Nightmares and Dreamscapes ... the match is coming

“I act like sh*t don't phase me, inside it drives me crazy, my insecurities could eat me alive.”
~Eminem

The match is coming. For all those involved, your emotions are probably all over the place. Your stomach is aching. You can’t sleep. I remember this time like yesterday. I just wanted to close my eyes and sleep until the day after match day. For me, it was like Nightmares and Dreamscapes. Welcome to my mind 2 weeks before the match.

This is the year

where hope fails you

The test subjects run the experiment

And the bastards you know is the hero you hate

But cohesion is possible if we try

There's no reason, there's no lesson, no time like the present

Tell me right now, what have you got to lose?

What have you got to lose, except your soul?

Who's with us?!

Slipknot (Pulse of the Maggots)

Please someone make the pain stop.

Why do we

Crucify ourselves

Every day I crucify myself

lf Nothing I do is good enough for you

Crucify myself Every day

And my heart is sick of being in chains

Tori Amos (Crucify)

Phone rings (RING, RING)

Mother mother can you hear me

I’m just calling to say hello

How’s the weather

how’s my father

am I lonely heavens no

Mother mother are listening

just a phone call to ease your mind

Life is perfect never better

distance making the heart grow blind

When you sent me off

to see the world

where you scared that

I might get hurt

Would I try a little tobacco

would I keep on hiking up my skirt

I’m hungry

I’m dirty

I’m losing my mind

Everything’s fine

I’m freezing

I’m starving

I’m bleeding death

Everything fine

Tracy Bonham (Mother Mother)

There are so many applicants that are better than me .... what if ....

Almost there ...... help ... make it stop

My end It justifies my means

All I have to do is delay

I'm given time to evade

The end of the road is my end

It justifies my means

All I have to do is delay

I haven't time to evade

THE END OF THE ROAD!

Slipknot (Before I forget)

...... Is that my name, my eyes .... I can't focus .... WHAT DOES IT SAY .....

May be your 2 weeks will be better than mine. Sleep well .....

“If you want a happy ending, that depends, of course, on where you stop your story.”

~Orson Welles

There is no crying in orthopaedics ... Do women really belong in orthopaedics?

"If you wait to do everything until you're sure it's right, you'll probably never do much of anything."
~Win Borden

Orthopaedics is such a male dominated sub-specialty. You walk into the orthopaedic resident's area, and you are likely to smell the testosterone. The adolescent jokes are endless. Gas and scratching is always funny. It is almost a fraternity atmosphere. So in comes the new era; in medical schools, the percentage of men to women is about equal . Women are making a move in high powered fields across business and medicine. So I ask, do women belong in orthopaedics.

When you look at the typical applicant to orthopaedic residencies, HE fits a mold. Usually, the applicant is a white, dark haired, about 5'8" to 6'2", male with a type A personality. He usually has had some involvement in sports, "an athlete." He is driven, some may say competitive. If you look at most residencies, they have a "type." And most of their residents fit it.

So, how can women make this specialty better? What do they bring? They are not strong enough. They are prone to crying. They are emotionally fragile. What can the fairer sex bring to this testosterone driven specialty?

Well, in my experience, most woman who choose areas that are not female friendly, tend to be of a little bit different personality type. I have seen it when I was in engineering as well as in medicine. The women who choose the surgical specialties tend to be extremely driven and thick skinned. They are still women mind you but the usually are more tolerant. They have to be or they won't survive.

Admit men and women are different. Woman bring a softer more cerebral side to surgery. They bring emotion sometimes absent in male surgeons. They bring patience and understanding. They bring something different. Most of the woman surgeons that I know fit into one of three basic molds.

1. The b*t*h - This female has very male traits. She is aggressive. She is dominant. She will tell you what to do and what was wrong in a heart beat. Usually disliked by the other woman, i.e. nurses, clerks, etc. who are below her. If she was a male, we probably wouldn't even question this because he is a surgeon, it is expected. But a dominant woman is considered a B*T*H.
2. The star - This is the female that stands above all others, both male and female. When you look her, you notice she is able to tow the line. She is able to control a service and get the respect of all. She understands men and works with our flaws. She never loses he femininity or "womanness." she is able to negotiate the delicate politics between her peers and those under her.
3. The crier - This is the female that cannot understand why the men act like men. They take everything personal. She lets her emotions get the best of her. Frequently, she is questioning herself and why other treat her in a certain way. She forgets the sure fact that boys will be boys.

I could probably categorize the male residents as well. These are just generalizations for those I have seen. There are probably more or mixtures of them all. These are just a few.

So do we need women in orthopaedics. I would argue yes. Regardless of what category they may or may not fit into, we need a change. Orthopaedics needs to be upgraded like a Microsoft© program. Orthopaedics needs less testosterone and the addition of some estrogen. So are we as a specialty ready, I don't know; but, the writing is on the wall and they are coming. So, all you rock star men get ready; bring some tissue and a Hugh Grant movie, and we'll all get along just fine.

"If we're growing, we're always going to be out of our comfort zone."

~John Maxwell

What gives me the right ....

“I have never met a man so ignorant that I couldn't learn something from him.”

~Galileo Galilei

I reread most of my posts several days after I post them. It is usually to check my thoughts and to see how pompous I sound. For the most part, I think the point I am trying to make is made. For me, I say a lot of things in jest and in the role of the devils advocate. As the great lyricist Eminem said, "sometimes the truth is said in jest." What I really want is for people to think about other's and re-examine their positions on certain topics. It is just to begin a dialog between people. I look at myself and ask, "what gives me the right to write about these things?" Well, I don't know. I do have strong opinions about somethings, but for the most part I am someone who is "on another level" as one of my residents put it. My thinking is not in line with the old guard or new guard, it is somewhere between. I try to see things from both sides and I can usually find valid points in both.

My ultimate desire is not to be famous or world renowned; it is not to be rich. My desire is to be a great educator. Someone who inspires others to develop their own thoughts and question other's thought. We tend to be so self involved about what our current positions are that we lack perspective. As a student, we see things as a student looking up; as an educator, we see things looking down. Maybe we should all come to the same level and look eye to eye. Maybe it should be more of a dialog than a lecture. But to do this, both student and educator need to meet half way.

I look at my teaching style now and wonder how to make it better. I draw from some of the great educator physicians in my past; as well as, some of my previous and current students. So those who read this and take offense to a topic or disagree with a point, I have done my job. I am not here to say what is right or wrong. I don't have the ultimate say, it is not a dictatorship. When someone writes a comment agreeing or disagreeing, I just smile; now we have a dialog.

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

~Galileo Galilei

You are not in training be a resident ...

"Wisdom is not a product of schooling but of the lifelong attempt to acquire it."

~Albert Einstein

In my residency, we had an attending that was particularly hard on the younger residents. He was of the old guard. He was a yeller and a thrower. He struck fear in most of the residents and hatred in others. He was my mentor. My respect for him and understanding of his method developed over time and with some frustration. What I learned from him is that residents need to be pushed a little and encouraged in their development. Not that I agree with his tactics, but I do understand and fear can be a great motivator.

When I was a 3rd year (PGY-4) orthopaedic resident, for 2 weeks I was the acting chief of the service while the chief was on vacation. I still had the fear in me from when I had being yelled at, as a lower level resident, for not placing a spica cast on correctly, or couldn't get the locking cap on the CD instrumentation. He comes to the scrub sink as I scrub for a spine case and he asks me, "When do you start thinking?" I said to him, "I am not sure." I mean what else do you say to that. "I think all day and night, I worry about you yelling at me in front of the nurses and saying how I have no operative skill." In my mind, I am thinking, "When am I not thinking?" As I talked to him more, I began to understand his motives. I began to understand his question. What he wanted to know was, "when do begin to think like an orthopaedic surgeon? When do you stop thinking like a resident, and start treating patients as if you are treating them? When do you develop the skill of evaluating the patient, reviewing the studies, and come up with an exact plan for treatment?" My mentor's way of helping you to develop the necessary skills was to prevent you from making the mistake, mostly by fear. He described it as, "if every time you come around a corner you see a tiger, you stop going around that corner." I disagree with teaching by fear, but I understand its effectiveness.

In July, we will have a new batch of residents. They will come in bright eyed and eager to learn. They will begin their internship with fear of making a mistake. The first call night will be filled with doubt and insecurity. They will aspire to be better, to treat patients well, and to be good physicians. They will complete their internship and make their way to their intended specialties. Ours is orthopaedics, the best of course and most important of all. They will look to their peers and attendings and aspire to be more like or less like them, depending on their experience. Your ultimate goal in coming into orthopaedic residency is to become an orthopaedic surgeon. So why do so many residents act as if they will always be a resident?

Although my mentor taught by fear, he did not discriminate. He treated you according to your year. As a 1st year (PGY-2) orthopaedic year, he was relatively lenient on you. You did the floor work and simple cases. You didn't know enough to be dangerous. It was the 2nd year (PGY-3) that he gave the hardest time. He felt they were a problem. They had enough orthopaedic knowledge to treat most basic things and not enough to know when they were over their head. So, it was that resident that was his "whipping boy." Nothing could be done right. It was a hard year. My ego took a big beating. As a 3rd year (PGY-4), he started to ask you what you thought. What was your plan? And as a 4th year (PGY-5), he treated you more as a peer. He allowed your input in developing a treatment plan and follow-up care, with some guidance. This helps you to develop you thought process. As you developed more skill, he allowed you more freedom.

Today, I still remember that day and they impact that it made on my perception of my own resident education. So to this day, when a resident calls me or presents a patient in clinic, I ask, "so what is the impression and plan?" What I am looking for is a thought process, any thought process. It is better to have a wrong thought than no thought. That is why I am here, to correct that wrong thought. So, when you are speaking with your fellow residents about a case or discussing it with your attending, ask yourself, how are you thinking?

“The greatest barrier to success is the fear of failure.”

~Sven Goran Eriksson

Don't quit in February

“Build me a son, O Lord, who will be strong enough to know when he is weak, and brave enough to face himself when he is afraid, one who will be proud and unbending in honest defeat, and humble and gentle in victory.” ~Douglas MacArthur

I trained prior to the 80 hour work week. I remember my first week of orientation. All of the interns went through all of the initial paper work and getting acquainted with the hospital. It was a great week. We met all the previous year interns. Life was good. I was finally out of medical school; I could finally officially call myself doctor. It was all good until the evening prior to our official first day. We went into a room and the previous years interns came into the room with the new chief surgery residents. We had been all well rested and most of us tanned from our month of relaxing and celebrating our graduation from medical school and matching into our residency program. We watched the previous years interns walk to the front of the room. They were all pale from the lack of sun; black circles were under their eyes. They looked tired. They proceeded to go through what needed to be done, what a normal day was like, how not to get into trouble, some basic survival tactics. But, there was only one thing that stuck out in my mind. It was this one statement, "Don't quit in February." That scared me, as well as many of the other baby faced new medical grads, half to death.

It was a tough year. There were months of every other night call. Times were time I took days of in house call in a row to get a full weekend off. It was hard. We could sleep anywhere. My wife still teases me and my friends about it today. She still tells people about the time my friends and I were all sleeping sitting up in a restaurant; or the time I was answering the alarm clock instead of the phone. At the time, I thought it was awful. When I look back at that period in my life, it was one of the best years in my life. My fellow interns are still some of my best friends to this day. Regardless of our specialty, general surgery, neurosurgery, urology, orthopaedics, ENT, and plastics, we all had gone through the same aches and pains, and it made us closer.

In the military, there are values that instilled into each soldier. These are things that are driven into every soldier in basic training and important ultimately for the development of that soldier into a leader. They are put though grueling tasks made to do many things that most of which seems senseless. But, over time, they develop a sense of:

• Loyalty - a faithful adherence to a person or unit
• Duty - a moral obligation to accomplish all assigned or implied tasks to the fullest of you ability
• Respect - treating other with consideration and honor
  
• Selfless-service - placing your personal duty before your personal desires
• Honor - being honest with one's self and being truthful and sincere in all of our actions
• Integrity - adhering to a code of moral and ethical principles
• Personal Courage - overcoming fears while doing what is right even if unpopular

And this is what my internship was like, boot camp. In the end, I would and will do anything for my classmate and they would for me.

The 80 hour work week has change the attitude of the "New breed" of resident. It has created shift workers. Once their time is up, they are gone. Lost is the sense of loyalty, duty, and selfless-service. Character traits that are I feel are essential when taking care of patients. Getting the work done no matter what it takes and not leaving it up to others. It is your patient, complete the task. Today's resident is more likely to pass over a case that they admitted to go home rather than stay to see the interesting case. It is not their fault; and I am in favor of the work hour restrictions. It is the implementation with which I have a problem. It has helped change the face of American residency as did the insurance companies rules on number of hospitals days allowed. But, remember the back lash from the woman forced out less than 24 hours after delivering their baby?

Residents need time for study. They need rest. They need a life. They need camaraderie. The question I have now is how do we teach them to complete the care of patients and not hand it off? There is no one that scrubs me out of a case. How can we train to have more stamina for the long days? When you are in practice, if you are up all night, will you cancel you next days cases or clinic? These are questions I think many people have. When the 80 hour/weekers graduate and come to your practice, will they leave work left undone because it's "not their shift?" Or, will they step up and do what is best for the team and group? This will be seen in the coming years. For now, I will keep working on trying to instill the values that were given to me in that year of internship and my army training; and I will hope some of that rubs off on our new physicians.

“The trick is in what one emphasizes. We either make ourselves miserable, or we make ourselves happy. The amount of work is the same." ~Carlos Castaneda

Stay off the pedestal because the fall hurts

“The self-confidence of the warrior is not the self-confidence of the average man. The average man seeks certainty in the eyes of the onlooker and calls that self-confidence. The warrior seeks impeccability in his own eyes and calls that humbleness. The average man is hooked to his fellow men, while the warrior is hooked only to infinity.”
~ Carlos Castaneda

One of my favorite things to see is the maturation of young surgeons. Watching the 26 year old intern who is unsure of his/herself, blossom into a confident surgeon is like watching you kids grow up. It almost makes you want to cry. With growth come growing pains. Like teach you teenager how to drive, the temptation to take the wheel is great; and as an educator, there is a fine balance between allowing for the growth of surgical skill and creating more grey hair.

Residency is filled with triumphs and failures. Perfect reduction of a fracture on first attempt or getting the guide pin in just perfect position, these are moments that make you fell like you are the "man" or "woman." With these triumphs, come a lot of failures and disappointments. The humbling experience of your chief resident or attending taking the knife out of your hands because it is just not going your way is probably one of the must ego deflating things in residency. You may hear in the background, "first day with your new hands," or "your hands are moving, but nothing is happening." As the years go on, most residence experience more positive experiences than negative. They begin to develop their own style.

As the residents progress in their years of training, the young surgeons become more and more confident. The trick is not to become over confident and overstep your skill level or skill set. It is important to know your own strengths and weaknesses. This self-awareness will make you over all a better surgeon. In a mostly male dominated specialty, we naturally know how to do it; we don't need help, it is a sign of weakness. Unfortunately, the patient in the end may suffer. It is important to know when to ask for help.

Some people are more self-aware than others. Competing for years in sports and in education, it is hard to let that part of your personality go. We are use to being the best. It is that confidence that has gotten to this point. Who would go to a surgeon who was unsure of him/her self? There is a difference from being confident and cocky. Young surgeons tend to get a little cocky after they have several good experiences. It may have to do with the young male mentality. These are usually residents somewhere between the 2nd and 3rd orthopaedic year. They usually overstep their level or skills set, and are quickly humbled. It is not until they are chiefs do they realize that they won't be perfect every time. Those who have operated over many years understand you will have good days and bad days. Hopefully, you will have more good than bad.

So, I will put out a plea to all those in training currently; stay off of the pedestal, remain teachable / trainable. You will never be the BEST at everything; there will always be someone better at one thing or another. Stay open to new things and opinions; this in the end will make you a better physician and surgeon.

“Intellectual growth should commence at birth and cease only at death”
~Albert Einstein

The selection is hard when it comes to the last 24 ...

When you start getting down to the last few, it gets really hard to pick those last few. Some are it's about untapped talent, others a great voice, and still others there is something special, the it factor. You may disagree with some of that Randy, Simon, and Paula choices, but they do have experience. They see something. Sometimes I disagree and others I have to agree. They have been choosing contestants for years and know what works.

So many residency applicants and even residents what to know what we use to select candidates. Rumors spread from person to person. There are whispers about USMLE cutoffs, AOA, and clinical grades. "TELL ME WHAT SCORE I NEED TO GET INTO ORTHOPAEDIC SURGERY," they scream. Well I can tell you one thing, I don't know. You may say, "well then what good are you, someone has to know." Well, maybe there are programs that do have cutoffs, but for my program, not so much. What I can tell you is that if you have a below average score, the likelihood of you getting into any competitive residency is less than if you have a high score. That's common sense isn't it. So then what is important? EVERYTHING.

Everything is important. We are interviewing people with names, not 240 or 205. So what about these "people" is important. I personally think there are several things we have to look at an applicant.

USMLE
Ok, yes I said it, the F**K*N USMLE. I think this is one of the things we most look at to help us evaluate how you do relative to you peers nationally. But, that being said, I don't feel it should be done by the strict number. I think it should be used like a blood pressure or cholesterol. There are numbers that are low that may put you on a little medication, but won't kill you; and then there are others that make you start pulling out the defibrillator.

Now, how can you salvage a bad score. It is hard to do, but possible. If you have a bad score, you need to take step II early as possible and rock it. This will show us that maybe your lower score was a fluke. Most people tend to score around the same score each time, within 10 points.

CLINICAL GRADES
I think this is more important as a measure of you abilities as a physician. Now you ask, "what do I need do? What grades do I need to get?" The best grades you can get.

Now clinical grades are more like trying to compare college football teams from different conferences. Some are strong conferences (SEC, Big Ten), and others weak (WAC). So it is difficult to interpret their competition. The assumption is made that the stronger conferences get more "quality wins" than the weaker. But, if you are undefeated, maybe you should go to the championship game. So, regardless of were you are, honors is better than pass. If you are in a very competitive school (proven but the %honors and school), a high pass may be just as good. If you are Boise State, maybe you will have your chance.

The most important honors are those in Surgery and Orthopaedics. I can tell you if you DO NOT honor orthopaedics, we will question your application.

MEDICAL SCHOOL
This is your conference. Presumably, you have stronger competition. So you get points for Doing well in undergrad and getting into a good school.


RESEARCH
Research is something that more academic programs look at to see if you have aptitude to do research. The most important research is published or presented research. I see a lot of applications that have research on the application, but it was a project done over several months in their 3 year of medical school. That appears as a desperate effort to pad your application. So that time is better spent working on another area of your application. Research that stands out is done over time (meaning may be a year or two), started early in medical school, that results in a publication, presentation, or poster. But, if you are interested in research please pursue it.

RECOMMENDATIONS
These tend to be more important in the interview. It helps us to see how others view you. If we know the person writing the letter, it is a plus.

AOA
Varies from school to school and is more tied to clinical grades.

LEADERSHIP POSITIONS
Elected leadership positions in college and medical school are helpful at assessing your personality and ability to be like by others. It doe not say if you are a good or bad leader, just that you may have the aptitude and/or the drive to lead. That says a lot about charisma.

THE OTHER (IT FACTOR)
Do you have it? Well, this is something I can't quantify. It may be you had a previous job, or some special volunteer position. May be a pro athlete or actor. May be you organized a mission to Haiti. It is something that makes you different from everyone else, and it's not because you or a family member have an orthopaedic surgery, or because you played sports, or because you are a team player. It is, hmmm, I i don't know, but i know it when I see IT.

IF WE KNOW YOU
This is easy. A known is ALWAYS better than a unknown. That is why people like to have rotators (from inside or out , because it is like a month long interview. It allows us to see your personality, the good and bad traits, your work ethic, and you knowledge base. It also allow us to see if you fit in with the other residents.

So, those are most of the factors. Not one thing is going to get you into a orthopaedic spot. Not one specific number is going to get you in to a program. But, the better you do in all of the categories, the better chance you have.