To be a good surgeon, you must be confident ... but do you need to be arrogant?

“Be who you are and say what you feel because those who mind don't matter and those who matter don't mind.”

~Dr. Seuss

It is cold, but not cold enough for snow. It is freezing rain cold. The kind of weather that brings rain and sleet. The kind of weather that covers the road and your car with ice. Driving is hard in this weather. With experience and patience, a driver can learn to prevent the skid into the side rail or another care during a sharper turn. Although you can read about how to drive on ice, many of us have learned more from the experience of driving in icy weather than any book can teach.

I drive a Subaru. The all wheel drive that provides me with the capability to move quickly on the icy roads, but does not give me improved stopping ability. I am aware of the limitations. Unlike the 18 year old with his dads SUV who speeds past me, I am patient. My speed is tempered by my previous experiences and fluctuates based on the number of curves in the road and cars on the road.

If you ask someone in the medical field to describe a surgeon, they may tell you that a defining characteristics of a surgeon is "arrogance". Of course this does not speak to all surgeons, but it is one of those stereotypes people have about surgeons. As a medical student I even asked a attending surgeon the question, "does the surgery residency make you an @$hole?" Okay I probably didn't use those specific words, but you get the picture. Her response was, "no, but it will amplify it if it already exists." Although the prevailing view of surgeons is that they are arrogant, my slightly biased view is that not all are arrogant, but their confidence is perceived as arrogance. I personally believe to be a surgeon it is important to have confidence; it is important to believe in your skill set and decision making ability. Who wants a wishy washy surgeon? There is a fine line between confidence and arrogance. It is arrogance that can get a surgeon into trouble; it is arrogance that can make you dangerous.

Driving on icy roads is much more difficult than new snow or even packed snow. Driving on ice or a zero friction surface makes the ability to stop and/or maneuver very difficult. There has to be anticipation and patience. It is not a time to multi task in the car. Full attention must be given to the road. There should be no quick movements, no sudden stops, no quick turns.

Arrogance is something that is common in academic centers. Unless controlled, it can fester. The belief is "we do it better that is why the tough cases get sent to us." I can't count how many times I have had a resident say in reference to a referral or second opinion, "why would they do something like that" or "I can't believe they did that." My response is "there aren't many dumb orthopaedic surgeons, therefore there is usually a reason." It is my role to guide the young surgeon in his/her thought process. To get the resident to understand we are not perfect; we don't get every question right; we can't understand everything about every disease process. What we can do is be understanding and responsive to other opinions, while being confident in our own opinions and skill sets.

What is the actual difference between arrogance and self-confidence?

• Arrogance: an attitude of superiority manifested in an overbearing manner or in presumptuous claims or assumptions.‘Arrogance’ is an attitude of overbearing, proud, self-importance that shows itself in contempt or disregard for others and their opinions.
• Self-confidence: self-confidence is an attitude which allows individuals to have positive yet realistic views of themselves and their situations. Self-confident people trust their own abilities, have a general sense of control in their lives, and believe that, within reason, they will be able to do what they wish, plan, and expect.

In icy weather, I drive cautiously. I don't fear the weather or road, but respect it. I understand that not respecting it can lead to disaster. We have an unspoken understanding.

Self-confidence is an important trait for a surgeon to have. Having self-confidence does not mean that individuals will be able to do everything. Self-confident people have expectations that are realistic. Even when some of their expectations are not met, they continue to be positive and to accept themselves. When a surgeon is self-confident, he/she is able to look critically at their decisions and adjust based on their outcomes (good and bad). They possess the "force of character" to take ownership of both their successes and their failures. Arrogance prevents a surgeon from having the insight to correct their own errors and thus, their growth will be stunted. The acceptance of newer ideas and other's insight into a disease or procedure is key in ones growth, both as a clinician and surgeon. Having self-confidence allows for growth; having arrogance prevents growth.

I have driven many nights on icy roads. I personally don't like doing it, but I am confident in my ability to perform the task. I respect ice. I am aware the obstacles it provides. I drive confidently on the road. It is not the time for risk taking. Unlike the teenage driver, I drive respecting the road.

As I write this post, I look back at my own career and can make note of countless times were I have been wrong. Knowing how people have taken other posts, I must state that I am not immune to being arrogant. I am not perfect. I write this to because I believe that the line between arrogance and self-confidence is extremely thin. We all must remain self aware. We must be willing to continue to grow and look at ourselves as lifetime students. I continue to grow both as an educator and learner. My views are constantly being reshaped and molded. Do you have the "force of character" to do continue or do you believe you know the right answer already?

“Confidence comes not from always being right but from not fearing to be wrong.”

~Peter T. Mcintyre

It is interview time again

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

~Frederick Keonig

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



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



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

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


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

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

~Marcel Pagnol

Happy Thanksgiving

I hope everyone has a wonderful Thanksgiving Day. God Bless.

~Someonect

China Mission - 2007

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

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

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

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

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

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

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

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

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

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

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

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

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

~Aristotle

I wonder if this makes me famous?

I am currently completing a mission trip in China. I made the Chinese news paper. I wonder if that makes me famous. I will be back in the US this coming week.

Teach so they can learn .....

“I never teach my pupils; I only attempt to provide the conditions in which they can learn.”

~Albert Einstein

As we go through residency and then become attendings, we like look up to those educators that we respect and would like to emulate and discard those things that we felt were unimportant or "bad" characteristics that we would not like to emulate. If we choose to be come an educator of sorts, our teaching style will mimic many of those characteristics for educators that helped you. You will infuse your own personality into this teaching style and create your own flare. But, no one actually explains to you what makes a good educator. What characteristics made these influential people in your education? What are the techniques that they used to achieve their ultimate goal of educating the learner? I look back at my own education as an example of how to educate others. But not every technique that was effective at teaching me will be effective at teaching everyone.

I have been to a number of conferences and been inspired by most of them. At every meeting, there is something that gets my mind stimulated. I routinely come home with a number of ideas for projects. The orthopaedic educators course was a wonderful forum of people who come for the similar purpose of learning to better educate. As the days went on, there were dedicated lectures to help us understand theories of education. What became evident early in the course was as much as we were learning from the instructors, we learned from each other. The course consisted of both new and old practitioners, as well as, program directors, new attendings and residents. There were people from very academic programs and very community based programs. We were in lecture from 8:30 am to 8:30 pm. We ate breakfast, lunch, and dinner with one another. I thought this would be over powering and rather boring. My experience was just the opposite.

During the week, I had discussions with many of the attendings about our concerns and problems. What I realize was that no matter where you lived or where you taught, we all had many of the same questions. We all have problem residents; we all don't quite understand some of the ACGME guidelines; and we all don't quite understand how to systematically educate residents. Who in college, medical school, or residency, teaches you adult education theory? You get the term of "professor" and all of the sudden you know how to teach. Now, I understand that this has been done for years and has produced thousands of good to excellent practitioners, but I think that we are in a time where we must become more efficient at educating.

With the restrictions in hours, decreases in both surgical and clinic time, and increases in both the numbers of diseases we treat and procedures we perform, we need to be more efficient with the time we are given. There needs to be reason to our madness. My experience is that like there are some educators that have the knack of efficiently conveying information that is retained by the learner. These people generally keep your attention by their presentation techniques or their enthusiasm about the subject matter. But, more commonly a lecture is given and the educator is teaching but nothing is being learned.

I think that education theory should be a requirement for anyone who is educating medical students, or residents. For some reason, physicians are given the opportunity to educate without any guidance to how to educate. You may be given a handbook of guidelines and techniques, but many physicians are placed in the educator role without any idea of how to teach in a way that people with learn. In my experience, we treat medical education like parenting. We teach by trial and error. We are given guidance from those elders (parents) and occasionally follow the advise from these elders (our mother in-law). This does not have to be so hap hazard. In this day and age where we are require to be more efficient, our approach to educating the learning must change. We must have an organized approach to educating the learner. We must communicate our goals for the learner to give them an understanding of what our intentions are. I am particularly bad at letting folks know what my intension or expectations are. You (I) assume that they have ESP and can read your (my) mind. I have made a secret pledge to my self to improve on this. I hope that all of you that are educating will join me in this pledge as well.

“The secret of education lies in respecting the pupil.”

~Ralph Waldo Emerson

When does the educator learn to teach?

This week I am away from my practice at the Orthopaedic educators course. The obvious reason that I am here is because I am trying to become a better educator. I am not sure what I expected to get out of the program, but I figured it would help improve me as an educator. After I got settled in the room with a number of other educators (young and old), a question came to mind. When do we as orthopaedic surgeons learn how to teach?

It was an interesting question that I asked myself. Looking back at residency, we are immediately placed in situations where we are supposed to be teaching/educating both medical students and junior residents. We are given this task without any clue on how to educate.

I am now in a room filled with people who are interested in the how of education; how do we teach the information so that the learner will learn and retain the information. We all have our biases about what is important and what is not. The tools and techniques that we all yous are slightly and sometimes vastly different. Our common purpose is to be better teaching our learners.

As the week progresses, I will try to convey some of the information I learn.