Achilles, Pascal, Occam, TUNC and Bonini

In the world of eponyms in surgery - Monteggia, Fournier, Chiari etc - I actually prefer the non-medical ones.

There is, for example, Achilles' Dilemma in hip resurfacing  ("to choose whether to live a short and glorious life or live a long and boring life"); Occam's Razor in diagnostics; Pascal's Wager in avoiding hip dislocation (just use an elevated lip - there is no down side). In case you're wondering, TUNC theory is an acronym not an eponym, for any confused readers.

Here, though, is a new one for me. Bonini's Paradox (courtesy of Kevin Williamson, writing on US politics).

Let us consider hip replacement first. A sphere sits within a hemisphere, as a near perfect fit. It can move freely in any direction for everyday function. It has intrinsic stability by nature of its shape. It is a fairly accurate facsimile of a real hip in many ways. It is a simple design philosophy, if subject to highly sophisticated manufacturing. It is very forgiving in practice, if you put it in slightly askew.

Not so knee replacement. Here there are several radii of curvature in coronal and sagittal planes, not one. A highly complex ligamentous arrangement ensures stability and translational movement. The lateral tibial plateau is smaller in life than the medial side. The lateral plateau has convexity. The shock absorption from the menisci varies between the two sides. Yet the knee prosthesis has a symmetrical biconcave tibial plateau with no difference in impact resistance, no benefit from the cruciates (except in those cruciate retaining cases with a pristine PCL), and relies on a difficult-to-consistently-get-right 'balancing' of the intact collaterals. It is a very unforgiving scenario, so no wonder that pretty much everyone admits these days that knee outcomes are poorer overall than those from hip replacement, particularly in high activity patients.

Attempts to make more complex knee replacements incorporating these issues have generally failed, with either poorer results or at best, unpredictable ones. It's not been for lack of trying by implant companies (1, 2).

Back to Bonini, who is a business professor at Stanford University, looking at reproducing complex systems, for example, a computer model of the brain:

And this is Bonini's Paradox: The less information a model carries about its subject, the less useful it's going to be in helping someone understand that subject. And yet, the more information a model carries about its subject, the less useful it's going to be in helping someone understand any single point of that subject. Any sufficiently detailed map of a region is going to be just as dense and difficult as the region itself. Any sufficiently detailed model of a brain is going to be a brain.

...and any sufficiently detailed model of a knee is going to be a knee. Wikipedia quotes French poet and philosopher Paul Valery, with a similar take, from years earlier in 1937: "Everything simple is false. Everything which is complex is unusable."

Indeed, a hip replacement is undoubtedly 'false', but it nearly always works. A more complex knee replacement is also false, but it just edges a little bit along the spectrum towards unusable.

Another quote from the Gizmodo article already cited: Any model, of anything, is in an act of editing. It picks out what we think is important regarding the subject, and directs our attention to how that important thing can be manipulated.

Even orthopaedic surgeons aren't gods. I suppose

...OK, everybody got that?

Classifications are often rubbish

I used to pride myself on knowing lots of orthopaedic and trauma classifications. Many of them still provide a useful lingua orthopaedica when discussing cases, a few - such as Lauge-Hansen - definitely guide treatment, and a lot of them eg femoral revision classifications, are usually fairly pointless for me in practice, much as I admire their authors

I gave a lecture on revision hips where I introduced a new classification - at least I'd not seen it used in this way before. I actually do use the broad categories, say for the acetabulum, where cavitary bone defect, rim defect and pelvic discontinuity, do have some sort of practical meaning. But I definitely prefer this one, which I presented  at a lecture in Budapest in 2007. A year later I saw someone - who'd been in the audience - repeat it word for word, without due credit. Such is life.

Here are the slides from that PowerPoint (with the odd redaction):

Anyway, I mention it because I saw of of my pet hates suitably challenged recently, on Twitter of all places. The pet hate is the question that it seems all medical students are routinely taught to ask: "on a scale of 1 to 10, how bad is your pain?"

I have never used this stupid question in practice, as it is almost a definition of why we're advised to avoid non-parametric data in research. It means almost nothing in every case that it's used. I've seen it asked, and more than once heard the sullen deadpan reply of '11'. Of course. Probably just after the phrase "I have a high pain threshold you know, doctor, but..."

So I was delighted to see the following, made available by cancer survivor and wit, @TeaLady24. It just needs to be provided in a wipe clean laminate (with the numbers removed), at every outpatient clinic. 

"...just point to the one which represents your feelings best..."

genius, in it's way (click to enlarge)

Heraclitus and the European Working Time Directive

Here's a post from a guest author - a highly regarded NHS stalwart - who is nearer the end of his consultant career than the beginning. A role model, no less, if you aspire to be a great orthopaedic surgeon without losing your humanity and affability. I haven't identified him, intentionally, but he's not me. 


He's responding to a post in the BMA news. There's lots of this stuff out there (1, 2, 3, 4, 5), and I even blogged on it myself.  See what you think. By and large he's right - this is real world medicine from a real world expert.


Front Page of BMA News:     

“One I am terribly sorry to have to say this but we have to train our young doctors to be prepared for life in the real world and not for life in some utopian fantasy land. I agree that the life of a trainee is less satisfactory nowadays than it was in the 1970s and 1980s where although hours of work were much longer and more arduous, and pay for overtime was only 1/3 of the basic rate, and when you could be on call on a 1:2, 138 hours in a week, you were valued, cherished, appreciated, helped by your seniors and by experienced nurses. You would live in the “Mess” with fellow housemen experiencing the same joys and hardships. These times have gone. 

At that time Housemen and Housewomen were expected to take on, and did take on responsibilities that our current young doctors would baulk at, but it prepared them well for the future. I fail to see how “sleep deprivation” can possibly be a problem in a situation where our trainees work shifts and never work more than 48 hours average a week. These are young, generally healthy, men and women.  Why should they be any less able to deal with a bit of hard work than we were? 

We have gone too far in our efforts to adhere to European Working Time Directives especially when those who travel in Europe and elsewhere know that the trainees there (in common with trainees in America, Australia, Canada and New Zealand) work much longer hours without complaint as they realise that it is the only way to become experienced enough to deal with the rigors of a senior appointment. 

I had the unedifying experience of hearing young trainees described as “Babydocs” by someone in our Deanery which I felt was not only demeaning to the mature men and women who had spent 5 years at University and another year as an FY1, but indicative of the lack of insight in our educationalists who do not begin to appreciate that the sooner someone stands up and takes responsibility for their own actions, the better equipped they will be in later life to deal with the difficult decisions that come to all of us. 

Medicine is not an easy job. People who can’t manage to cope with the stresses and strains, with the long hours and challenges may be better to be advised at an earlier stage to consider an alternative career."

The great man has just looked at the New Deal regulations...

You may think it's harsh, the voice of an old fart, perhaps, who doesn't get the groovy new way of doing things. I'm afraid though, that some aspects of medicine don't change. Two of our most effective operations today, for example, were practised by Hippocrates and his pals, in not dissimilar ways to our current techniques - amputation and draining abscesses. 

Note that part of this relates not to service delivery or alleged risks to patients from 'tired doctors', but to the happiness and job satisfaction of the medics themselves. However physically and mentally challenging work has been, there is immense satisfaction from having done it and done it well. A point neatly encapsulated by another experienced medic, Theodore Dalrymple, in a classic Spectator piece:

No one wants to be treated by a dog-tired doctor, but even less does he/she want to be the parcel in the medical game of pass-the-parcel that is now commonplace in our hospitals. The European Working Time Directive has transformed doctors into proletarian production-line workers, much to their dissatisfaction with their work and to the detriment of their training and medical experience. It means that doctors no longer work in proper teams, patients don’t know who their doctors are and doctors don’t know who their patients are. The withdrawal of the directive would improve the situation.

Medicine in general, and surgery in particular, is ruled by Eternal Verities**, whatever the New Deal, the EWTD and the BMA say. 

  **although he didn't invent the term, Greek philosopher and writer, Heraclitus, from about two and a half thousand years ago, was the father of the Eternal Verities. He realised that reason and wisdom are what leads to contentment, with all the moral, metaphysical and religious implications that might flow from that. Somewhat more profound than complaining after not getting a mandatory 30 minutes break following 4 hours of work (or whatever this week's formula is).

The best hip fracture ever?

Taken from Twitter. No comment required:

Naaman orthopaedics: avoiding the complex option

Ferdinand Bol, Elisha refusing the gifts of Naaman, 1661. Rembrandthuis, Amsterdam

Most orthopaedic surgeons are renowned biblical scholars, so they will be aware that the earliest example of "keep it simple, stupid" in medicine, was probably in the Book of Kings in the Old Testament, so around 600 BC.

The story in question is that of Naaman. A recap:

Naaman was a general in the pagan Syrian army, and a confidant of the king. Unfortunately he was also a leper, a big deal then (and now). he happened to have a slave girl who was a captured Israelite, who pointed out that back where she came from - Samaria - there was a prophet who could cure him, Elisha. As nothing else had worked, Naaman went for it. He loaded up with gifts and a fancy retinue, and headed south. His first mistake was to go to the king of Israel, who got mad when Naaman quizzed him, on the reasonable grounds that he couldn't cure leprosy, so the Syrians were clearly at it.

Elisha got wind and sent a message to have Naaman visit him. So the whole convoy ended up at Elisha's place. I'll let the scripture take over here:

Elisha sent a messenger to him, saying, “Go and wash in the Jordan seven times, and your flesh shall be restored to you and be clean.” 11 But Naaman was furious and went away and said, “Behold, I thought, ‘He will surely come out to me, and stand and call on the name of the LORD his God, and wave his hand over the place, and cure the leper.’ 12 “Are not Abanah and Pharpar, the rivers of Damascus, better than all the waters of Israel? Could I not wash in them and be clean?” So he turned and went away in a rage.

I can understand it, I suppose. However, the unnamed slave girl was not impressed:

“My father, had the prophet told you to do some great thing, would you not have done it? How much more then,when he says to you, ‘Wash, and be clean’?” 

So he did, and it worked. No more leprosy. And I believe that the long term clinical outcome remained satisfactory, although I don't have the PROMS data.

Thank you for sticking with me this far. Why does this matter in orthopaedics? Well, here are a few examples:

1. The CSAW RCT showed that operating on subacromial pain was not really any better than not operating

2. The PROFHER trial, even at 5 years, showed no benefit in operating on proximal humeral fractures than not operating (I accept that there will be some self-evident exceptions to this)

3. The DRAFFT RCT found no benefit of locking plate fixation over MUA and K wires for distal radius fractures (I accept that there will be some self-evident exceptions to this, too)

4. (my favourite) Complex, expensive and fiddly revision femoral stems are no better than the unfashionable monobloc ones, which are also much easier to use. Modular may also have more implant specific complications.

I am very far from being a surgical Luddite, nor do I tend to favour conservative management - although it's a skill we need to teach more in certain areas. But...

...there is no intrinsic merit in complicating treatments, although there are many intrinsic potential risks.

Alt.orthopaedics: 10 things I hate about you

Orthopaedic surgeons are well known for being romcom fans, of course, so it seems appropriate to reprise the title of one of the more adventurous examples of the genre - given that it's a straight lift from Shakespeare's Taming of the Shrew - which is 10 Things I Hate About You.

This post derives from a recent conversation with consultant colleagues from various other hospitals, the chat turning to the most annoying habits/traits/actions of trainees. We're not saints ourselves, we know we annoy, frighten and upset our trainees occasionally - no gain without pain etc.

In fact we love our trainees, really, but sometimes you end up meeting situations that are really, really annoying. It's best to know these things, both to amend one's errant behaviour now, if as a trainee you recognise yourself in the list, or just as importantly, to prepare yourself for the weighty responsibilities of being a consultant, and having to yourself nurture the delicate talents of future generations.

Please note, any trainees/residents who read this, I am very happy to publish your Top 10, 9, 8  whatever, things you hate about consultants, attendings etc. Just get in touch or add something in the comments

So, in no particular order:

1. Inappropriate familiarity

I don't think most surgeons are too up themselves. Friendliness and camaraderie are by far the commonest features of the trainer/trainee relationship, in my experience. Most trainees recognise that there is an assumed (and inevitable) hierarchy, and that it's there for a reason. One day they will sit at the top of it. Not all trainees seem to get it though. The famous incident that springs to mind relates to a shoulder surgeon painstakingly dissecting in the axilla in an unusual and complex trauma case. As the axillary vessels came into view, with the theatre atmosphere quiet and a little tense, the trainee exclaimed "...whoah! Easy there, tiger".

Not good.

2. Obsequiousness.

It doesn't hurt the patient, but boy, can it be irritating. My favourite example is the experienced and highly regarded surgeon who'd been pestered by a visiting surgeon in the department to allow him to scrub in, to which he assented, out of courtesy. The visitor's attitude was grovelling from the start, larding praise on unremarkable observations in a particularly annoying way. The nadir came early, when after starting a standard total knee replacement, the visitor lavished praise on the execution of the incision.

Too much. Way too much.

3. Telling the surgeon how other people do it

Actually, all of us gain the odd pearl from our trainees, based on what they've encountered elsewhere. Indeed, it can add to the camaraderie.

But...

Some trainees have a tendency - possibly induced by nervousness - to spend operations telling the boss how someone else they've come across does the procedure. It doesn't matter that you're the world expert with thousands of cases under your belt, they're still going to persecute you with tidbits that frankly you don't want, nor need, to hear. Reps do it too.

My worst ever offender had done 6 months in a bone tumour unit. It's amazing how virtually every procedure has a bone tumour link, if you try hard enough.

4. Tiredness

Actually, I've never had this happen to me, but there have been occasions when during a busy on call the boss asks the trainee if they'd like to do the case and they reply, something on the lines of "not really, I'm pretty tired". It may be true, it may even be 'prudent' (on dubious safety grounds), it may have the virtue of candour.

However, it is highly unlikely to make your boss admire you more.

5. Not taking advice (or instruction, as it's otherwise known)

If I say to the trainee, this ankle fracture would benefit from a stronger plate such as a  DCP on the fibula, and a syndesmosis screw (a real example), it is only in part a fascinating clinical discussion. It is also a not-very-coded instruction to actually do that. When the postop X ray shows a third tubular plate and no syndesmosis screw, it creates mysterious feelings of anger and disappointment. When, on questioning, the trainee says that they did it because an even more junior trainee said "that's all it needs", these feelings well up and may lead to unpleasantness.

If you decide not to follow instructions, then let your boss know at the time. Another interesting discussion will ensue.

5. Economy with the truth

A phrase which reached maturity in the heady days of the Thatcher era. It does not sit well in clinical practice. An example will suffice:

Trainee arrives late for the first theatre case, but seems to be expecting to do the operation...

"Why are you late?"

"I was at the trauma meeting"

"I didn't see you there"

"I was on the ward"

"Oh, what was Mrs Smith's last haemoglobin?"

"...er...12.5"

You know where this is heading. The wretched trainee had not been in the trauma meeting, on the ward, or seen Mrs Smith. There is no need to lie, as it's normally called. But once you do, you will easily be found out, if your boss can be bothered. Your card is marked. You now have a (deserved) reputation. Being late is a far lesser crime than lying.

6. Picking on underlings.

One Saturday night, in the middle of a weekend on call, a Junior House Office (F1 doctor in today's money) knocked on my office door, and was weeping profusely. She stated that she'd had enough, and was quitting medicine. This had two effects on me at the time. One was a genuine sympathy given the real distress that she was feeling. The other was the annoyance at being landed with a problem of this kind at the wrong point in the week. What had happened to her?

Well, as is often the case in acute surgical practice, a patient had become profoundly unwell postoperatively. I forget the details at this point, but she'd struggled with both diagnosis and initial management, and had called the registrar, quite correctly. He quickly sorted things out then had a go at her, concluding with the stinging rebuke "you nearly killed this patient", which wasn't remotely true. He had major self aggrandisement traits, average surgical skills, and a tendency to be jovially matey with the consultants. Wrecking his colleague's week was meat and drink to him. It wasn't the first time.

Another example. The urology registrar wanted the image intensifier for calculus removal, fair enough.  However, the radiographer was just about to start a hip fixation, and the urologist wanted to get home (this was a Saturday morning). His next tactic, with the 'lowly' radiographer? "If my patient suffers because of this delay, I'll make sure that you're sacked!"

I had no idea the lad had so much power. Typically though, when I phoned him to point out his 'behavioural issues', he turned into full grovel mode, and claimed he was just worried for his patient. Of course he was.

As the saying goes: The same people you misuse on the way up, you'll meet up with -  on the way down




7. Not visiting the bedside.

This got a whole post devoted to it. The problem is getting worse. Recent examples include: a patient with back and leg pain, previous disc prolapse and intermittent difficulty in peeing. The neurosurgeon, busy playing the odds, said at the end of the phone "doesn't sound like a cauda equina problem". He didn't come to see the patient. Another: possible necrotising fasciitis (treated mortality ~ 25%, untreated mortality ~ 100%) in an oncology patient (not an 'orthopaedic' problem in our hospital), the plastic surgeon said "it's cellulitis", we're not seeing it. Ho hum.

Read the post.

8. Complacency.

In the UK, if you get an orthopaedic training job in what is called 'run through training' - for which the competition is fierce - then you're set up for 8 years, barring death, emigration, imprisonment, or possibly, these days, a new career in reality TV.

This happy state does have some negative consequences, however. Here's just one example. In the days when you had to reapply for a job after three years you might be trying harder to impress. In my case this would mean that after two years as a registrar I would (reasonably) expect a trainee to know all the common fracture classifications, apply them, and discuss the 'classic' papers (eg femoral nailing: 1, 2), plus the most recent journal stuff of note. That will all come from self learning, which with the internet is easier than ever.  And it does happen, sometimes. Often as not though there'll be blank looks at the trauma meeting. People tend to view this stuff as exam preparation - which it is - as opposed to helpful in practice - which it is as well.

Complacency actually stops people from discovering what a treasure trove the published literature - old and new - actually is. If you don't know the Lauge-Hansen classification after two years of training jobs, you are officially complacent.

9. "Yes, I know how to do this"

Actually quite a nuanced complaint, raised by an esteemed colleague. When a trainee is starting out with a new boss, however experienced the trainee is, there will still be things you can learn (good and bad). Therefore when, at the start of your first lists together, your boss says something like "can you do a knee replacement", an answer along the lines of "yes, no problem" may in fact be counterproductive. Particularly if the boss is fairly expert in the procedure.

Far better to say that yes, you've done quite a few, but there's always stuff you can pick up, and it would be great to assist in the first instance, to see how the boss likes it to be done.

A small distinction, you might say, possibly even pandering to someone's surgical ego, God forbid. But one of the greatest virtues you can take into your burgeoning surgical career is humility. For lots of reasons.

10. Ingratitude.

The state has probably trained you in medicine to the tune of about £250,000 (for UK readers). After that you've been paid well, with years of job security,  and you are possibly on the way to become an actual expert, courtesy of the taxpayer. People have let you practice on their bodies, potentially to their detriment. Unless you royally screw up, the chances are that you'll have guaranteed and well remunerated employment - with a handsome pension, paid sick leave, study leave, maternity/paternity leave, parental leave - for 20-30 years.

Not bad, eh?

So when you reach the consultant pinnacle, it doesn't look that great, when you either:

a. Declare that you don't do procedures X, Y and Z, even if they work and are needed in the population you serve, because you only want to do procedure A. This is often dressed up in a spurious 'safety' argument. It is a common example of entitlement, a harbinger of troubles to come.

b. Disappear into private practice.

Seriously, spend a few years honing your general skills, getting peer credibility and respect, and gradually establishing an authentic subspecialty expertise. It's only fair.

...this is what it was like in the 1980's, kids...