Tuesday 27 February 2018
Sunday 11 February 2018
Naaman orthopaedics: avoiding the complex option
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| 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.
Friday 9 February 2018
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.
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 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:
7. Not visiting the bedside.
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... |
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