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

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

It always starts with good intentions .... Not everyone will like you ...

“You don't develop courage by being happy in your relationships everyday. You develop it by surviving difficult times and challenging adversity.”

~Epicurus

The other day I went to Starbucks before my clinic. The cashier asks me for my order and shouts it out to the person at the espresso bar. I said hello to the person behind me and walked to the pick up counter. My drink comes up. I thanked the barrister and went to the condiment bar. I smiled at another patron as we put cream and sugar in our caffeinated beverages. Walking to my car, I waved to the person in the car that let me cross the street. Then I was off to clinic. During this time, I counted no less than five interactions with people. For the most part, the day to day interactions with people on the street or in a store do not cause much of a problem. Knowingly or not, we all make quick judgments about people without consciously realizing it. It is human nature.

For the most part, physicians and nurses are well intentioned people. Everyday physicians and surgeons have multiple patient encounters. Just like the patrons of Starbucks or the people we may pass on the street, patients pass judgments on the physician based on a number of factors. Many of the factors used in making the prejudgment are out of the physicians control. Like patients, physicians also prejudge the patients. For the majority of encounters, there are no problems. Patients are either happy or indifferent, and we all go about our day. On other occasions, there are the interactions that don't go as we planned. Because of the volume of encounters physicians have, eventually there will be a bad interaction that cause a patient to fire the physician, or seek second opinions.

The other day one of my residents had a patient fire him. Understandably, he was quite upset. I heard his side of the story and witness' accounts of the interaction. To me, it sounds like the good intentions the resident perceived wrong and the questions of the patients were seen as hostile. I don't think that either party involved intended for this to be the case, but it is what it is. It brought up the topic of how do you deal with these situations. Anyone who has seen patients has had a bad patient encounter. There will be patients who will not be happy with what you say or the way you say it. People will go for second opinions. They will choose another doctor over you. It happens. It is a fact of life. How do we/you deal with it?

When doing an After Action Review (AAR) of the situation, the first step is not to take it personal. Of course, that is easier said than done. Don't blame yourself or the patient and above all, don't "blow off" the incident. Second, you must look at what role you played in making this a bad encounter. You must look at yourself critically and be brutally honest with yourself. Remember, for every bad encounter you have, there is only one common thread, you. Finally, you must look at what changes you can make to prevent a similar situation from happening. It seems like a lot to do, but it isn't. This is a simple exercise to improve your self-awareness. You must be self-aware and/or you must have people around you who will honestly tell you about yourself. This is not a time to have a "yes" man. Although a bad encounter is emotionally distressing and self-deflating, it provides the opportunity for the most growth as a clinician.

When I look at my personal experience and observation of others, the common flaw is communication. In the past, physicians were presumed to learn their "soft" communication skills at patients' bedsides, in their rounds as residents, and as students observing master clinicians and their interactions with patients. Today, the communication and interpersonal skills of the physician-in-training are no longer seen as immutable personal styles that emerge during residency but, instead, as a set of measurable and modifiable behaviors that can evolve. During the typical 15- or 20-minute patient-physician encounter, the physician makes immeasurable choices regarding the words, questions, silences, tones, and facial expressions he or she chooses. These choices either enhance or detract from the patient's perception of the physician's clinical skill. From obtaining the patient's medical history to conveying a treatment plan, the physician's relationship with his patient is built his/her ability to communicate. In these encounters, both verbal and nonverbal forms of communication constitute this essential feature of clinical practice.

What are some tips at improving the effectiveness of our communication?

1. Assess what the patient already knows

Before providing information, find out what a patient already knows about his or her condition. It is important to determine what a patient already understands, or misunderstands, at the outset.


2. Assess what the patient wants to know

Not all patients with the same diagnosis want the same level of detail in the information offered about their condition or treatment. Physicians should assess whether the patient desires, or will be able to comprehend, additional information. For the physician without advance knowledge of the patient, this level of need will emerge by degrees as the discussion unfolds and as the physician attempts to synthesize and present information in a clear and understandable manner.

One telling sign of whether the patient is understanding the information is the nature of the questions patients ask; if questions reflect comprehension of the information just presented, a further level of detail may be warranted. If questions reflect confusion, it is advisable that the physician return to basic information. If the patient has no questions or is obviously uncomfortable, this is a good opportunity for the physician to stop the discussion, ask explicitly how much information the patient desires, and adjust accordingly. Continuing to provide further information is not always the best approach.


3. Be empathetic

Empathy is a basic skill physicians should develop to help them recognize the indirectly expressed emotions of their patients. Once recognized, these emotions need to be acknowledged and further explored during the patient-physician encounter. Further, physicians should not ignore or minimize patient feelings with a redirected line of inquiry relentlessly focused on "real" symptoms. Patient satisfaction is likely to be enhanced by physicians who acknowledge patients' expressed emotions. Physicians who do this are less likely to be viewed as uncaring by their patients.


4. Slow down

Physicians who provide information in a slow and deliberate fashion allow the time needed for patients to comprehend the new information. Other techniques physicians can use to allow time include pausing frequently and reinforcing silence with appropriate body language. A slow delivery with appropriate pauses also gives the listener time to formulate questions, which the physician can then use to provide further bits of targeted information. Thus, a dialogue punctuated with pauses leads to deeper comprehension on both sides.

In situations involving the delivery of bad news, the technique of simply stating the news and pausing can be particularly helpful in ensuring that the patient and patient's family fully receive and understand the information. Allowing this time for silence, tears, and questions can be essential.


5. Tell the truth

It is important to be truthful. In addition, it is important that physicians not minimize the impact of what they are saying.


6. Keep it simple

Physicians should avoid engaging in long monologues in front of the patient. Far better for the physician to keep to short statements and clear, simple explanations. Those who tailor information to the patient's desired level of information will improve comprehension and limit emotional distress. It is wise for the physician to avoid the use of jargon whenever possible.


7. Be hopeful

Although the need for truth-telling remains primary, the therapeutic value of conveying hope in situations that may appear hopeless should not be underestimated. Particularly in the context of terminal illness and end-of-life care, hope should not be discouraged.


8. Watch the patient's body and face

Much of what is conveyed between a physician and patient in a clinical encounter occurs through nonverbal communication. For both physician and patient, images of body language and facial expressions will likely be remembered longer after the encounter than any memory of spoken words. It is also important to recognize that the patient-physician encounter involves a two-way exchange of nonverbal information. Patients' facial expressions are often good indicators of sadness, worry, or anxiety. The physician who responds with appropriate concern to these nonverbal cues will likely impact the patient's illness to a greater degree than the physician wanting to strictly convey factual information. At the very least, the attentive physician will have a more satisfied patient.

On the other hand, the physician's body language and facial expression also speak volumes to the patient. The physician who hurriedly enters the examination room several minutes late, takes furious notes, and turns away while the patient is talking, almost certainly conveys impatience and minimal interest in the patient. Over several such encounters, the patient may interpret such nonverbal behavior as a message that his or her visit is unimportant, despite any spoken assurances to the contrary. Thus, it is imperative that the physician be aware of his or her own implicit messages, as well as recognizing the nonverbal cues of the patient.


9. Be Prepared for a Reaction

Patients vary, not only in their willingness and ability to absorb information, but in their reactions to physician communications. Most physicians quickly develop a sense for the various coping styles of patients, a range of human reactions that has been categorized in several specific clinical settings. Patient responses may range from no response, to blaming the physician and medical team. There may be a display of emotion that rages from the mild depression and anxiety to the extremes of emotions with displays of crying, denial, or anger

In responding to any of these patient reactions, it is important to be prepared. The first step is for the physician to recognize the response, allowing sufficient time for a full display of emotions. Most importantly, the physician simply needs to listen quietly and attentively to what the patient or family are saying. It is extremely important to acknowledge their feelings and emotions. The physician's body language can be crucial in conveying empathic concern in these encounters.

When does the communication break down? Some of the pitfalls in the patient physician dialog are:

• Using technical language or jargon,
• Not showing appropriate concern for problems voiced by the patient
• Not pausing to listen to the patient
• Not verifying that the patient has understood the information presented
• Using an impersonal approach or display any degree of apathy in communications
• Not becoming sufficiently available to the patient

In the end, the patient-physician dialogue is not finished after discussing a diagnosis, tests results, or proposed treatments. For the patient, this is just a beginning. As a surgical sub-specialist, we are not typically the most effective communicators. It is not uncommon for the surgical sub-specialist to be seen as an uncaring technician. In today's ever changing medical world, we need to be better. With internet access to information, patients are becoming more educated consumers. Many patients are not acutely aware of a physician's technical skills, but they do know how a physician makes them feel. Regardless of how technically skilled you are, it is you communication skills that will be remembered.

People in the service industries understand the importance of the initial consumer perceptions. At Starbucks, the young cashier greets you with a smile. Takes your order, asks if you would like anything else, gives you your change, and tells you to have a nice day. We expect this as a consumer. The medical field is a service industry and patients the consumers. Should they expect anything less?

“I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
~Maya Angelou

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

Good luck .... you did a good job ... remember to delegate

To Dr. Hibiclens,

Good luck with your new life. Thank you for your time on our service. You did a wonderful job. Remember to delegate to those below you and not to take all of the burden on yourself. You will be an excellent orthopaedic surgeon.

Dr. P

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

Are we there yet?

“You have your way. I have my way. As for the right way, the correct way, and the only way, it does not exist.”
~Friedrich Nietzsche

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

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

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

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

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

How do we educate residents with todays restrictions .... (part III)

“It is a miracle that curiosity survives formal education.”

~Albert Einstein

So the next question is how do we, educators, teach our audience, the learners, our craft with in the restrictions of different governing bodies, while appropriately meeting the specific needs of the current generation?

As we look at the need of the current generation, we can see that there is an emphasis on the individual yet they want to be mentored. They are in touch with the newest technology and may require different ways of communicating. You may be required to give them instant feedback. Heck, we have cell phone and the text messaging. I want to know now. Why didn't you pick you your phone? I think we, educators, must keep in mind that everyone’s time is important. The learners do not need to learn all of the information in one sitting. People learn and think best when well rested and fed. This progression to a kinder gentler medical training is a change in philosophy. It will make less bitter people.

The learners, on the other hand, must understand that they will be required to be active participants in their own education. Because less will be learned directly from the educator, the learner must be facile with the other learning media. Learners must seek out knowledge. There is not enough time to do passive learning; the learner must seek out the opportunities to gain clinical skill. This is something in the past that was provided by shear volume; now, it must be sought out and learn through alternative means. Unlike many things that can be learned by reading, those who are in clinical specialties must learn from patients. Patients and their diseases do not always follow the rules. The more patients you see, the better understanding of the possible variations in presentation. This can not be learned by computer simulation or by reading in a text book. There is no algorithm will incorporate every clinical scenario. So, the patients must be seen and evaluated. With all of the new technology, one of the key skill set of the physician is slowly being lost, the physical examination.

There are some significant changes coming in the future that will effect resident education. Many current residents and medical students harp on the 80 work week and the low pay. There are the arguments that say that the hospitals and universities get 100+ thousand dollars for each resident and the resident should get more money or have to work less hours. I say, be careful what you wish for. Let's go into some basic changes that will effect resident education directly and indirectly.

NEED TO INCREASE PHYSICIAN NUMBER

Although there are some that believe that,

There has been a systematic attempt to limit the number of spots in medical schools. With a limited supply of training institutions, there was insufficient supply to meet demand.

There have been some significant changes over the past few years to actually increase the number of physicians. Here is a little history.

In 1992, the Council on Graduate Medical Education (COGME) issued a series of reports expressing concern with potential surpluses of physicians and recommending an increase in the percent of physicians trained and practicing as generalists. These concerns led the Council to develop a recommendation that 110 percent of the number of U.S. medical graduates in 1993 should enter residency training each year (or about 19,750 physicians) and that half of these physicians should be generalists. This recommendation became known as the “110/50-50” goal for the physician workforce in the U.S.

Recently put out in the COGME's 16th report, they assessed the future supply, demand, and need for physicians in the United States (U.S.) through 2020 for both generalist and non-generalist physicians will exceed what we are currently producing.

Summarizing some of their findings:

1. Under current production and practice patterns, the supply of practicing physicians in the U.S. is expected to rise from 781,200 full-time equivalent (FTE) physicians3 in 2000 to 971,800 in 2020, a 24 percent incease.

2. At the same time, for a number of reasons and under a number of scenarios and models, the demand for physicians is likely to grow even more rapidly over this period than the supply.

3. The need for services, reflecting primarily the use of services under universal insurance and increased utilization review processes, is also expected to increase over the period.

4. The models and alternative scenarios used to make the predictions included a number of factors that could have a major impact on supply, demand, and need and, consequently, on a potential gap in the physician supply. Many of these factors are likely to add to the shortage of physicians.
> Changing lifestyles for the newest generation of physicians, with the possibility that new physicians will work fewer hours than their predecessors;
>Continuation of the rate of increase in the use of physician services by those over 45, which has been increasing for the past 20 years, and increased use of services by the baby-boom generation compared to prior generations
> Expected increases in the Nation’s wealth that would contribute to continued increases in the use of medical services.

Other factors could also lead to larger shortages and are not included in the baseline projections or alternative scenarios. These include the following:

> A potential increase in non-patient care activities by physicians, including research and administrative activities;
> A potential change in practice patterns for physicians over 50, including a reduction in hours worked before retirement and earlier retirement patterns;
> Possible increases in departures from practice due to liability concerns of physicians;
> Decreases in hours worked by physicians in training;
> Possible decreases in immigration of graduates of foreign medical schools;
> Possible increases in the number of physicians limiting the number of patients on their panel (sometimes referred to as “boutique medicine”);
> Advances in genetic testing that could lead to increases in the use of services as individuals learn they are at risk for certain illnesses or conditions; and
> Additional medical advances likely to keep individuals with chronic illnesses alive longer without curing their illnesses.

THE MEDICAL SCHOOL RESPONSE

In response to the findings of COGME, medical schools have started the process of increasing the class sizes to help with predicted future needs. This is in contrast to the past where there was a decrease in both medical school classes, as well as a push towards the primary care specialties. With the current findings, there will be a need across the board. There is less of a push for those primary specialties. In June of 2006, AAMC came out with a Statement on the Physician Workforce. They recommended:

1. Enrollment in LCME-accredited medical schools should be increased by 30% from the 2002 level over the next decade. This expansion should be accomplished by increased enrollment in existing schools as well as by establishing new medical schools.

2. The aggregate number of graduate medical education (GME) positions should be expanded to accommodate the additional graduates from accredited medical schools.

3. The AAMC should assist medical schools with expanding enrollment in a cost effective manner; assuring appropriate medical education for traditional and non-traditional students; and increasing the number and preparedness of applicants.

4. The AAMC should continue to advocate for and promote efforts to increase enrollment and graduation of racial and ethnic minorities from medical school; and promote the education and training of leaders in medical education and health care from racial and ethnic minorities.

5. The AAMC should examine options for development of: (1) a formal, voluntary process for assessing medical schools outside the U.S.; and (2) a mechanism for overseeing the clinical training experiences in the U.S. of medical students enrolled in foreign medical education programs.

6. The AAMC should undertake a study of the geographic distribution of physicians and develop recommendations to address mal-distribution in the U.S.

7. National Health Service Corps (NHSC) awards should be increased by at least 1,500 per year to help meet the need for physicians caring for under-served populations and to help address rising mdical student indebtedness.

8. Studies of the relationship between physician preparation (i.e., medical education and residency training) and the quality and outcomes of care should be conducted and supported by public and private funding.

RESIDENCY FUNDING

Residents are mostly funded by Centers for Medicare and Medicaid Services (CMS) and this is for taking care of Medicare patients. That funding is split into 2 parts: DGME and IME. The DGME (Direct Graduate Medical Education payment) is the direct cost of the resident (salary, benefits, malpractice, etc). The IME (Indirect Medical Education) is the indirect cost of medical education (teaching, supplies, cost of personnel for each residency and GME, and the increased cost of training institutions because of trainees). The dollar amounts vary based on an algorithm, but the gist is that the DGME is about ~$70-90,000 and the IME is ~$30,000. In the near future, like next year, the IME is being decrease by about 1/2. Another change that will affect residencies is that if a resident goes to a course for education, the government will not pay for those days, unless they were vacation days. If a resident is in an outpatient setting, unless approved by CMS, the hospital or facility will have to cover the residents salary for that given time. Every hour of a resident’s day has to be accounted for and reported to the government. If there is a question, that time will have to be covered by the institution. Many would have you believe that the hospital make a mint of of the residents. They get money from the government and then they are able to bill for facility fees and attendings bill for their work. There are actually some articles that are coming out to dispute this.

Along with the CMS guidelines the numbers of medical graduates will be increasing but the residency "cap" has not. Therefore the number of residencies paid for by CMS will not change. There have been some policies to change this, but they are not currently in place. Hospitals have responded to the lack of governmental GME funding by funding residency positions themselves.

Why do I say be careful what you wish for? I can see in the future requiring tuition for residency. When the government pulls most or all of the funding, this may be happening.

TIME

Time is going to be an issue. With many of the newer generation wanting a "life", they are going to spent less time learning in the hospital. We have run into this problem with trying to fit in a curriculum that is considered a necessity by the RRC. When do you find time to have didactics? In today’s world, the didactics must be taught between the hours of 630 am and 6pm, Monday through Friday, no weekends, no holidays. This makes things tough in the surgical specialties. Yes, we can hire PA's and NP's to cover floor work; and yes, the attendings can start the cases by themselves (I actually prefer this because I get to operate). The problem is that this is education time too. In the surgical specialties, noon conferences don't work. That means it must be at the beginning or the end of the day.

Hospitals are being crushed by decreases in reimbursements so they are pushing to get more done with less. More cases are done in less time. Start the cases early and on time so that they can get more done before the end of the day shift. They don't want to pay overtime. Many hospitals want to push the OR time back to 7am. Hospitals administrators know that residents slow down many attending surgeons and would rather not have them operate to decrease OR time. So how are we going to prevent monetary problems from effecting the education of our needed practitioners?

WHAT'S THE ANSWER?

In the end, this question I wanted to solve has only brought more questions. I will continue to reevaluate my on education styles. I hope to keep this generations eyes open. I want them to look not only at how they are affected, but at how their choices and actions affect those who will follow them. As an educator, my ultimate goal is to put out a good product (physician/surgeon) in the end. The means of doing that may vary but hopefully the outcomes will be the same.

"In youth we learn; in age we understand.”

~Mari Von Ebner-Eschenbach

Making beautiful music ...

"I have been impressed with the urgency of doing. Knowing is not enough; we must apply. Being willing is not enough; we must do.”

~ Leonardo da Vinci

Many people view medicine as an art and I am one of these people. Although, there is a lot science to back up much of what we do, there are many thing that we do that are not based on science; they are based on experience and intuition. I refer to this as an "emotional" issue. We are all products of our environment and training. We are influenced by those around us, both our educators and colleagues, as well as, our personal experiences outside of the field of medicine. Medicine is an art and surgery is like a symphony. The operating theater is the orchestra and the surgeon is the conductor.

What does it mean to be the conductor? The purpose of the conductor is to communicate real-time information to performers. The conductor is also responsible for the preparation and rehearsal of the orchestra, and for making interpretative decisions - such as whether a certain passage should be slow, fast, soft, loud, smooth, aggressive, and so on. There are no absolute rules on how to conduct correctly, and a wide variety of different conducting styles exist. As the conductor you must have an understanding of the basic elements of musical expression and the ability to communicate them effectively to an ensemble. A conductor communicates these decisions both verbally (in rehearsal) and during the performance using different movements, gestures, and facial expressions. It is the conductors role to communicate his/her interpretation of the music to the ensemble.

Many conductors have at least a basic understanding of all of the instruments and and that instruments role in the music being presented. The modern symphony orchestra consists of around 20 different musical instruments. There are four main groups: Strings (violin, viola, cello, bass, and harp), Woodwinds (flute, oboe, clarinet, bassoon) Brass (trumpet, horn, trombone, and tuba), and Percussion (including the piano). The conductor must have an understanding of each of these instruments and their importance to the music that is being interpreted. Their understanding of these instruments and their role in the musical piece are affected by their experience and previous instructors or conductors. This is why the same music will sound different when performed by different orchestras and conductors. Each conductor has developed his/her own style or flare; their understanding of the music is different because of their experiences. The outcomes are ultimately the same, but the approach may be different.

The operating theater is very similar to the orchestra. You have strings (residents/PA's), woodwinds (scrub nurse), brass (circulating nurse), and percussion (the instrumentation rep). It is the attending surgeons responsibility to assure that his interpretation of the procedure as s/he sees it is performed to his/her standards. The conductor (attending surgeon), who has been influenced by his her mentors, must communicate with his 1st violin (primary resident or PA) what he expects for a particular musical piece (procedure). S/he must speak with the percussion to assure that the proper instruments are present so that the tempo and flow of the procedure is consistent and unimpeded. The conductor must keep those woodwinds and brass from getting too loud and overpowering the strings. On occasion, the woodwinds many have their own solo (first assist) when the strings are unavailable. The more time the group have together, the better they all understand the particular nuances of the conductor and can anticipate his/her expectations for a particular piece.

In surgical residencies, the attending staff are training many future conductors. In the first few years, the residents are gaining knowledge of the basics of their craft. An understanding of the different musical instruments and how they can effect the musical interpretation. The residents learn from many master conductors. The resident's style is a combination of the many different influences of his/her residency training. The future conductor will read the techniques in a text book and have a basic understanding of how music can be played. They also see how the masters have conducted the particular musical pieces and will form their own style based on their interpretation. That is what makes this fascinating. The patient's presentation, your understanding of the basic science and your experience will determine how you will approach a patient and which techniques you may use to solve the problem.

It is an interesting thing to watch form as interns transform into chief residents and young attendings. In watching a chief resident conduct the operating theater, you can see the influences of the different conductors that they have trained under. Their use of different instruments in a procedure shows a preference to certain surgical techniques. At the end of the year, the chief residents begin to spread their wings and start to show their own interpretation of the different musical pieces. It is almost July and in the coming months there will be a number of new conductors out into the world. In the surgical residencies, we a getting a whole new group of bright eyed new students and losing a number of talented young conductors. My hope is that we have given them the necessary skills to produce beautiful music.

“The beginning of love is to let those we love be perfectly themselves, and not to twist them to fit our own image. Otherwise we love only the reflection of ourselves we find in them.”

~Thomas Merton

"Everyone's special!" ... "Which is another way of saying no one is." ... How do we educate residents with todays restrictions .... (part II)

“Every generation needs a new revolution.”

~Thomas Jefferson

Now let's look at the next generation. I had previously talked about generational differences in educating styles. I do believe it is important to first understanding where your educational style comes from as well as understand your audience. Who is our audience? The current resident probably are mostly at the end of Gen X, but are flavored with some of the upcoming generation known as the Ne(x)t generation, Gen Y, or Millennials. So, what are the educational expectations of the mellenials? Susan Heathfield, a management and organization development consultant who specializes in human resource systems, issues, and opportunities, wrote:

“Unlike the Gen-Xers and the Boomers, the Millennials have developed work characteristics and tendencies from doting parents, structured lives, and contact with diverse people. Millennials are used to working in teams and want to make friends with people at work. Millennials work well with diverse coworkers.”

They have been referred to as the most protected, watched-after, structured, achievement-driven generation in American history. Born in the late 70's to early 80's and after, their formative years saw unbridled economic prosperity. Because this generation has grown up with such a protected and technological time, we must take the time to understand what teaching styles would be the best.

There has been a lot of press on the Gen Y or Mellennials. The Mellennials have even taken it on to themselves to but the system by debunking the myths that may be proliferated through different media. Jaerid on his blog rants about being called "praise junkies". He references an article by Jeff Zaslow in the Wall Street Journal, Most-Praised Generation Craves Kudos at the Office. The first line from this article states:

You, You, You -- you really are special, you are! You've got everything going for you. You're attractive, witty, brilliant. "Gifted" is the word that comes to mind.

For many educators, they may feel this is a trend for this generation. A very "selfish" generation. I would have to agree that this is partially the case, they do like the feedback. This is opposed to my generation, Gen X, who did not want to be mentored; we knew what to do and how to do it. The Mellennials crave mentorship and guidance. Jeff Zaslow writes in another article In Praise of Less Praise which talks praising and how people know when a praise has merit. He talks about the Simon Cowell affect of debunking the praise parade. My favorite anti-praise reality Brit is Gordon Ramsey. Chef Ramsey is in a similar situation to most who are mentoring someone in a trade. He is bringing them along as Sous-chefs with his reputation on the line if they should make an error. So although his doesn't take care of patients I can see where his rage comes from at times. I do like to give praise, but try to limit the praise for occasions which warrant special praise. Mentoring can at times be taxing, but I feel it is necessary. Mentors today have to think about who they are mentoring and may require more guidance and instant feedback than in previous years.



Besides the emotional part of expecting more direct guidance or mentoring, they would also like to have more control of both their life, lifestyle, and education. There is the belief, most of which is true, that they are highly educated and ready to perform the tasks at hand. They want the scalpel soon as they enter the OR. It has been said that they have "put in their dues" already and that they "deserve" the right to operate without putting in time on menial tasks such as patient care responsibilities. Some have the opinion that they do not need to put in the foot work before getting in to complex procedures. Simple things like reading about a case beforehand, which was standard practice years ago, has some how gone by the way side. Come to the OR and expecting to be spoon fed the information without putting in the initial leg work. Mellennials value their free time and do not want to spend every hour thinking about their career or occupation. The want genuine "free time". This is something that puts a restriction in when a "lecture" can be done. Weekends are pretty much out. Late afternoons and evenings are just as problematic. For dedicated lectures, we are really restricted to somewhere between 6am-6pm. So how do we teach them with the restrictions on time?

It is easy for me to assume that I know all about this generation or to categorize everyone from this time as having these beliefs or characteristics. Most of my comments are based on recent personal experience, discussions with colleagues, and reading different articles. I think on of the important things to do is know what are the some of the right questions to ask. The first questions to ask include:
Who are our learners? It is increasingly important to have a dialogue with the learners to better understand their perspective.

How are today’s learners different from (or the same as) faculty/administrators?
Although they may be different in many ways from previous generations, some things stay the same. Learners are still socialize and obtain information but through different media. There may be more of a role for alternative media to get important information out such as Blogs, chat rooms, or Podcasts.

What learning activities are most engaging for learners? Traditionally we have done our education through lectures. There may be more of a need for expanding this to small group activities or interactive lectures.


Having an understanding of the audience is extremely important in determining what types of teaching styles will be most effective. Orthopaedics and other surgical or procedural sub-specialties have a a number of different skills or skill sets to teach. Most of the general medical conditions can be read about and leaned on line. The problem arises when teaching specific skill which require actual hands on time. Because orthopaedics is a very technically driven field, we can not just depend on lecturing and self teaching. The clinical teaching and operating becomes extremely important. So the next question is how do we, educators, teach our audience, the learners, our craft with in the restrictions of different governing bodies, while appropriately meeting the specific needs of the current generation?

“Life is no brief candle to me. It is a sort of splendid torch which I have got a hold of for the moment, and I want to make it burn as brightly as possible before handing it onto future generations.”

~George Bernard Shaw