March madness ...

“Luck is what happens when preparation meets opportunity.”

~Seneca

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

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

Does diversity matter?

“We all should know that diversity makes for a rich tapestry, and we must understand that all the threads of the tapestry are equal in value no matter what their color.”

~Maya Angelou

I am not a poet and don't claim to have some great understanding of poetry. I do appreciate poetry and the allusions that many authors use to explain certain opinions. The Hollow Men, by T.S. Elliot, is one such poem. It makes many allusions and references to other poems and historical figures to explain his displeasure of society and war. Some believe that it is written from 5 different perspectives; each perspective representing a phase of the passing of a soul into one of death's kingdoms. This is a complex poem which requires an understanding of the time in which it was written, past history, and previous writings of both the author and other authors (such as Dante's Divine Comedy). As complex as this poem is, it is easier to understand than understanding another's perspective.

(Image Credit)
Our perspectives are formed over time. We are affected by our upbringing and experiences. There is no denying this fact. Like our musical tastes, our perspective is shaped by our initial influences and changes with our experience. Differences of perspective is one of the reasons for the emphasis on diversity. Some believe this is a repackaging of "affirmative action", but in my view it is not. Diversity is about bringing together different perspectives. I have been avoiding this topic because it is a hot button issue. Now, with our current political race placing both a African-American man vs a woman and having seen a number posts in different forms that have mentioned the topic, I felt it was time.

Before I speak about diversity, I think I have to give you my personal perspective and history. Who am I? I am the great-great grandson of a Bishop of the AME church. I am the great grandson of a former president of Wilberforce University and one of Yale's first African-American graduates. The nephew of a Yale medical school dean and a descendant of Henry O. Tanner. My parents met at a Williams and Bennington college social function. In the 60's and early 70's, my father was very involved in both SNCC and CORE. In my youth, I grew up with Afro's and dashikis. I listened to stories about Medgar Evers and other leaders in the Black power movement. Yes, I am a black man.

I am the oldest in my family. I have a total of 5 sisters, 1 by marriage and 4 half sisters. I was raised in Wilkinsburg, PA and went through the Wilkinsburg public school system. Considered one of the smart ones, I was protected by many of my friends from some of the bad influences. At age 16, my best friend had his first child; he was 15. At age 18, I had mine. At age 19, my best friend was shot in the head, because he was selling drugs in the wrong area. Needless to say, I grew up in what some would consider a "rough" area.

If you look at my family history and my environment, you may say that they were at odds. In truth, it was always understood in my family that academics was important. There was an unspoken understanding that going to college was a given, which one was the only question. You see, the competition came from within the family, not outside. My cousins class rank of 2 bettered mine by 2 positions. My other cousin's SAT score of 1580 bettered my uncle's (her father) by 20 points. I wasn't that close. Although I grew up with gangs and teenage pregnancy, my overpowering influences came from history, family history.

For me, college was initially a culture shock, but I continued to do well. I majored in Biomedical Engineering and like many times in my life, I was "the only." For some reason, may be I had vision or laps of judgment, I decided to go to medical school in the second semester of my junior year. The prerequisites were made up over the summer, and the next year I applied to medical school.

For me, medical school wasn't that hard. It was a lot of work, but nothing was nearly as hard as some of my engineering courses. My medical school resume was pretty good. As I look back, it was not as good as I thought, but still it was pretty good. Because of concerns about this "affirmative action", I chose not to state my race on my application and did not provide a picture. It may have been a stupid move, but it was a choice I made at the time because I wanted to get there on merit only. Fortunately, it didn't hurt me. You see, because of my fair complexion, people usually can't place my race. It wasn't until I was a 3rd year resident that my chairman realized I was black. That still gives me a little chuckle.

Since medical school, I have been the only black resident, fellow, and faculty member. I am different in a number of ways. You can pick any one of the many things that makes me different. Whether it be race, family history, area where I was raised, or my marriage to a British citizen, I bring something different to the mix. There are people in my field that have the similar backgrounds, but not many. Can you now see my perspective?

Diversity is important. Different opinions and upbringings are important. Whether it be race, gender, or social status, it is important to have a heterogeneous population of physicians. Physicians that can relate to different patient populations. Be it a small town or the inner city, people from these areas tend to return to provide care in these needed areas. Patients also like to see people who are like them providing care. It is important that we mirror our population.

As I have seen and heard many times in the past, if a majority student doesn't get a spot and a under represented minority (URM) does, they wonder if they "lost a spot" to an under qualified URM. Well, let's look at the numbers. In a recent article in the Journal of the American Academy of Orthopaedic Surgeons, Templeton et al addressed the discrepancy in the percentages of URM and women between the medical school population and the orthopaedic resident population. The opening statement of the article states this:

Women and underrepresented minorities make up smaller proportions of orthopaedic residency programs than their numbers in medical school would predict, according to our evaluation of self-reported orthopaedic residency data from 1998 and 2001, as well as information on medical students published in 2002. Based on race, ethnicity, and sex, comparisons were made between students entering and graduating from medical school and those in orthopaedic residency programs. With few exceptions, the percentages of women and underrepresented minorities were statistically significantly lower among those training in orthopaedic residency programs compared with those same groups entering and graduating from medical school. The percentage of women and minorities in orthopaedic residency programs remained constant between 1998 and 2001. Further study is necessary to determine whether fewer students of color and women apply to orthopaedic residency programs becauseof lack of interest, lack of appropriate mentoring and role models, or other factors.

When I hear or read majority students make statements in relation to URM getting spots over a qualified majority students, I laugh a little. If you look at the numbers, there are far more white males competing than any other demographic. If you take a look at the tables from this article in 1998 and 2001, the discrepancy is incredible, especially for women. Majority students occupy 78.8% of orthopaedic spots in 1998 and 76.9% in 2001. The biggest discrepancy noted in the study is with women. The percentage of women in medical school was 44.3% of students in 1998 and 47.6% in 2001 with the percentage in orthopaedic residencies being 7.6% and 9.8% respectively. These numbers are not even close to the general population.

Even our national organization AAOS has started an initiative to encourage URM and women to apply to residency programs. The AAOS realizes that this is something that needs to change and they make this statement:

As the demographic face of our nation changes, the orthopaedic community is evolving to reflect and adapt to these critical shifts in the landscape. Recognizing the value and strength inherent in our diverse population is a first step. But our larger goal remains embracing solutions and mechanisms that give all people access to and a place in our healthcare system.

These are exciting times! The world is changing. Its face grows more diverse each day. The AAOS is committed to keeping, and setting, the pace. As our population grows rapidly more diverse, our need grows significantly for physicians who reflect this diversity and are accessible to communities and individuals with unique needs. The AAOS is taking the lead to ensure all people will be served appropriately by the field of orthopaedics.

Diversity is not just for the underrepresented populations, it is also for those majority students and physicians. It brings the different perspective to a program. Many may take care of these populations, but do they understand the perspective? Whether it be understanding the differences in the Hispanic cultures, or understanding the inner-city culture, having a diverse group of physicians helps everyone become more sensitized to all of these issues.

If we go beyond the clinical setting to research, there are diseases and conditions that are specific to certain populations. Issues like gender differences in bone structure and outcomes after total knee arthroplasty have created a new line of gender specific implants. There have been a number of studies that have looked at Ethnic and Racial Disparities in Diagnosis, Treatment, and Follow-up Care and Disparities in Orthopaedic Surgical Intervention; they have noted both racial and cultural differences. Who is more likely to investigate these conditions and issues than those who could or have been directly effected by the conditions.

Understanding that our numbers are low, how can we improve the numbers? One of the biggest problems is the lack of mentors. In my education, I lacked a "like" mentor. My mentors came from my "majority" physician mentors and my family. Looking specifically academic physicians, the numbers of URM or female are few. Nationally, there are powerful people who fit these groups. Dr. Rankin will be our academy president next year. In my own field, Dr. Crawford has been a leader in the pediatric orthopaedic community for years. The problem is that, if you are a URM or female student interested in my chosen field, it is hard to find someone "like" you who can share their experiences. If I look at my own background, I don't know if I ever could have found a mentor with the same history, but I don't think that was as important as finding someone that I could have related to. Be it cultural similarities or personal history, having a mentor who I could speak frankly about my fears and insecurities would have definitely helped me along the way.

Over the years, I have learned to adapt to my different situations. As such, I am able to view things from many perspectives. I have stated in this blog previously that I have tried hard to remain humble and approachable. Today, I put myself out there as someone that medical students and residents can relate to. I believe it is important that we understand our differences. Whether it be race, gender, culture, religion, or generation, we probably have more in common than we think.

T.S. Elliot writes a poem from 5 different perspectives. Like this poem, each physician/patient interaction is seen through multiple perspectives. The perspective of the patient with all of his/her fears and past history. The perspective of the physician and his/her personal experiences, as well as previous interactions with like patients. The perspective of the nurse and other physician extenders who bring their past history and experiences to view this interaction. Ultimately, understanding our differences is what helps make these interactions better. Regardless if it makes us color blind or more culturally sensitive, diversity ultimately makes us all better physicians.

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

~Galileo Galilei

We all have our quirks ...

“The great aim of education is not knowledge, but action”

~Herbert Spencer

Looking back, residency was one of the best times of my life. Some of the experiences were priceless. I remember sitting in the resident's room and speaking with the other residents about the day. We would complain about the day. We would talk about the interesting cases that we had seen or done, what we had been accused of doing wrong (because we were always in the right), and what our upcoming plans were. Inevitably we would begin to speak about our "attending staff" and what they had said that day. We would commiserate about how we all had similar things said or done to us. I guess you could say after a while, some of the attendings became caricatures of their sayings and behaviors. If a resident would say a particular attendings "saying", we would all smile in acknowledgment. It was like an inside joke. Now, I am on the other end. I am one of the people that they mimic or mock. I guess we can't help it, we all have our quirks. It is fun to poke fun at people's eccentricities.

As an educator, it is important that you are self aware. We must understand out strengths and limits. To be effective at educating, we must understand what teaching style fits our quirks the best. I believe your teaching style should fit your personality, because the possibility of changing your general nature is slim to none. For instance, if you are not an outgoing and humorous person, you are not going to be that kind of educator. It is just a fact.

In evaluating myself, I realized I am a fire starter. Ok, that doesn't mean that I go out setting fires, but I like to look at things from the other point of view. I quite enjoy being the instigator. I do this during dinner conversations. My wife says she can see when it is coming because I get a little devilish grin. It is in my nature. I can't help it.

Usually when a resident comes to me with a plan, I like to take the opposing view point and argue that position. Even if I agree with the resident or medical students plan of care, I want to see if they have a reason. You may say that's mean. I don't know if it is, but it sure is fun. In truth, I want to see if they really understand why this is a good plan and aren't just parroting back what someone told them or what they read. I want to know that the understand enough to debate the subject. For example, a common debate I like to have with the residents is what type of graft to use for an ACL reconstruction, PROS and CONS. The resident usually fumble through this question because they usually haven't thought about it. Why do I ask it, because patients ask the same question. They need to have a good answer for why they recommend one over the other. Coming up with a plan is one thing, but being able to defend that plan is another.

I know we all have our quirks. I don't like a lot of futzing in the OR, I like foam in my casts ('cause it's cozy), and I like my coffee with cream and 1 Splenda ® (dam it). I say, "s/he's gonna love it," when I love it; and I say, "that makes me sad" or "that hurts my feelings," when I don't. If I am teaching, I want to see if the resident is actually thinking. The best way I have found to test someone's understanding of a subject is to debate of the topic. That's just how I roll. So, for now, I'll keep setting fires to see where it takes me.

“Tell me and I'll forget; show me and I may remember; involve me and I'll understand.”

~Chinese Proverb

Interviews are over ....

“The greater the difficulty, the more the glory in surmounting it.”

~Epicurus

Today was our last day of interviews. The rank list is done. The more I am involved in this process; the more I realize that it is not that scientific process. It gets difficult when you get to the last few applicants. What I have learned this year?

As I previously posted, I asked all of the applicants the same group of questions. In most of my interviews, these questions an provided the opportunity for further conversation. A couple of interviewees fell flat. I don't mean that the answered wrong or poorly, just that were flat. It is like a girl who likes a guy. She gives him every opportunity to "impress her," and he misses the cues. You know what I mean? All in all, the questions went pretty well.

For my first question, I asked, "in one sentence, tell me who you are outside of medicine?" To this question, the common themes were:

• hard working
• loves outdoors
• loves being with friends and family
• easy going
• loves sports

Very few actually gave me a sentence. Most just gave a bunch of adjectives that described attributes that they think would be good attributes in an orthopaedic resident. For the few that gave me sentences, here are a couple I liked:

• I am a geeky girl from the midwest.
• I am a father, husband and friend, that loves music and the outdoors.

To the second questions, favorite book and author, I surprisingly got some interesting answers. Mostly popular authors and books. Several people enjoyed Dumas. A few like historical and biographical books. For most of them, this was not a difficult question to answer.

To the third group of questions, favorite song/album and artist/group, the answer was not as obvious. Most had multiple choices from Country to Indy rock. U2 and the Beetles where probably the overall winners. Groups like Shane and Shane were new to me. GNR and metallica were also popular choices. Lupe Fiasco and Tupac came out of no where from one application. I liked that.

Overall, I think the questions did what I wanted. They initiated conversation made most feel comfortable. I learned a non-medical side of the applicant. I got a glimpse into their psyche. It surprised me that no applicants in their review of our program prior to coming found my blog with the questions. Oh well, I tried to give a heads up.

I do think I will use these again next year. I may change them a little. May be I will ask what ringtone they would give to my phone number. Maybe they would use the Imperial March from Star Wars, like I use for all of my partners (other attendings).



One of my residents just told me he tagged my number with Pantera's Walk. That was FFT.

Pantera's - Walk


Avenged Sevenfold's - Walk cover


May be I will ask what CD's are in their car or songs on their IPOD's recent played list? Or may be I will ask what their ring tone is? I will continue to search for ways to assess an applicants past the USMLE and grades. I look forward to this next year.

“What is not started today is never finished tomorrow.”

~Johann Wolfgang von Goethe

We are all in this together ....

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

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

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

It is interview time again

“We tend to forget that happiness doesn't come as a result of getting something we don't have, but rather of recognizing and appreciating what we do have.”

~Frederick Keonig

It is that time of the year. All of the applications are here. We have to go through the tedious process of review resident applications for interview. It is a difficult process for our program because we actually go through all of the applications for the pre-screen. AARRRGGGHHH. I wish there was a fail-safe approach to screening applications and selecting residents. I have not found one yet.



So many people ask the question, what does it take to get into orthopaedics? I have posted before some statistic on what many programs look for in an applicant. But, my view of this is like drafting in the NFL. The statistics do not give you the intangibles. Randy Moss and Terrel Owens are great receivers; but if they are in the wrong system or with the wrong combination of players, they don't do well. And, who can forget the Ryan Leaf or Akili Smith. Then there are players that put in the right systems they flourish, Willie Parker and Tom Brady. With that prospective, I believe that there are people and programs that are a better fit. That is not to say that if you have some of the basic stats (USMLE, Grades, etc) you are or are not a shoe-in to a program. But, I do believe that there are better fits.



From the program end, what we try to do is know who we are. We understand what type of program we have an what residents do particularly well and which don't. We can look back over years and know what is our normal pattern of applications. We know what schools and states we receive a lot of applicants from and which ones we do not. This makes that application selection process different. In our program, we are not necessarily looking for some statistical wonder or the ugly duckling. What we generally prefer is a solid individual that fits what we feel is our personality profile.

From the applicant prospective, I believe that best approach to applying is to be realistic with yourself. Know what you strengths and weaknesses are (yes we all have them) . This is an important inventory but difficult to do, well. Next, you need to see where you would like to be located regionally, and look at you school's history of placing people in programs in that location. Then you should look the programs in that area and evaluate how they fit into your personality profile. This will help you in choosing the best program that will help you flourish.


In the end, most of those that obtain a residency will complete and become an orthopaedic surgeon. The more important question is will those same people have a positive experience and become the best with their abilities. My view is that not every flower will be beautiful in every soil; but, given the right soil, every flower can be beautiful.

“The reason people find it so hard to be happy is that they always see the past better than it was, the present worse than it is, and the future less resolved than it will be”

~Marcel Pagnol

China Mission - 2007

“If you only do what you know you can do- you never do very much.”
~Tom Kraus

It is your typical stuffy airport. We arrive early Friday morning. The team assembles. It is a long fight (1hr to Detroit, 14 hrs to Tokyo, 3 hrs to Shanghai, and a 2 hr car ride to Suzhou). All of the members of the team except one know each other. We are excited and anxious. Many questions flutter through our minds. What cases will we do? What equipment will be available? Did we bring enough to do our cases? What are the facilities like? Etc.

We arrive in China at night. There is a large greeting party with a sign that says WELCOME HTC, and has all the members names. We are all dragging, but there is still a 2 hour car ride to go. We receive a welcome packet and the agenda for the week. Hmmm ... the agenda is pretty packed.

Sunday is a recovery day. A little site seeing. We are introduced to old China, through a tour of a several century old garden. I feel a bit jet jagged. We are taken for a traditional Chinese dinner with the president of the hospital, head of the CDC, and the head of the pediatric orthopaedic department. Dinner was very interesting, especially the jellyfish.

View Album
Get your own

Monday was a clinic day. All of the perspective patients were viewed. The pace was different than I am use to, not the usual 35-40 patients in the morning. Patients were brought in and examined, decisions were made, and surgeries planned. We took breaks for tea. I spoke with one of the Chinese pediatric orthopaedic masters. He is greater than 80 years old and still his mind is vibrant.

“One generation plants the trees, and another gets the shade”
~Chinese Proverb

After all of the patient were seen. We then toured the hospital and looked at the OR's , evaluated our instruments, and planned for the coming day. We get the lay of the land.

The inpatient facility was not attached to the operating rooms. Therefore, the patients would have to be transported across the small street post operatively. The inpatient unit was filled with beds. There were beds everywhere. They lined the hallways and filled the rooms. We walk past children in skin traction for elbow fractures. We learned that the patients care on the floor is rendered by the family. The family changes the beds, provides the food, and does the primary observation of the child. We learned that in the Chinese system there is no rush for people to be discharged. The hospital stay is relatively inexpensive for the families (about $5/day). These were slight differences from the US system.

During our first day, we were also introduced to a number of residents. I learned that their system is similar to the British system, yet different. There are 2 tiers, an academic path and what I would call, a "worker" path. In the Chinese system, medical school is 5 years. After medical school, you can do a residency and start to practice. To receive you license and become officially a "doctor" then you must obtain a masters to sit for the licensing examination. In this path, the "worker" path, you will not be considered for the higher level positions within the hospital. This is good for some, but if you desire to have a higher level position, you must do more formal classroom training. Those in the academic path continue schooling and receive a Ph.d. in medicine. Now, my understanding of the registrar and resident roles is fuzzy. I am not sure if they are like junior attendings or high level residents. But, the registrars and residents are guided by a senior attending and appropriate cases chosen for them. Needless to say, in every case, we had 4-7 residents, registrars, and attendings in the room. This hierarchy took a little getting use to.

View Album
Get your own

We operated from Tuesday through Thursday. Our cases varied from Scoliosis (idiopathic and congenital) to clubfeet. During the first day, we operated primarily with our team. For the subsequent days, we operated in tandem with the physicians from China. It was a wonderful experience. The hardest part was communication. Many of the physicians understood some English, but not enough to fully describe surgical procedures. So, there were a lot of hand signals. We learned a little mandarin. Just enough to get by. (You know, yes, no, ok, and like a good American, we learned a couple swear words.)

All of the surgeries went well. There were no immediate surgical complications. Overall, the surgical experience was good. We didn't take on any cases that we couldn't handle. We kept it simple. Of course, our ultimate goal was to DO NO HARM. We hoped for a good learning experience. Our education did not come in the form of surgical procedures or clinical cases; it came from learning a different culture. We learned a different approach to medicine. We saw some older techniques and treatments that we typically do not use. The patients were very appreciative. They even came in their best clothes to the appointment. This was a great experience.

On the final day of our mission, we were able to do a little more site seeing. Then back on the the plane for a full flight and a long night. Was the trip worth it? I would say without a doubt. It reminds you of the basics of medicine, the practice of medicine. The worries of documentation, malpractice, billing, hospital administration, and university policy, were gone. All we thought about was treating patients. It was nice.

“Happiness is the meaning and the purpose of life, the whole aim and end of human existence”

~Aristotle

Why don't we get to discuss money in medical school?

“The object of education is to prepare the young to educate themselves throughout their lives.”
~Robert M. Hutchins

Long ago, I remember sitting in an interview for medical school and the interviewer asked me, "what do I want to do?" A typical question that most applicants get. I had already decided on orthopaedic surgery as a specialty, but I still had the idealistic views that I could make a difference. My answer was like so many others who said in some way, shape, or form that they wanted to help the "world." This idealistic views do change as time goes by and we realize that this is a business and that money makes the world go around. In medical school, especially at an academic powerhouse, no one ever talks about the financial side of medicine. It is money that fuels the machine and without it the machine does not run. So, why is it that there is such a lack of training on the business end of medicine?

I began to write this post about a month ago and Howard J Luks, MD posted before I could complete the thought. He raises the same question that I have. When is it that we talk about business? (which really means talking about money)

No question that our students are well trained in the science of medicine. Unfortunately, very few students prove to be well trained in the business of medicine. Many students are even embarrassed to ask questions pertaining to the business of medicine because they are afraid they will betray their idealistic or altruistic beliefs that made them commit to a career in medicine in the first place. What do I mean? A student who recently rotated with me felt she could not discuss the business aspects of a career in medicine with her professors or colleagues in fear that she will appear to be cold or unfeeling. I had a student rotating on my service recently who wanted to go into Cardiothoracic surgery because it was "really cool." He had no idea how much their reimbursement has been cut. He had no idea that their case load has diminished dramatically over the years and he had no idea that true cardiac centers were performing some "pretty cool" new cardiac procedures. Some women are afraid of a career in ortho because they are petite. Some think that a pediatrician makes 300-400k per year.

I must say that I feel we owe the students much more than a book based education about the science of medicine. They need to know about what a career in medicine entails. They need to know about some of the hardships we are experiencing now and some that we are afraid may materialize. They need to know about EMRs, P4P, reimbursement changes, and the people/organizations behind the push to change the way that medicine will be practiced in the near future. LEAPFROG, PROMETHEUS, CMS, Payors, PBMs, EMRs, PHRs etc should be terms the students should be comfortable with. Otherwise they will plod through their residency, learn little more about the biz of medicine than they already do and then they will be thrust into a practice environment they have no idea how to navigate through.

WEB SITE LINK

The other week I was sneaking some brownies in the general surgery conference room and all 30 of the medical students where present (okay that was an exaggeration, there were only about 5, but it seemed like 30). I asked them if they wanted a lecture on something. I was in between cases and would be glad to teach a little. Of course they said no, but I forced myself on them anyway. I asked what their plans were etc.. Some how we got on the topic of coding. I informed them by CMS guidelines the medical student note means nothing. For billing purposes, we can not "link" to their note and bill. They seemed astonished.

For about 20 minutes or so I went on about ICD-9 , E&M, and CPT codes. We discussed billing, overhead, and collections. We discussed what it means to "par" with insurance. I spoke to them about the differences in incomes between military, academic, employed, and private practice. I think I over loaded them. But, I think it was a conversation that they needed to have.

As Dr. Luks points out, many of those in medical school today do not get the training in business; yet, when they graduate medical school, they are asked to run a business. I hear so many medical students speak of the "salary" they will have when they are done. Unfortunately, in todays world, it is becoming more of an "eat what you kill" type of world. There is really no "salary" anymore. So, should the business side of medicine be taught? I would scream YES. The question then is when do we teach it? The information in medical school is already more than one can manage. Residency time (total hours) is decreasing yet the complexity is increasing. Where do we find the time? I wish I had the answer.

“You are the embodiment of the information you choose to accept and act upon. To change your circumstances you need to change your thinking and subsequent actions.”

~Adlin Sinclair

Tying the attendings hands ...

“Wisdom is knowing what to do next, skill is knowing how to do it, and virtue is doing it.”
~David Starr Jordan

The 80 hour work week restriction has gotten a lot of attention over the past 5 years. Many believe that these are the only changes that have significantly affected resident and medical student education. Over the past 20 years there have been a number of things that have change the way physicians practice. As much as the 80 hour work week was a shock to the training system, there have been small changes in requirements for billing, resident supervision, and reimbursement, that have probably affected resident education in a more subtle way.

In the early 90's, many academic medical centers were evaluated by CMS and levied huge fees on a number of academic medical centers. From these evaluations, a number of new guidelines were set for billable encounters in teaching situations. The changes have require more of an attending presence in clinical and surgical procedures. Although this did not directly change resident education, it changed the attendings participation in patient care. The days of (billed) resident run clinics went away. The days of (billed) surgical procedures without attending presence are gone. These changes are good for patient care, but changed resident education. It increases the duration of the learning curve. There is no room for allowing the young surgeon to figure out how to get through the cases. I call this the "futz factor." Young surgeons need to "futz" to figure out what works best for them. With attendings present, they tend to become impatient with "futzing" and take over the case. Most young surgeons need to do, observation is not as helpful unless you have the experience on which to build. This change the resident attending interactions and cause many attendings to become more hands on.

Along with increased requirements for billing came a decreases in physician reimbursements. Decreases in reimbursements caused an increasing need for surgeons to become more clinically active. Department chairmans began to see the departments overall income decreasing. Systems to encourage increase clinical production (incentives) were set up. Now, you income became more like true private practice. The mentality of "you eat what you kill" began to creep into the mentality of new attendings. The days of seeing few patients, doing a couple of cases and getting a large salary are gone. With less overall (clinical) income, salaries became effected. It has caused attendings be like Snoop said, "with my mind on my money and my money on my mind."

The question may be posed, "why would this change resident teaching?" You would assume that more attending presence there should be better education. You would assume that more cases and more out-patient and in-patient experience would be better for resident education. Unfortunately, I don't see this as being the case. What I see is more patient being seen in clinic and less time for teaching. What I see is more cases being done with a limited amount of time, requiring more attending participation and less time to "futz". What I see in an increasing number of different procedures and increasing complexity of these procedures with less time to learn them. I see residents being over extended because of the increasing demand to produce clinically. I see the use of PA's and other physician extenders taking away residents ability to learn some of the basic skills, such as casting. With money being the driving factor, education suffers. Teaching does not pay, therefore education suffers.

So, as much as I harp on the "new generation" and on the 80 hour work week, I also think that our ability to educate well has also been affected. I think that we are not educating as well. Our ability to spend time educating our future surgeons has changed. We will have to develop new techniques for educating them. I fear things will get worse before they get better. I worry that we may be graduating future surgeons who are less prepared than in the past. Is this better for patient care?

“Real education must ultimately be limited to men who insist on knowing, the rest is mere sheep-herding.”
~Ezra Pound

Practice makes perfect ... or something like that

“The surest way to corrupt a youth is to instruct him to hold in higher esteem those who think alike than those who think differently”

~Friedrich Nietzsche

Over the past 10 years, I have had the opportunity to work with residents from different backgrounds, undergraduate majors, and orthopaedic programs. I have worked in 5 different academic settings. I state these facts because my upcoming view is not based on a view of one way of educating (i.e. the Harvard or Duke Way), but based on an understanding of the differences in both teaching and learning styles, academic and clinical settings, and generational changes. In my anecdotal point of view, residents in today's residency setting are technically delayed. The technical skills that I observed in residents 5 years ago don't seem to appear in the residents until about 6 months or so later. Some people reading this may feel that it is a slam. It is not; it is just my observation. When I ask myself why has there been such a change across the board, the only significant change has been the institution of the 80 hour work week.

One of the main reasons I like teaching is because I like to watch the intellectual growth of young surgeons. I enjoy seeing their development from novice surgeon afraid of cutting too deep, to a confident graduating chief. It is almost like raising your kids. "Oh, look he is using the cob like a big boy, now. He makes me so proud." Recently I have begun to notice that some of the skills that I had, I guess, taken for granted are not being developed. Basic skills that many learned in their internship in the past are being learned as second year residents. I wonder if we are failing our residents by not providing them with the tools they need to practice on their own. Are we setting them up for failure?

When the 80 hour work week was initially proposed, many surgical programs and grey-haired, "old school" surgeons said this will never work. I believed and still believe that the change was necessary. I also believe that once all of the data comes out that there will be changes in the duration of residencies (increase in time), the operative logs will be used for hospital credentials (no enough cases in residency = no privileges), and increases in the requirements for initial hospital monitoring of new surgeons and board certification. This is what I see in my crystal ball; although, it is sometimes cloudy.

There has been a recent study that have noted a decrease in cases logged.

Weatherby and fellow researchers used ACGME case logs to study PGY2 and PGY3 students' operative experience gained in a two-person orthopedic residency program in 2002-2003 (before the 80-hour week) and in 2003-2004, after the longer week took effect. Researchers also gave junior residents logs in which to record subjective caseload information, Weatherby said.

In 2003-2004, PGY2 and PGY3 residents performed 759 operations, or 195 (21%) fewer than in the previous year, Weatherby reported. Cases per rotation averaged 79.5 in 2002-2003, compared to 63.3 the next year, showing a 20.44% decrease (P=.009).

"The trend is obvious," he said. "It is obvious that it is national, too."

Residents missed 9% to 13% of total surgical case volume between November 2003 and January 2004, with each resident missing an average 10.8% of cases, totaling 254 cases over 64 post-call days, Weatherby said.

"Our study shows that residents who have begun training after the 80-hour work week will do significantly fewer procedures, particularly at the PGY 2 and 3 level," Weatherby said. "This may result in a decreased level of skill acquired during training or it may shift the majority of operative experience to the PGY4 and 5 years, prolonging the learning curve."

Weatherby called for more research and more assessment of how the new hour regulations affect surgical training. He also voiced concern about residents having fewer opportunities to learn surgical procedures in a reasonable amount of time.

"We must ask ourselves if we will at some point, in fact, build up the skill of orthopedic surgery," he said. "This also supports the theory that operative experience is deferred ... throughout the year, thus prolonging the learning curve."

Weatherby B, Rudd R, Ervin TB, et al. The effect of resident work hour regulations on orthopaedic surgical education. #121. Presented at the American Academy of Orthopaedic Surgeons 73rd Annual Meeting. March 22-26, 2006. Chicago.

I ask myself, how do we accommodate for the decreased numbers? Years ago, many surgeons would practice at home. They would learn how to drill and sew outside of work. They always worked on their technical skills. In the current generation, I have not seen the desire to work outside of “work” to learn how to perform their craft. Technical skill can not be read, it must be practiced. My residents and medical students are well read. They can quote literature, know how to gather information, and put on a heck of a power point show; but operative skill "not so much." The chiefs feel the need to operate because they what to gather the skills before graduating (and they are avoiding clinic) and the juniors operate less because of floor, clinic, and ER responsibilities. Then the cycle continues the next year because the rising junior becomes a chief and needs the operative experience.

I can hear people now saying, "Well just let them operate and get PA's and NP's to manage the floors and clinic." That is not the answer either. One of the most important skills for a surgeon is making good clinical decisions. Decisions like when to operate and when not to operate; which patients are good candidates and which ones are bad candidates; and what your outcomes are realistic expectations from procedures. That experience comes from follow-up. As they say, there is nothing like follow-up to ruin your good outcomes. We haven't even addressed billing, coding, and the other business aspects of a practice that are barely taught in residency.

As I look forward, I wonder if we are failing them by not providing them with ways to develop technical skills without actually operating on a patient. I know that there are simulators that are being used to help address these deficits (arthroscopy simulators), but are they being utilized appropriately? How can we accommodate for a decrease in case volume without increasing residency time? Maybe some of you have ideas. For now, I am still trying to keep from getting frustrated.

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

Step, Step, Breathe ... that is all you have to do .... life is not hard

“Knowing others is intelligence; knowing yourself is true wisdom. Mastering others is strength; mastering yourself is true power. If you realize that you have enough, you are truly rich.”

~Tao Te Ching

Step, step, breathe.... Pace yourself. Control your breathing. Check .... arms too tight. Need to concentrate on keeping loose. I need to preserve energy. Check .... stride is comfortable, pace is good. My legs feel loose. Need to keep from leading too much with my dominate right leg. Step, step, breath, step step, full breath. Check ... slight elevation. Check foot position, arms position, pace. Settle your knees down, they are coming too high. You will fatigue your hip flexors. Check ... down hill. Control your fall down the hill. Stay away from decelerating heel strikes. Remember St. Louis at the 24 mile ... lactic acid build up .... aaarrrgghhh. Step, step, breathe .... check .... Arm position, foot position, stride length, heart rate, pace.

Chicago marathon is coming up soon. I am in my taper. Most of this next 1 1/2 weeks runs will be to keep my legs fresh, remembering my planned pace, preventing injury, and preparing for race day mentally. The marathon is a mental exercise for me. I think I will do OK this year. I have been hampered with injuries this training period. So, my training was not up to what I would have liked. This year I hope to finish without injury. I hope not to make the same mistakes I made in St. Louis. I learn what my body can tolerate with each marathon and training period. Sometimes I push to hard and fast; and other times not hard enough. The more races I do, the better I get at preparing physically and mentally. It is very similar to surgery.

Yesterday, we did a basic case. As I do, I have a mental plan of how I would approach the procedure. From the set up, to the size of implants, I have in my minds eye the way I would approach this case. I know where the rate limiting steps are. I know what is acceptable and what the room for error is. How do I know these things? It comes from experience. I have enough experience to know what works for me. I know what my skill sets are and how to work with my skill deficits. But, this is a perfect case for a chief to spread his/her wings. So, I step back and let the chief make decisions. This is how they find out their own limits.

It was routine that in surgical cases, residents would come with a very descriptive plan of how to approach a particular case. They would write out the details of each case from bed positioning, C-arm positioning, and draping, down to what sized screws and suture. For my partners, it used to be a reason a resident would get yelled at or possible thrown out of the OR. But, in today’s world, it doesn't happen as frequently. But, it serves a purpose.

I watch my chief make decisions on a basic case. Occasionally I make little suggestions, usually when I am asked. The case goes relatively smoothly. The results are FFT. The x-rays look OFT. So, now let’s look at the case as a whole and be critical. What was done well? What could have been done better? Yada yada yada. I think this assessment of surgical cases is extremely important in the growth of a surgeon. It is how we improve our skills and limit our mistakes. My critique of this procedure was “time”. He was leaking time during this case making it longer than it needed to be. We talked a little about how to be more time efficient. I recommended that he work out ways of limiting the down time. You should always be moving forward. Hands should be moving with a purpose. This is a vital training tool that sometimes gets lost in the dust of intramedullary rods, locked plates, and pedicle screws. Sometimes we get caught up in the end result and not how we got there. Heaven forbid we talk about outcomes.

Step, step, breathe .....

As I complete this training period. I will look back at the faults of my training. I will make adjustments. I will readjust my goals. I will look at what I did well and what I didn't do so well. I will look at my marathon attack plan and see how well I was able to keep to it. I will make adjustments to both my training plans and marathon plans. Then back to the grind.

As a medical student and resident, we do get caught up in many things. There is mental and physical fatigue, and lots of information to learn. Please always remember, you are not in training to be a medical student or resident. You will eventually be a practicing physician. You must start developing those practicing thought patterns. And as with running, don't forget to breathe.

“Sometimes I lie awake at night, and ask, 'Where have I gone wrong?' Then a voice says to me, 'This is going to take more than one night.'”
~Charles M. Schulz

Think before you shoot ....

“I know that you believe you understand what you think I said, but I'm not sure you realize that what you heard is not what I meant.”

~Robert McCloskey

I really enjoy the interaction with my medical students and residents. I like to see their eyes light up with new knowledge and experiences. It is like hitting the sweet spot on the golf club; it is what keeps you coming back for more. As much as it can be a joy, it can be an enormous headache.

For many surgeons, there are cases that we commonly do. We do them so often that it becomes like second nature. Our moves are effortless. We have our favorite instruments and our favorite retractors. We know what works for us. When teaching someone your techniques, you have to put into words what has become second nature to you. This can bring on some frustration from both the educator and the learner.

In my practice, the most difficult techniques to teach are the percutaneous techniques. What makes this difficult to teach? For percutaneous techniques, you need to have a mental picture of what is underneath the skin without seeing. Using skin land marks, 2-D xray images, and other room indicators of position, you should be able to determine your position in a black box. For most novice surgeons, there 3-D understanding of anatomy is very limited. They rely a lot on vision and fluoroscopic images to determine position. In percutaneous procedures, vision is taken away. The lack of visual input created a void of input and the causes an extreme reliance on fluoroscopic images. With only one input, they become confused and frustrated; they lose orientation; they lose focus. I lose hair.

For the pediatric orthopaedist, the supracondylar humerus fracture (SCH FX) is the most common fracture that we operatively treat. In my hands, >95% of SCH FX can be treated closed or percutaneous. If I do a Type II or Type III SCH FX, after draping, it takes about 10-15 minutes. Quickly, my routine. Patient in the room and intubated. Metal anesthesia Christmas tree on the operative head side with a foam pad. Patient moved to the edge of the bed, on the operative side. The bed is turned. The C-arm is turned upside down and used as a table. The are is prepped and draped. Using fluoroscopy, the elbow is reduced and arm is held flexed with a coban. Then I place 2-3 lateral to medial 0.625 K wires. The coban is released. The positions are checked and the fracture is stressed. Pins are bent and cut. Easy as pie right. But, the hard part is placing the pins. This is where I struggle.

The placement of percutaneous pins or any percutaneous procedure requires a specific understanding of the anatomy and the ability to uses references to identify the position of what you cant see. If you can imagine, you have a black box that you can not see into and you have to place instruments in a specific position based on references and a 2-D image. Oh, and the box is moved to get the opposing 2-D image. This is difficult. Because the young surgeon relies so much on the fluoroscopic image, they are easily disoriented. They start randomly placing pins without much other reference/sensory input. This is what I refer to is the Young Skywalker Effect.

Ben: Remember, a Jedi can feel the Force flowing through him.

Luke: You mean it controls your actions?

Ben: Partially, but it also obeys your commands.

Han: [laughs] Hokey religions and ancient weapons are no match for a good blaster at your side, kid.

Luke: You don't believe in the Force, do you?

Han: Kid, I've flown from one side of this galaxy to the other. I've seen a lot of strange stuff, but I've never seen anything to make me believe there's one all-powerful Force controlling everything. There's no mystical energy field that controls my destiny. It's all a lot of simple tricks and nonsense.

Ben: I suggest you try it again, Luke. This time, let go your conscious self and act on instinct.

[Ben puts a helment on Luke covering his eyes]

Luke: With the blast shield down, I can't even see. How am I supposed to fight?

Ben: Your eyes can deceive you. Don't trust them.

When doing percutaneous procedures, you must begin to take away variables in the room. You must make unknowns a known. You must take what things you know and make assumptions about the unknown. Of course the more you do, the easier it is. I ask my residents to "think before you shoot." That means, before you take an x-ray, think about where you position is in relation to your other knowns (skin and bone landmarks). (One thing I hate is x-raying without a purpose.) Then I have them place a pin in the best position. We check both an AP&LAT x-ray. If it is good, next pin; if not, leave the pin and USE IT AS A REFERENCE. You know where you pin is on the AP&LAT x-ray, place you next one using the first one as a reference. Use it like a compass. It is just that easy. Well, it sounds easy. It is easier said than done.

For all of you novice and advanced beginner surgeons, think before you sho0t. Learn your anatomy and find ways of making the unknown of the "black box" known. If you are using a fixed anatomy, pinning a hip on a fracture table, use fixed room land marks (the floor, the fixed fracture table post relative to the floor, alignment of the C-arm) to help guide you. At times, it does feel like you are using "the force."

“You are rewarding a teacher poorly if you remain always a pupil.”
~Friedrich Nietzsche