All they need is calm assertive leadership ...

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

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

SLIPKNOT - The Nameless

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

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

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

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

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

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

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

~ John Quincy Adams

I am the boss of me ...

Invictus

William Ernest Henley

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

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

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

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

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

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

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

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

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

So, I continue to model.

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

Fly on Little Wing

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

~Frederick Smith

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

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

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

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

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

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

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

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

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

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

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

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

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

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

6 word meme

MWWAK tagged me with a 6 word meme.

Life is a constant process of improving on previous experiences. We should learn something everyday. Our lives should be constantly adapting, changing, growing, and improving. When I stop learning, then it will be time to retire.

"I live; therefore, I must learn."

I have chosen not to pass it along. Sorry MWWAK.

Total Awesomeness.....

“Don't wait until everything is just right. It will never be perfect. There will always be challenges, obstacles and less than perfect conditions. So what. Get started now. With each step you take, you will grow stronger and stronger, more and more skilled, more and more self-confident and more and more successful.”

~ Mark Victor Hansen

Life is beautiful. There are a number of times in our lives that we achieve something and feel like we are on top of the world. Whether it is a graduation or the birth of a child, the feelings of accomplishment are overwhelming. These are probably the most appropriate time to use the word awesomeness.

I have done all of my graduating and I think I am done with the kid thing, so the only thing I have that gives me the feeling of awesomeness is completing marathons. I recently finished the Vancouver marathon. I chose Vancouver because, well, I thought it would be a nice run in a beautiful town. Since it was a beautiful course and an awesome town, I thought I would document the race with pictures so that maybe you all could share in my total awesomeness.

The morning is May 4, 2008. It is a clear Sunday. A good day for running. I reach the start, my head phones in my ears. You may ask what is playing, but those of you who are familiar with my blog have already guessed it .... TOOL



I look down, and visualize the course in my mind's eye.
The horn blows. I look up as I make our way to the start line. My hand is on my watch .... the timer is started.

The weather is beautiful. A slight chill in the air. Everyone is in good spirits. The first part of the course is in the city. I pass a wheelchair racer along the way. He waves.

I come up to about mile 3. This is where I see the front runners for the only time during the race. They were moving.


We make our way through Vancouver. As with most marathons, for some reason you have to go through China town. I am not really sure why.




As we crossed one of the bridges, you can see the city amongst the mountains. Breath taking....

At mile 10, I see my family and friends cheering me on. It was nice. I got a high five from my son. Total awesomeness....

Ahhh ... water stop ... I caught this dude by surprise. The water was much appreciated though.


Ah, there is nothing like running though a park. Out of the concrete jungle and into paradise.



(ROCK HANDS IN THE AIR) The band is rocking out doing some cover songs of 80's music.


Now at this water station I did not suprise her. Look at the smile.

Ahh, looking at Vancouver from the park, what a city.

How would you like to have this gig. Hanging out in the park playing for the runners. What a view.


Ok, this woman was at about the 16 mile point. I have never seen someone having so much fun by herself. She was just high on life, I guess. The only thing that would have made this better would have been a disco ball.


And back into the city we go. We are welcomed with a 1/2 mile up hill at mile 24. Nice .....


Ok, right about now the blisters on my feet were killing me. I came to a corner and this little guy was just cheering for us. Awesomeness ....


At this point, I can smell the finish. Foot pain, quad burn ..... irrelevant. It is the finish line.


So there you have it. It was a nice time. I hope you enjoyed it. It was total awesomeness.



Ok, four cellos rocking out with the singer from slipknot is also qualifies as total awesomeness.

“Success means having the courage, the determination, and the will to become the person you believe you were meant to be”

~ George Sheehan

Not everyone will like you - part 2

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

~Vincent van Gogh

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

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

Dr. Someonect,

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

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

Sincerely,
My Patient

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

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

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

Stepping to the plate ....

“Nobody can go back and start a new beginning, but anyone can start today and make a new ending.”

~Maria Robin

It is Spring. It is the time for flowers, yard work, and baseball. I was watching the Cardinals the other day, and I got a great idea. Wouldn't it be awesome if surgeons came into the OR like a player stepping up to the plate to bat?

(Down with the Sickness playing in the background)

ANNOUNCER:

"Coming into room 9, we have Somonect. This year he is operating very well with an infection rate of less than 0.01%. He has only thrown 2 instruments this year with no personnel injuries. His surgery times are steadily improving, only gone over his operative time twice in the last 30 case. Today, his is handicapped by a first year orthopaedic resident, a new scrub tech, and a circulator that "doesn't usually do orthopaedics." In these situations, he averages 15 minutes over his scheduled time, no thrown instruments, and 4 curse words."

How would you step to the plate?

“Don’t ask what the world needs. Ask what makes you come alive, and go do it. Because what the world needs is people who have come alive.”

~Howard Thurman