When you have experience you need less exposure...

“I am enough of an artist to draw freely upon my imagination. Imagination is more important than knowledge. Knowledge is limited. Imagination encircles the world.”

~Albert Einstein

One day when I was an intern, I had one of the general surgery attendings say to me, "when you have experience you need less exposure." I had no idea what he was talking about, but I did smile and nodded as your suppose to do. As I matured as a physician/surgeon, the meaning of this statement became more evident and I was astounded at the immense wisdom in such a simple statement. It is something that our medical counterparts will never truly understand.

Today, we had a wonderful lecture from one if the greats in orthopaedics, specifically total knee arthroplasty, Dr. Booth. Why was the lecture so good? Because even though I do not do TKA's, it helped me with my understanding of changes in philosophies and implants that have occurred over the last few decades and what the future holds. What was of particular interest to me was his references to medicine as the art of medicine and the performance of surgery.

He made several references to artist/sculptor Michelangelo Buonarroti. Michelangelo was extremely technically gifted and through his work you can see his maturation and his development of his own style. The Pietà which was one of Michelangelo's fist major works. It took him 2 years to complete. During this time, he studied anatomy extensively verifying that everything was perfect. He did all of the work from beginning to end, including the final polishing. It has been noted to be highly finished and showed that he had mastered anatomy and the disposition of drapery and had solved the problem of the representation of a full-grown man stretched out nearly horizontally on the lap of a woman. This is regarded as one of his most famous works. When you look at one of his later sculptures, such as the Moses, in it's creation, he saw what he wanted to carve in the single block of marble and carved it. He did not need to study the anatomy or revisit the models or paintings. It was done all from memory, from what he envisioned in his mind's eye. He could see what needed to be done without seeing. With his experience, he needed less external input to get a wonderful result. The comparisons of surgery to art is amazing including the differences in styles or the phenomenon of how the second side of a bilateral procedure is quicker; like Michelangelo when he painted the Sistine Chapel, the second half was done much quicker.

I thought this correlation with surgical techniques was wonderful. It illuminates the fact that in a technical craft you must have an understanding of the concepts and be able to perform the techniques. The technical skill comes with time and aptitude. Dr. Booth pointed out that when he had residents, only about 1 in 3 could immediately visualize things in three dimensions. It is not something that can not be taught. Some people have it and some don't. I do believe it can be eventually learned. The ability of seeing something without seeing takes the experience of seeing. So, what is happening with todays surgical fields? We are going to more minimally invasive techniques which do not give our learners the experience of seeing the anatomy as in the past.

I can look at my own practice. I have seen the change of styles and the increase in residents dependence on fluoroscopy. I watch during surgery the need for a learner to gather more input. "What is this structure?" Immediately the finger goes into the wound to touch it, gathering more information from another sensory source. "Why do you need to put you finger in the wound?" This is really a rhetorical question. I know the answer. They don't yet have the vision to see what I see. I realize now that the time to develop this vision is increasing. Why, you may ask? Most of what we do now is done minimally invasively. We do scopes and percutaneous procedures. We use the new technology to make smaller incisions for a more aesthetic result. So, what skill or vision that many in the past developed doing open procedures is lost. The ability to visualize what is under the skin without seeing is being replaced by technology.

Dr. Booth reference several articles that where proponents computer aided total joint arthroplasty. He review their results and made the point that the amount of error in the non computer aided total joints may have been a result of inexperience with doing non-computer aided surgery or increasing dependence on the computer and decrease experience on relying on anatomical landmarks. He pointed out that no matter how good the computer gets, it can not duplicate or correct for some of the things that an individual surgeon develops over time. He noted that every time he has watched a demonstration of the computer aided techniques, the surgeon ends up making multiple cuts in the femur or tibia to appease the computer. That is the exact opposite of the old mantra, "measure twice, cut once." He pointed out that technology is improving orthopaedic surgery and will continue to help improve it, but the human factor must always be present and that it is hard to put a value on experience.

As generations come and technology evolves, things will change; it is the nature of living. Medicine is an art and the scalpel is the surgeons brush. We all approach things base on our experience and the techniques of our masters. We evolve over the years of practice developing out own flare and styles. Some of us paint with oils and others with water colors; we carve wood or chisel marble. We become comfortable with what we know. How will technology change our art? I am not sure, but it will be fun to watch the future unfold. Now we don't have the exposure, when will we develop the experience?

“In art the hand can never execute anything higher than the heart can inspire”

~Ralph Waldo Emerson

It's like peanut butter, cheese, and bacon ...

“Believe me! The secret of reaping the greatest fruitfulness and the greatest enjoyment from life is to live dangerously!”

~Friedrich Nietzche

You know there are some things we do and say that make everything better. Like for example, peanut butter, cheese, and bacon. Add any of the scrumptious items to a dish and it is ten times better. This also goes for fake cheesy powder or spread. I think it may be even better if you have to lick it off of your fingers. (mmm mmmm good)

There are a few words that have this effect as well. They can make something great even better, like a pan seared scallop wrapped in bacon. In slang or in speaking with the unsophisticated folks like myself, they can be used like gerunds and participles. One such word is fuckin'. Notice this is not the curse word, f!c(ing. This is like bi+(h verses Biatch. A word like f#%k!n' can make something that is already great so much better.

So, in the future I predict that there will be a trend to introduce some of these new words into the Webster's Dictionary. I can see thinks like fan-f#%k!n'-tastic (FFT) or the very orthopaedic ana-f#%k!n'-tomic (AFT) used as freely as many other word are used today. People will answer questions like "how are you" with answers like f#%k!n'-great or or ff#%k!n'-awesome. It may even be added to high school education once everything is done on-line and no one has to go to school anymore.

This is the future of language as I see it and our time will come. This is the Nuevo English language. But for now, we will have to keep these words to ourselves and use acronyms like a teenage text message.

“The world's a rollercoaster and I am not strapped in. Maybe I should hold with care, but my hands are busy in the air.”

~Brandon Boyd

He is dead to me ....

“Everything that irritates us about others can lead us to an understanding of ourselves.”
~Carl Gustav Jung

It is rare that orthopaedic surgeons know much about medications beyond the 2 antibiotics (Ancef and the other on when they are allergic). We occasionally know several NSAIDS and other post-op pain medication. If a patient is on more than Prevacid, we are likely to get a medicine consult because we have no idea what that new cardiac medication does. So, we rarely are visited by the well dressed pharmacy representative. (Well, ever since the who Vioxx debacle.) Orthopaedic surgeons are a high user of equipment, particularly implants. Therefore, we are always being visited by implant representatives, Zimmer, Styker, Medtronic, Biomet, Depuy. They bring their bagels and their new fancy devices just approved by the FDA through X amount of clinical trials. They keep scheduling you meetings to talk to you about new technology; take you to dinner to wine and dine you with a "special" lecturer. They smile and talk to you like a stripper wanting a 10 dollar tip. So, how should choose your implant company? My opinion is you choose the one with the best representation. Let me explain.

I do spine cases. Spine implants cost a lot of money and the rep gets a percentage of the money from each case. Let me give you an idea of dollars. A pedicle screw costs about ~$400-1000 per screw; a rod cost ~$500; and a cross-link~$1000 . I do scoliosis cases. On average, I will use 15 screws, 2 rods, and 2 cross-links (~$15,000-20,000/case). The rep gets 5-20% of that amount depending on where they are in the food chain (~$750-4,000/case). Because of the amount of money and the number of companies, they are always trying to get you to use their implant.

Now, I can tell you that most of the companies have the same "stuff." The fancy doodad and the whoosie whatsit will be on everyones implant set. The companies have become so big that even patents don't mean much and if they really want something from a small company, they will just buy the company. What separates one company from another, besides having a specific new device, is the representation. The representative must be knowledgeable, courteous, prepared, eager, unbiased, and the all important, not annoying. The rep has to be cautious as not to hurt anyones eqo as well as providing information that is helpful. It is a fine line. Let me tell you what puts a rep on "probation" in my OR. Saying you are prepared and you are not.

Today, I was doing a tibial osteotomy. I decided to use a company that I had used previously but had not for sometime. I was approached by the new reps who where eager an knowledgeable. They even brought their "specialist" in for the case. I check the set the day before, they assured me they had everything.

The day began, same as usual. Talked to patient. Walk the patient to the room. Checked with the rep and my staff to make sure we had all of the equipment. I began the case. Life was good. Pins were in place.

"OK Don, where is the whoosie whatsit?"

"Dr. P it's right over here." Pointing with his laser pointer.

Eve hands me the whoosie whatsit. I place it on the external fixator. I start to use it.

"Hey, Don. Is it says template on it? Is this the right one?"

"Sure is. That's the one you use."

"OK," I say. I put the next pin in place. Wouldn't you know that whoosie whatsit held that pin like a BB in a box car.

"Uh, Don. This doesn't fit. Do you have something else? Another whoosie whatsit? Maybe in you car or at the office?"

"UUhhh no, we don't have any thing else," he says.

Silence.To my scrub tech,"Get me the Ilizarov trays."

I didn't speak to him the rest of the case. My scrub tech, Eve, and I put together a new fixator. And the case turned out beautifully.

The leg looks FFT (Fan-Fu&@*ng-tastic).

For now, he is dead to me.

For all of you going into practice, don't be fooled by the fancy equipment, the nice dinner, or the pretty representative with the low cut dress. When you are choosing a total joint, spine, or fracture implant company, choose them based on the companies equipment and their representative. If you have a good rep, you can make almost any system work; with a bad rep, you may not have the equipment you need even if the company makes it.

Oh and by the way, always have a back up plan.

"Judge a man by his questions rather than by his answers"
~Voltaire

What you can do if a telemarketer calls you ....

Hello all,

This has nothing to do with medicine, residency, or teaching. It is just plain ole funny. Check it out.

"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

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

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

~Albert Einstein

When I was a resident, I really didn't appreciate what my attending had to endure. As we all tend to be, I was selfish in believing that they give me what "I" needed. They were not tending to "my" needs. Most of my thought were on me and my fellow residents. I had a belief that the "man was keepin' a brotha' down." As a system, I though it was built to maintain the status quo. Through our resident union, we even threatened to go on strike. As I progressed through residency and eventually became executive chief resident (otherwise known as the chief resident responsible for paperwork, schedules, and making nice between your residents and everyone else), I had more access to things outside of just my residency and became more aware of the political nature of the academic institution. This really opened my eyes to many things. My opinions of my older attendings changed. I realized that for the 20-30 years, they all had seen changes within the institution, residents and residency requirements, and the politically charged academic system. Most were acutely aware of what techniques were affective in helping a young surgeon to develop certain skills. Each had developed their own way of adapting their training style to accommodate the changes in the incoming generation.

The evolution of an orthopaedic surgeon from medical student to board certified orthopaedic surgeon is extremely complex. Understanding way of educating the surgeon is even more daunting. It requires an understanding of more than just a particular procedure and disease, but also require an understanding of the current generation and must be done within the restrictions of the environment of the time. All of our perceptions are based on our own experiences; so it "makes sense" that our teaching styles would be based on our personality and affected by educators that we found helpful in our own education. We currently are also working around restrictions set by the ACGME, RRC, and other governing bodies. As we try to come up with better and more efficient ways of educating the young surgeon, the resident's perception (in my view) is that we (educators) are not attuned to their needs and we only do things that are beneficial to us (attending staff). I do believe that many of the dedicated educators are more aware of what is needed to become a surgeon than you would probably think. So, how do we adapted to the system and current generation? Well, lets look first at some of the restrictions that are currently in place.

Most allopathic residency programs are under the guidelines created by the ACGME and the RRC. Residency programs must operate under the guise of the American Board of Orthopaedic Surgery, becaue our ultimate goal is to put out board certified orthopaedic surgeons. Most residency programs receive funding from the federal government; therefore, they are also affected by both medicare and medicaid regulations. The one restriction that gets the most publications is the hour restrictions. I may humble opinion, this does make educating a resident a little harder, but not for the reasons many think. The 80 hour restrictions have cause most residencies to react by hiring mid level provides to help or by employing moonlighters to cover shifts/call. For the most part, mid-level provides do not interfere with resident education but should help to make it somewhat more efficient. So, what are some of the restrictions?

ACGME and RRC

Through the ACGME and RRC, residencies are required to do several things for the educational component. These requirements must be uniform. One of the requirements is that there must be 4 hours of didactics that every resident in the program has access to. Service lectures do not count. The question then comes is when to you provide these didactic lectures so that everyone can attend and it does not interfere with the clinical education (surgery or clinic). Each program is also require to have a set number of months in the different specialties. In the near future, I foresee the requirements to even be more strict with require X amount of particular "key" surgical cases.

Medicare and Medicaid

Because hospital receive funding for residencies, there are several restrictions that were developed that directly effect surgical training. HCFA found that because medicare already paid for residents, they should not have to pay for care provided for a patient unless there was an "attending" that was directly involved with the care. With that determination, there went a majority of resident run clinics, and the amount of supervision in surgical residencies greatly increases. As time went along, even stricter rules began to develop with medicaid placing restrictions on the types of encounters that can occur at once. One restriction does not allow a physician to be involved in 2 separate clinical encounters at once without having someone who is completely free of clinical responsibility covering. You can not be both in clinic and in the OR at the same time. You can not run 2 rooms at once (with a resident) with out having someone who has no clinical responsibility covering you (that means they have no clinic or OR). This limits the number of things that can be done at once and by default decreasing the residents access to more exposure to both surgeries and clinical learning opportunities.

Hospital administration

Hospitals to have been effected by the medicare and medicaid regulations causing the hospital itself to create policies to ensure these guidelines are obeyed. Some facilities require the attending surgeon never to leave the operating suite. Dictations must be done within 24 hours. Surgeries can not begin without the attending surgeon being in the room. Many of these policy restrictions are definitely patient protective, but they do interfere with resident education and autonomy. The final thing you always have to keep in mind is that the Administration is always looking at the bottom line, things that interfere with that goal tend to get eliminated.


I could create giant lists of different rules, regulations, and policies that cause interference in the clinical educational component of resident education, but I just want to bring to light some of the restrictions that educator must work around to help educate residents. Next, I will look into the upcoming generation and what limitations educators have secondary to their experiences and perspective.

“Oppressed people cannot remain oppressed forever.”

~Martin Luther King, Jr.

If the shoe fits ...

“Being happy doesn't mean that everything is perfect. It means that you've decided to look beyond the imperfections.”

~Unknown

I think one of the hardest things to to for a runner is to find the right pair of shoes. Each foot and shoe is different. Sometimes you find a shoe that is recommended; it has a great write up in the Runners World magazine; and it gets great reviews. It is a good fit in the store. You pay the $100+ and walk out of the store. You walk around in the shoes to begin the break in process and may be few short runs to get use to the new shoes. Then you begin the longer runs and you realize that you feet are killing you, there are blisters, and your toenails are turning black. That was probably not the shoe for you. Choosing a specialty within orthopaedics is very much like choosing a pair of running shoes. There are a lot of specialties and all have positives and negatives. Not every specialty is for everyone. Over the next several months, I will have a number of guests on my blog. I have asked some of my friends to describe their specialty practice. We will have a discussion of the pluses and minuses in each specialty and speak a little about particular practice types. The titles of these posts are listed below.

NEW BALANCE: General OrthopaedicsASCICS: SportsNIKE: Shoulder and ElbowREEBOK: HandSAUCONY: SpineADIDAS: Total JointKEEN: Foot and AnkleBROOKS: TumorMIZUNO: PEDS
NORTH FACE: Trauma

So, please stay tuned. I hope these topics will be helpful at distinguishing the different specialties. It is only a guide. I will try to be as unbiased as possible. Although, I may have to make a couple of digs at each specialty. (Smiley face)

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