opinions? I hope not because that is why I am here.

"No man who knows aught, can be so stupid to deny that all men naturally were born free."
~ John Milton

Sunday, March 2, 2008

Inspirational ...

My mother sent me this and I thought I would share with my blog friends.

In the final analysis, love is not this sentimental something that we talk about. It's not merely an emotional something. Love is creative, understanding goodwill for all men. It is the refusal to defeat any individual. When you rise to the level of love, of its great beauty and power, you seek only to defeat evil systems. Individuals who happen to be caught up in that system, you love, but you seek to defeat the system.

~Reverend Dr. Martin Luther King

Training Wheels ...

“If you hold a cat by the tail you learn things you cannot learn any other way.”
~Mark Twain

Over the years, I have been observing the maturation of resident surgeons. I find it extremely interesting and inspiring. In my mind, the question has always been, when to take the training wheels off? When I was a resident, I remember when the transformation from the advance beginner to the competent surgeon happened. The metamorphosis was palpable. Growth and change can be painful, but this was not. All of the sudden, my vision became clear. My ability to read about a procedure and put the plan into action became obvious. The amount of mental work decreased. My movements became more natural. The next step was clear. It was a defining moment in my surgical training. I finally felt like a surgeon and not an impersonator.

Now, as an educator, I look for signs of this transformation in my residents. One of my mentors had an understanding of the maturation of a surgeon. He trained the residents not as individuals but by their year in training. I believe he did this because of his observation of resident's growth and tendencies over greater than 20 years. In my less than 20 years of observation, I have noticed similar trends. His previous observations may be a little dated but in general they hold true. Understanding how I matured as a surgeon, I have tried to relate this experience to today's young surgeon. Are they ready?

In the past, residency was a free for all. Residents frequently operated without the guidance of an attending surgeon. The skills that developed were from their own trials and errors. In the recent past, that has changed. The powers that control both residency training and funding have significantly impacted the resident surgeon's education. I believe that most of these changes have benefited both patient and trainee. The change that has impacted residency the most is the requirement for more attending supervision. Although this improves patient care and decreases the number of foreseeable errors, resident's feeling of independence has suffered. Attendings have become like training wheels, keeping the learners upright. Some attendings have more restrictive training wheels than others; none the less, they are there to prevent errors and give direction to the young surgeons before they are out on their own.

For surgeon educators, it is a difficult task to asses a trainees level of knowledge and comfort level with the procedures. Prior to changes requiring increased attending involvement in surgical cases, the resident's surgical skill was tested time and time again. Many times they were on their own. City hospitals and "resident cases" provided multiple opportunities for resident to develop operative skills. In these instances, residents were immersed in orthopaedics, learning from shear volume of work and fear of making an error. Now there is more attending involvement, which means there is more attending involvement. For most surgeons, it is easier to do than it is to explain how to do. Because surgeons are not the most understanding and verbal individuals, they lack the patience and communication skill to allow a young surgeon to "futz" their way through a procedure with the verbal guidance and demonstration of technique (i.e. surgical training wheels) from an expert or master surgical educator. It is easier to just show them how to do the procedure. For a competent surgeon, this technique of education is appropriate; for a novice surgeon, it is not as effective. Early in a surgeons education, the act of doing affects growth more than observing. Because of the requirement that surgical educators be more involved in cases, basic surgical skills may be delayed. Because young surgeons are unable to make decisions on their own, many are less comfortable making decisions. As attending surgeons, we have to loosen the training wheels and allow the surgical growth of the novice surgeon.

I believe in allowing the "futzing" with surgical training wheels. As a second year orthopaedic resident, I remember believing that I had truly done a total hip in under an hour. I was brought back to reality when I operated at the VA without the same attending guidance. My time wasn't so good. I had not noticed the subtleties of retractor placement, light position, adjustments in assistants placement, and use of surgical instruments. I was more the puppet of a master surgical educator. A residents futzing or fumbling is important in their growth. I know what works for me, but do they know what works for them? As the learner goes through the procedure, subtle nudging by the teaching physician keeps the resident from making egregious errors. With more independence, they gain both confidence and skill. Does confidence equate skill level and understanding? Not so fast padawan. An educator must pay attention to the learner and realize when they are at the end of their skill set. They must be allowed to futz with guidance. The attending is alway there as a ripcord if they are at a loss.

As residents progress, an educator must observe their clinical and surgical development. It is imperative that the balance of the training wheels be removed. There should be less cues and guidance. I like to observe their adaptations to this change. They should be allowed to be involved in making decisions about treatments, surgical approaches, room set up, and postoperative care. They should begin to instruct and guide the younger surgeons. In the role of teacher, they are given a different perspective on the procedure, viewing it from the opposite side of the table. Their complete understanding of the procedure is tested. It encourages independent thought. Because they have been guided for most of their career, many residents have not thought about how they would treat a specific problem. A common reason for doing something is because that is the way we do it. At some point they must be tested not on how I would treat something, but how they would.

We are the safety net. At some point, they are going to have to fly on there own. My approach to allow them to test their skills while I am watching. If they begin to fall, I am there to catch them. We stabilize them and direct their thought process to what we consider the standard of care. I don't know if I will ever know when they are ready. I will continue to challenge their understanding of surgical technique, clinical decision making, and the standard of care. In the end, I hope that they have the knowledge and surgical skill set to ultimately be an excellent surgeon.

“Experience: that most brutal of teachers. But you learn, my God do you learn.”
~C.S. Lewis