"Sorry about Michigan" ...

Do not dwell in the past, do not dream of the future, concentrate the mind on the present moment.
~Buddha

Life is always throwing us curve balls. In medicine, it is easy to get caught up in work. Medicine consumes. As I have said before, I am a grunt. I work. I teach. I mentor. It is my work persona. Outside of work, I am a husband, father, friend, and blogger. Balancing these roles is very difficult. Often, one overshadows the other.

Over the last few months, I have been engrossed in medicine. My long days at work brought on by emergent surgeries, OR delays, and over booked clinics. Mentoring keeps me in the office answering the questions and concerns of residents and medical students. Administrative meetings for the residency, medical school, or hospital, fill my lunch hours and evenings with bad coffee and cookies. Mentally fatigued, I come home to a family starved for attention. The dog needs to be walked. My daughter needs to tell me about her day. My son needs to be read a story and put to bed. Then there is my wife who wants to share with me what the kids are doing, changes she wants to make on the house, vacation plans she has for the future, and things friends and family are doing. There were days that I don't think I had anytime for myself.

Last week started like every other week. Monday was a long clinic day. Tuesday was a long OR day because of OR delays. Wednesday kept my head spinning with OR, clinic, OR, Clinic, and then a consult that changed my week and probably helped to bring me back to humanity. I was consulted on a patient that is well known to me and the hospital. His disease is chronic and likely fatal. Studies were ordered. I reviewed them and realize that he needs surgery, a big surgery. I sit down with the patient and his father. We discussed the options and our goals. Mom was not present because of another family emergency. After going through the options and expectations, they elected for surgery.

Wednesday night, I was on call at the adult hospital. I was up all night. Thursday long OR day and I was on call at my little hospital, luckily did not have to go in. Friday, surgery day, we had a pre-, post- op spine conference, I gave Grand Rounds to rheumatology, and then went to clinic. The case was in the afternoon. OR was ready. All of the implants were available. Anesthesia was informed of all of the problems and they wereready. Pre-operative plan was done. I was ready.

I walked out to talk to the patient and his parents. Mom was there apologizing for being out of town dealing with a family tragedy. I explained the planned procedure to the mother and she understood. At the end of my discussion, my patient said to me, "dude, I am sorry about Michigan." He is a Notre Dame fan. Although he struggles to be like other kids, he was at ease here. He has been in the hospital more than he has been in school. He knows that he has a disease that is likely fatal. He and his family have come to terms with this. Now, it is about quality of life.

We went back to the OR and anesthesia places lines. I visualized my plan. My mind's eye showed me the procedure, step by step. I was ready. After lines were placed, we positioned the patient. At that moment, a wave of emotion came over me. Tears filled my eyes. I didn't want to make a mistake. I questioned whether I was doing the right thing. I didn't want to be the person that shortened young man's life. He trusted me. His family trusted me. Never before have I doubted my own skill. So, I composed myself, re-centered. I said a prayer and ask for guidance.

In the end, the case went flawlessly. My breathing became easier. I spoke with the family. They were sitting comfortably smiling and joking. I explained that everything went well. They were at ease. They were dealing with this big surgery and a family tragedy, yet they were comfortable. Their family was centered.

There are times when I feel sorry for myself. Whether I am working too hard or have too much family responsibility, my life is never as hard as my patients life. Dealing with death and dying requires strength of character and is by far more emotionally draining than anything I ever encounter. I wish I had the spirit of my patient. Today, I am going to follow his lead. It is time to re-balance. It is time to get out of myself and back to life. To my friend, I say thank you for your wisdom and GO BLUE.

The price of anything is the amount of life you exchange for it.

~Henry David Thoreau

All they need is calm assertive leadership ...

Pathetic/benign
Accept it/undermined
Your opinion/your justification
Happy/safe
Servant/caged
Malice/utter weakness
No toleration - Invade
Committed/enraged/admit it
Don't condescend/don't even disagree
Destroy/decay/Disappoint/delay
You've suffered then, now suffer unto me.

Obsession - take another look.
Remember - every chance you took.
Decide- either live with me
Or give up - any thought you had of being free

SLIPKNOT - The Nameless

We just got a new dog, a Rhodesian Ridgeback. She is a beautiful dog. She is both sweet and feisty. She is a puppy and, as such, has all the puppy traits. To break her of all these traits, we attend puppy class and read all sorts of opinionated books on puppy training. We have even watch, on occasion, Ceasar Millan . What I have learned is that dogs have a pack mentality. They look for a pack leader, and try to improve their position within the pack. As I work on my own family pack and being the pack leader within my home, I couldn't help but recognize the similarities of the dogs' approach to a pack and residents' approach to residency.

It is July. The month that all residencies have the transition. The Spring residents are experienced and polished. They understand their roles and are comfortable their position. This is in total contrast to the Summer residents. They have yet to figure out their role. Like dogs in a pack, they are all jockeying for position. As an attending, I am suppose to be the pack leader. I find humor in this battle for position. Sometimes, they challenge one another. On occasion, someone in the pack challenge the pack leader. How the pack leader approaches this confrontation determines his/her status in the pack and can not be taken lightly.

In training my dog, I have learned some training techniques that are different from when I had my first dog. The choker chain seems to be out. There is no more rubbing your dogs nose in their accidents. Now, the trend is crate training and the kinder gentler pack leader. The overall goal is still to assert your dominance in a less painful but assertive way.

As a residency pack leader, I can't follow Ceaser Millan's fulfillment formula of exercise, discipline, and affection. Although it would be fun, the ACGME may frown on it. Ceasar does have some advice that can be parlayed into residency education. He recommends setting rules, boundaries, and limitations. Along with being consistent and fair, these can be effective techniques in teaching/training adult learners.

In the past, if a resident would question or challenge his/her attending, s/he would be handed an embarrassing beat down comparable to a WWE smack down. Many would use their favorite tools of fear and humiliation. In the new age of the educator, things have changed. Socratic questioning is losing favor and may go the way of the choker chain. Although the techniques have changed, the ultimate goals have not. As a dog trainer, our goal is to have an obedient dog that follows commands, doesn't make a mess of the house, and is kind to others. As a physician educator, our goal is to produce a competent physician/surgeon who has the needed skills, is considerate of others, and understands his/her limitations.

Calm assertive leadership is Ceaser's recommendation to the pack leader. Following this rule is tough. When the puppy nips at your toes or the resident questions your treatment method, you just want to smack them, figuratively speaking. I like to tell my residents, "my pimp hand is strong." I know this is not the way to approach it, but the urge is there. In the end, I have to fight that urge and smile. Instead of the physical punishment, I have to use guidance, reinforcement, and occasionally a treat. Eventually, they will learn, and if they don't, I could always just take them to the pound.

“Patience and perseverance have a magical effect before which difficulties disappear and obstacles vanish.”

~ John Quincy Adams

I am the boss of me ...

Invictus

William Ernest Henley

Out of the night that covers me,
Black as the Pit from pole to pole,
I thank whatever gods may be
For my unconquerable soul.

In the fell clutch of circumstance
I have not winced nor cried aloud.
Under the bludgeonings of chance
My head is bloody, but unbowed.

Beyond this place of wrath and tears
Looms but the horror of the shade,
And yet the menace of the years
Finds, and shall find me, unafraid.

It matters not how strait the gate,
How charged with punishments the scroll,

I am the master of my fate;
I am the captain of my soul.

We are well into another July. Like all of the previous years, nothing seems to change except my age. The residents switch over and ascend to their new status: interns to residents, juniors to chiefs. Everyone is in their new role, but my role stays the same.

In this new academic year, I continue in my role as surgeon educator ... lecture, clinic, surgery. I am a team player. If my partners as for help, I am there. I have a difficult time "dumping" on others, instead "I suck it up". Again, I am a team player.

I try to model for my residents what I feel are good characteristics of an orthopaedic surgeon. Giving them insight into errors I and others have made in both thought and technique. I model characteristics I hope that they will pass on to those behind them and utilize in their practices. It is my way of giving back in homage to those who spent that time on me.

Today, I sit in my office after 7 waiting for a case and I am not on call. Why? I feel it is the right thing to do for the patient. On the other hand, my all of resident have gone home. I guess I can't expect that they too would feel the need to stay, but I can still hope.

So, I continue to model.

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

Fly on Little Wing

“Fear of failure must never be a reason not to try something.”

~Frederick Smith

You know it is hard for me to resist a challenge. So, when my father-in-law asked me if I wanted to climb Snowdonia, I said sure. I am reasonable fit. I can put on some hiking shoes and walk up a mountain, no problem. I think I forgot I have a little fear of heights.

I looked up from the bottom of the mountain. The top was cloud covered. There was a chill in the air, a few clouds, but no rain. I put on my gear and away we went. We were the first on the well traveled. There had been many before us.

Like many journeys, it is hard to imagine how hard it will be. We rely on those before us to lead the way. Educational journeys are no different than physical ones.

The path residency is well worn. At the beginning, the end is hard to see. We are given a glimpse of the end by those ahead of us. For the most part, we feel prepared. Our gear has been packed.

We walked to the base of the mountain at a brisk pace. The mountain streams flowed into clear lakes. Barely breathing heavy, we reached the beginning of the difficult climb. My father-in-law led the way. This wasn't his first time. I needed his wisdom to show me the way.

In residency, it is important to be given guidance. Those with wisdom should guiding you way through the difficult tasks. Although the books and literature give you some perspective, they do not give the whole story. Those colored pictures by Netter do not give you an idea of how to place retractors or set up a room. Most technique books fail to give you all of the information needed to go through a procedure smoothly. This is when your guide comes in handy.

Walking up the mountain, it was clear to me I would not be physically challenged. Although it was steep in areas, it was not physically hard. I quickly over took my guide, bounding forward far ahead. As I looked back to see where my partner was, the reality of what we were doing hit me. We are climbing a F%#k#$g mountain. What was I thinking?

As the years go by, it is common for learners to feel that they have surpassed their educators. With more experience and confidence, the learner may question his/her educator's rationale for a specific treatment. They may feel there s a better way, but lack the experience to know all of the positives and negatives of the treatment they have chosen. It is only when they are allowed to go forth with their choice or to complete a procedure without much educator input that they see their inexperience and the holes in their education. With their errors in thought or technique brought to light, the learner and educator can work together to improve and in the end succeed.

My heart beat faster. How am I going to complete this task? I adjusted. I found ways of decreasing my fear and improving my chance at succeeding. Keeping my head down and pushing forward, I overcame my fear and made it to the top. I completed the challenge.

With every other step forward, there may be a step back. But it is only with being self critical, that we can grow. It is only with acknowledging you weaknesses, fears, and errors that you can improve. It is important to continue to push forward, always taking into account your limits.

As I smile for my summit picture, I had the scary realization that I wasn't done. I still had to walk down.

For all of you graduates, remember this is not the end, only the beginning. Your education has just begun. This is only the first peak at the beginning of your career. As you begin in your journey, here are a few words to remember: stay self aware, listen to you gut and your patients, you can always be better, and always do the next right thing.

So, with my task only partially completed, I grabbed a hold of the mountain and walked down.

“Courage is not the absence of fear, but rather the judgement that something else is more important than fear.”
~Ambrose Redmoon

Not everyone will like you - part 2

“For my part I know nothing with any certainty, but the sight of the stars makes me dream.”

~Vincent van Gogh

I posted last year about a good patient experience. It was a story about a patient that actually liked me. I titled it "Not everyone will like you." Some people criticized the title as false advertisement. I received some comments that stated I was basically tooting my own horn. For those that know me, they know that is not the case. For most of us in clinical practice, we hear more of the bad than good and occasionally someone will actually like you. My personal opinion is that we should not practice so that people will like you, because not everyone will; you should treat people like human beings. It is not a popularity contest. So for all of those who were a fan of that one, here is another.

It is Sunday. As usually, I am completing some work, signing forms, writing letters, etc.. In my pile of work, I came across a hand written letter from one of my patients. I will share it with you.

Dr. Someonect,

Although you may not remember me, I wanted to thank you for the tremendous impact you've had on me this year. At the beginning of my Junior year, I was feeling overwhelmed by stress - I didn't have any of my best friends in my classes, I had just been rejected by a girl I'd been trying to charm for two years, and to top it off, I fractured my ankle in three places. I'd been in surgery before and broke a finger too, so at first it just seemed like a nuisance (I was the fastest cripple on two crutches at XXX school, which has a surprisingly large number of cripples), but then there came the worries that I might limp for the rest of my life - something about my growth plates, I still don't really understand it.

But when I met you and was told you'd be performing the operation, I had total confidence that I'd be back to my old ways in no time. I was especially impressed by your knowledge of Hendrix, RATM, Megadeth, and all the other guitar greats (I'm starting my lessons with my friend - I think he's the next Steve Vai) Just to see that a doctor could be that awesome yet so talented really inspired me. I'm not really sure what career path I'll take in life, but I've definitely added "awesome surgeon" to the list. The entire staff at XXX really made an impression me; I've never met a friendlier staff that seemed genuinely concerned with their patients, and I know that without their help I'd still be lurching around my house on home-school watching Seinfeld re-runs. You're the best doctor I've ever had.

Sincerely,
My Patient

*P.S. - My step dad's getting getting his summer Mohawk next weekend.

That letter made my weekend. So I thought I would share it. It was nice.

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

Brain mouth filter ...

“A lot of truth is said in jest.”

~Eminem

Socratic questioning has been at the heart of clinical medical education many years. Traditionally, the educator asks a question so that the original question is responded to as though it were an answer. The central technique of Socratic questioning is known as elenchus, meaning a cross-examination for the purpose of refutation. In medical school, this technique of education is more commonly referred to as pimping. This style of teaching is seen as a way of the educator showing his/her greater knowledge of a subject. Depending on how and where it is enacted, pimping is perceived as a unique kind of questioning practice with a wide range of intentions from knowledge checking to humiliation. Some educators use elenchus for knowledge checking; others educators pimp. The students perspective of this style is the same regardless of the intended purpose.

The earliest use of the term pimping dates back to 1628 in a statement made by Harvey in London. Harvey, feeling his students lacked enthusiasm for learning the circulation of the blood, stated: "They know nothing of Natural Philosophy, these pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O that I might see them pimped." In Heidelberg (1889) a series of questions titled "Pumpfrage" or "pimp questions" were recorded by Koch for use on his rounds. And the first American reference to this was by Flexner in 1916. He wrote about his visit to Johns Hopkins: "Rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it 'pimping.' Delightful."

Now, if we look truly at the Socratic questioning, its purpose is not politically motivated. It is for the purpose of educating and to improve the students understanding of a subject through questioning. On the other hand pimping can be more politically motivated. Many times pimping is used as a way for an attending to show his/her knowledge. Knowledge is power. Pimping sets the hierarchy.

In the art of pimping, questions should come in rapid succession and be somewhat unanswerable. Questioning can be grouped into approximately 6 categories:

1. Arcane points of history - facts not taught in medical school that have no relevance to medical practice.
2. Teleology and metaphysics - questions that lie outside the realm of conventional scientific inquiry. Most often found in the National Enquirer and addressed by medieval philosophers.
3. Exceedingly broad questions - for example, what is the differential for a fever of unknown origin. These questions are best asked at the end of conference. Regardless of how many good points the student makes, s/he will always be criticized on the points missed.
4. Eponyms - questions like, what is the Hoffa fracture? These are usually dated terms that should be struck from memory.
5. Technical points of basic science research - enough said. These technical points, although showing academic prowess, have no clinical relevance.
6. The Devil's Advocate (my personal favorite) - with this technique, the educator takes the opposing view. This challenges the learner to understand the strengths and weaknesses of both views. For learners, defending against this takes experience, skill, and understanding. Novice learners are easily swayed away from their correct thought process down the wrong path.
   

For a master pimp, these are important categories to understand. Their utilization, while at a nursing station or in front of many naive on lookers, can gain the questioner many power points. It is like flexing your muscle in the gym mirror in front of the elliptical machines.

While understanding the ways of pimping tactics is interesting, it is more important for the student to understand the classic defense strategies to stymie the master pimp. When using these tactics, the student must be careful not to anger the questioner making the situation worse. If done improperly or if the technique is not properly disguised, it will quickly be countered with quickly countered. There are several classic techniques: the stall, the dodge and the bluff.

• The stall - this is commonly used in x-ray conferences. The student typically looks at the study squinting, and bring their face so close their nose almost touches it. Then the study characteristics are described. "This is an AP, Sunrise, Notch, and lateral in a skeletally mature patient dated January 5, 2007." The next step is to describe what is not present. It is important interject pauses, face holding, and pointing, as diverting gestures. The hope with this technique is that the questioner will fatigue and ask someone else.

• The dodge - this is a way of avoiding the question and wasting time. The most common ways this is applied are by answering the question with a question and/or answering a different question.

• The Bluff - (3 classes)

1. Hand gesturing - this is making reference to hot topics in medicine without supplying either substance, detail, or explanation.
   
2. Feigned erudition - answering as if you have an intimate understanding of the literature and a cautiousness born of experience. For example, "To my knowledge, that has not been addressed in a randomized prospective controlled study." These statements are usually made after clearing the throat, standing professorially, and while holding something, coffee cup, glasses, etc.
   
3. Higher authority - this is done by referencing someone higher up in the hierarchy or another institution. Using a senior attending as a reference is common. "In my discussion with Dr. x, he stated ...." It is also common to mention another institution where the student may have trained. "At Duke we .... "

Now, once the offensive questioning tactic is put into play and the student's defense is chosen, where do the errors occur. Probably the most common error for the inexperienced student is the misuse of defensive tactics. When a student shows his/her hand early, it allows the educator to see their lack of understanding of the subject and is like blood in the water for some educators. These are easy pickings for malignant educators. Just as problematic as improper use of a defensive tacts is not having good control of the "Brain Mouth Filter." Although knowledge is power, welding a little knowledge without an understanding will get a novice in deeper than s/he can handle. Once a novice learner gains some experience and knowledge, they begin to overstep their understanding and bring up other topics and controversies without being asked. Students that has a running dialog of his/her thoughts, it opens them to more questioning.When this is done, one of 2 things can happen: the student can get an endless onslaught of questioning there by saving all others from questioning or the team will share in the beating. The learner must develop ways of diverting questioning and putting a closure to the questions. Filtering their thoughts prior to speaking is a must.

In the end, the pimping phenomenon is a game. The educator is the game master controlling the many of the parameters of play. With time, a learner will develop both a knowledge base and thought process. They develop there own styles of processing and answering "pimp" questions. Hopefully at end game, education occurs.

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

Regardless of how many times I do it 20 miles is still a long frickin run ...

"The range of what we think and do is limited by what we fail to notice. And because we fail to notice that we fail to notice, there is little we can do to change until we notice how failing to notice shapes our thoughts and deeds."

~R. D. Laing

About 5 years ago, I started running. On a dare, I ran a 1/2 marathon. I needed to be challenged. For someone who had never been a runner, the 13.1 mile distance seemed like an unsurmountable distance. After the race, I realized that it wasn't as difficult as I had expected. It didn't require a lot of training. Like many amateur runners, I quickly made the leap from 1/2 marathon to marathon. I read the books and got training plans. I talked to marathoners. The truth is that the marathon is not just running a 1/2 marathon twice. Most will tell you it is much more; the marathon begins after the 20th mile.

Marathon training can be painful. In the beginning, it's fun. Most of the runs are rather short. The average training plan is about 3-4 months. If you run regularly, the first few weeks are just a continuation of what you have been doing previously. The challenges come when the middle distance run is greater than 8 miles and your long run is greater that 16 miles. Training runs that use to be 30-60 minutes become 1 1/2 - 2 1/2 hrs. Injuries begin to pile up. Your body aches. You ask yourself on a number of occasions the question, why? For me the answer is, because it is there. It is a challenge. I will defeat the 26.1 mile monster. The training is a necessary evil. The long runs of 18-22 miles on a Sunday must be done to prepare me for the marathon day. If I don't prepare, I won't be ready and I will fail.

In one of the early posts, I wrote about how I felt residents and medical students today are soft. Maybe that was a little harsh; they are more like the new, the proud, and the privileged. Some who read this thought I was speaking to the hot button issue of the 80 hour work week. My opinions don't have anything to do with the hours spent in the hospital. It has nothing to do with them wanting to have a life, i.e. not being in the hospital all the time. It has more to do with how they view their chosen career. When you are training, you can't do it part time. Medicine is not a DELL computer where you choose only your favorite components. You can't come into a specialty without having at least a basic knowledge. These basic components become the building blocks for future learning and professional growth.

When I look at my residents and the young medical students, there is an inherent lack of drive to learn their craft. It is no longer a priority. Like many of my generation, Gen X, and even more so in the Mellinial generation, there is a undercurrent of entitlement. It is their right to be taught this information and to do these procedures. They are not here for so called "scut." Heaven forbid we talk about patient care and continuity of care. We are in the era of teams and patient hand offs. No one is responsible for a patient. Patients are handed from one person to another like a hot potato. The residents are well rested but who is actually responsible for the patient. Who is taking ownership? Ah yes, it is the attending's responsibility. So, now if I am going to do everything, why should I teach? And if the attendings and mid level providers are going to be doing a majority of the patient care, are we training 1/2 a physician? Are we training physicians who can pass a test but can't treat a patient?

Regardless of the rules and regulations placed on training, patients still expect you to be a physician. When a patient asks you a question, you can't answer "I missed that lecture because I was over hours." No matter how low the hour restrictions go, physicians in training will still need to gain the experience. They must put in the time to train.

Medicine is mountain, regardless of your specialty. The amount of information that you need to understand is increasing. In todays medicine, the number of known diseases, medications, diagnostic testing, and procedures, are probably double of what they were 20 years ago. The business end of medicine is more complicated. Medical practices have adjusted because of medical legal issues. The style of medicine practiced is affected by both private insurance and CMS. There are regulating agencies, like JCAHO, that make suggestions hospitals have to follow. Then there is the possibility of P4P. You must be a physician, business man, politician, and lawyer. To say we teach them all well would be the understatement of the century.

Like the marathon, medicine requires endurance training. It can be fun, but for the most part it is painful. For clinical medicine, you simply have to get the clinical experience. Book learning helps but experience solidifies the information and places the written word into perspective. Regardless of how smart you are, you still have to put in time outside of the hospital to read. The reading must be not only on clinical and basic science, but also on the business, and health policy, ect. You must train yourself to prepare for the end game, you medical career and practice. Everyday is a school day and contrary to popular belief, your learning and educating does not end at 80 hours; just like my run doesn't stop at 20 miles.

“Never mistake knowledge for wisdom. One helps you make a living; the other helps you make a life.”

~Sandra Carey

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?
...

Vicarious
TOOL

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
Defy
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!

Yeah!

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

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.

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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

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

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.

Thanks,

Someonect

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