 |
| Goya: Saturn devouring his son, 1823. Museo del Prado, Madrid |
**for non-British readers, the ARCP is the Annual Review of Competency Progression. Nothing to be afraid of. Definitely not.
Tuesday, 17 December 2019
Orthopaedic art: the ARCP**
**for non-British readers, the ARCP is the Annual Review of Competency Progression. Nothing to be afraid of. Definitely not.
Alt.orthopaedics: seal clubbing edition
A number of years ago I was in a teaching session with one of the UK orthopaedic greats, Richard Villar, who was the first person that I heard voice publicly what we had all begun to realise, "let's face it, our knee replacements, overall, are just not quite as good as our hip replacements".
He was right, and mostly it was not to do with surgical technique. Like with so many operations, success is predicated on good patient selection. Dissatisfaction is in up to 25% of patients, seriously.
By a poor outcome I don't mean infection, PE or any of the 'standard' complications. I am referring to - as was Ricky - the patient who is never quite satisfied with it, they have chronic non-mechanical pain, it "just doesn't feel right".
If only we could identify this group preoperatively. It would save them (and us) from considerable stress and disappointment.
There have been some valiant efforts. Our Edinburgh colleagues have produced quite a few papers on outcomes, looking at age, concomitant back pain, rather loosely defined 'surgical factors', mental disability, preoperative patient expectations, and 'general physical well being'. With all this data, does that mean we should refuse a TKR to someone with definite pain and severe arthritis, who unfortunately is a male under 55 years with back pain, poor mental health, not in great shape, and who has an expectation that TKR will solve everything?
The objective answer might be 'yes', but when you're with them in the clinic, it's not that simple.
Some Korean surgeons carefully reviewed all this in 2016, and with reference to the vexed issue of personality, stated the following:
Gong and Dong ( 27) retrospectively investigated the relationship between the outcomes of TKA and patient's personality classified into 4 types: patients with extroverted personality were more satisfied than those with introverted or anxious personality after TKA. In our opinion, however, the influence of personality on the outcome of TKA is not straightforward to determine due to the difficulty of categorizing various human personalities.
They have a point.
What to do?
Well, one of my esteemed colleagues, whom I will refer to as TBN, had been chatting to one of the more senior trainees about this conundrum, and they came up with the following suggestion. See what you think.
If in the outpatient clinic you have decided that someone might benefit from a TKR, they get directed to a separate cubicle, where they watch a video. It shows an Inuit in a snowy barren waste, and before him lies a seal, which he is beating to death with a heavy stick, assisted by a harpoon.
If the prospective TKR patient cries out that it's appalling and no animal should be subjected to that, then you might be better off with a Pain Clinic referral.
If, on the other hand, they say that he's just getting his tea, and in addition he could probably use a warm coat and some new boots**, then they can safely be added to the TKR waiting list.
Clearly this would need to be studied prospectively with an appropriately sized cohort***, but the technology is already there. It's already better than banning people because they're a bit overweight.
**Wikipedia: Traditionally, when an Inuit boy killed his first seal or caribou, a feast was held. The meat was an important source of fat, protein, vitamin A, vitamin B 12 and iron, and the pelts were prized for their warmth
***There's already evidence that CBT (Cognitive behavioural therapy) can play a role in improving outcomes of bariatric and spinal surgery. A cure for catastrophising?
He was right, and mostly it was not to do with surgical technique. Like with so many operations, success is predicated on good patient selection. Dissatisfaction is in up to 25% of patients, seriously.
By a poor outcome I don't mean infection, PE or any of the 'standard' complications. I am referring to - as was Ricky - the patient who is never quite satisfied with it, they have chronic non-mechanical pain, it "just doesn't feel right".
If only we could identify this group preoperatively. It would save them (and us) from considerable stress and disappointment.
There have been some valiant efforts. Our Edinburgh colleagues have produced quite a few papers on outcomes, looking at age, concomitant back pain, rather loosely defined 'surgical factors', mental disability, preoperative patient expectations, and 'general physical well being'. With all this data, does that mean we should refuse a TKR to someone with definite pain and severe arthritis, who unfortunately is a male under 55 years with back pain, poor mental health, not in great shape, and who has an expectation that TKR will solve everything?
The objective answer might be 'yes', but when you're with them in the clinic, it's not that simple.
Some Korean surgeons carefully reviewed all this in 2016, and with reference to the vexed issue of personality, stated the following:
 |
| ...oh dear |
Sunday, 10 June 2018
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
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..."
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) |
Saturday, 10 March 2018
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."
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).
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... |
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).
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... |
Wednesday, 8 November 2017
Lessons from the movies - how to be a consultant surgeon
When the more senior trainees approach me, as they frequently do, seeking my advice on how to behave as a consultant, I can offer no greater example than this early training film**:
Of course he's a dinosaur, completely out of touch with the modern world - the labs haven't done the bleeding time for years.
**under no circumstances should you base your practice on this other movie.
PS: thanks to my Greenock colleagues for the recommendation
Of course he's a dinosaur, completely out of touch with the modern world - the labs haven't done the bleeding time for years.
**under no circumstances should you base your practice on this other movie.
PS: thanks to my Greenock colleagues for the recommendation
Tuesday, 17 October 2017
The midnight hour
It seems not to be like it was however, and in many ways that's a good thing.
In the early 90's, before we had consultants in Casualty (which became A&E, now Emergency Medicine, these guys are very into semantics), patients still survived. I do welcome senior Casualty/A&E/Emergency Medicine presence, and I'm sure it's saved a few lives, though there can be a downside in terms of ownership of the case and the early decision making. But I digress.
It was correctly recognised that having a raw untutored SHO trying to resuscitate two polytraumas on his or her own, waiting for the cavalry to arrive, was not ideal. I've been there, it was pretty tough. So in my hospital we instituted the 'Trauma Bleep'. The deal was that there were three pagers held by the senior registrar in orthopaedics (me), the senior registrar in general surgery, and the senior registrar in anaesthetics (the important one, though I hate to admit it). If the bleep went off, you went straight to Casualty, no questions asked. It worked over many miles, so there was no escape. In any event, there were no mobile phones then, if you were out and thought you'd call in to see if you were really needed.
Most of the calls were not that critical, plenty of low grade stabbings that barely made it through the dermis, but there were still quite a lot of people who benefited from rapid resuscitation, airway security and all that. It coincided with the emergence of ATLS in the UK and the whole thing was really a big step forward in quality.
However, it could be bruising. My worst night I went in (a 6 mile round trip, so not too bad) at 11.30pm, got home at 2am, in again at 3am, home at 4.30am, in again at 5.30am, home for a shower at 7.30, staggering in to work for a full day starting at 8.30am. None of the cases was major trauma, but we were there, just in case.
You have to be at the bedside/trolley side to properly assess things, and it's a dying art.
I'm not recommending a return to that, but I still do on call from home, and I still go in. It's easier now as a consultant - much easier in fact, for various reasons - than it was 10 years ago and 20 years ago, when we were always having to go back in.
All this is a long winded preamble to a piece lifted in its entirety from the magnificent GomerBlog, which is mostly written by frontline clinicians. You can always tell....
On-call ophthalmologist heroically manages eye emergency from bed
“It was intense,” says Barnett. “At first I was propped up on one elbow when I answered the phone. Then the emergency doc told me the patient had severe vision loss. At that point, I sat straight up in bed with my down comforter only covering my legs. I started getting a chill, but you gotta take these things seriously.”
Barnett was able to listen to the patient’s history in between yawns, occasionally having the consulting doctor repeat things while he rubbed the crust from his eyes. After several seconds of thoughtful consideration, Barnett thought it would be best to see the patient in clinic in the morning.
“This was a tough situation,” reports Barnett. “By the end of the conversation, my sheet was all bunched up and my pillow was flat in all the wrong places.” When asked why he elected to see the patient in the morning, Barnett replied, “By the time I get out of bed, get in my car, drive all the way to the hospital and see the patient, it will only be a few hours until morning anyway. This is the best thing for the patient.”
At press time, Barnett was seen coordinating care for a patient with ocular trauma while wearing his eye mask.
I don't want to just pick on the eye guys, when did the on-call (and paid for it) dermatologist/breast surgeon/nearly all physicians/psychiatrist last come in at 3 in the morning?
It's bad enough trying to get a bedside visit during the day**.
**there are of course many honourable exceptions to this genuine and somewhat alarming trend
Sunday, 8 October 2017
Celebrity trauma: Deniz Tek
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| Deniz with Iggy |
At last, somebody getting back to basics. You compare it to maybe one or two years before, everybody’s listening to a triple album by Yes called Tales from Topographic Oceans, and if there’s anything more boring in the world, you’d have to tell me about it. That was just the epitome to us of the dreadfulness and horror of what music had become, and it was a breath of fresh air when these New York bands started blowing all that away.
There's a lot out
there on this polymath, but put simply, if you like punk, metal, surf
music, and the darker edges of those, like fellow Australians (sort of) The
Saints playing Nights
In Venice, then you'll love Tek and his awesome band, Radio Birdman. Or
as this website
said, he’s the “axe-wielding rock soldier commanding the legendary Radio
Birdman blitzkrieg”, which is about right. Think also Stooges, MC5 (both bands were his
buddies), Blue Oyster Cult, early Alice Cooper etc. Halcyon days.
But why am I writing this? Most orthopaedic surgeons these days seem to listen to Ed Sheeran or U2, who make the previously mentioned Yes seem like the Sex Pistols. The above named bands are the antidote.
Well Tek is different. When he was in his band in Australia (he's
actually from Michigan) in the 70's he was studying medicine at the University
of NSW. He got the textbooks out on tour.
In the 80’s he joined the US Navy, based in Hawaii and ended up as
a flight surgeon organising medic evacuations, major trauma protocols and
delivering emergency care all over the world, in all climates. His radio call
sign actually was Ice Man.
He subsequently went on to run an Emergency Medicine service with
a lot of trauma in Montana, and now combines music with painting, writing and
doing EM work part time in both the US and Australia. You thought you had a
complicated life?
Here he is on the professional medic/rock musician dichotomy:
"usually if it's a busy shift or there's heavy things going
down I don't think of anything else until the shift's over. The other thing is
you can compartmentalise and whilst I'm taking care of sick people music
doesn't intrude. I think that in aviation there's a lot of value in that also. Guys
that climb into the cockpit of a jet have to be able to leave their family
problems behind. Y'know...the wife's goin' out with someone else or the kid's
on drugs. They climb into that cockpit and if they don't do everything
exactly right they're gonna die...and may be kill other people too.
One of the requisites for that is to totally compartmentalise your mind. They screen pilots for that ability in psychological tests. If you're not that sorta person...you're just not right for the job."
Fair point - ever had the stress-inducing bleep about a family matter when you’re in the middle of a long operation? Compartmentalise!
His website is excellent on many levels, but I particularly commend this tale of being called out to a military plane crash in Arizona. Even the Guardian likes him.
He gives career advice too:
"Any encouraging words to the young kiddies?
Work hard at whatever it is you like to do. Nothing worthwhile comes easy. And stop complaining."
Saturday, 7 October 2017
Old farts strike back: surgery and bible edition
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| ...obviously not ALL the old stuff is good |
If I may get biblical, from the Book of Job, 12:12 - With the ancient is wisdom; and in length of days understanding.
With this in mind, although I've nothing against him personally, when I'm urged to read Atul Gawande's books about aspects of surgical practice, particularly outwith the technical skills, I wonder what makes him such an expert.
Here's the evidence:
Qualified in Medicine at Harvard in 1995 aged 30
Master of Public Health degree in 1999, then 6 years of residency training in surgery - ie. junior doctor acquiring experience - till 2003.
He spent quite a bit of time from the late 80's involved in writing magazine articles and working in Democratic politics.
His first book, Complications: A Surgeon's Notes on an Imperfect Science, came out in 2002, when he was still a junior doctor in training, far from the finished product. The next one Better: A Surgeon's Notes on Performance, was released 5 years later. I assume he'd been busy in clinical practice for this time, with possibly some of the previously noted extracurricular activities getting in the way occasionally.
An NHS consultant surgeon, 5 years in, working in a busy hospital is, in my view still very much on the learning curve. 'Surgical maturity', I would say, is at least 10 years in. Some people never get there.
Gawande's Wiki entry implies that from about 2009 onwards he was doing more and more non-surgical things, fair enough, he seems an interested and accomplished fellow, but I feel very strongly that the way you get better in medicine is, I'm afraid, long hours, year in year out, in the wards, the theatres and the clinics. It's a lifelong thing, even if - as I do - one has plenty of other interests.
One of the classic scenarios in the NHS is the consultant who having got to the top - as it was perceived in the old days - realises that he or she wants to get out. Often 'management' and 'governance' are the dubious beneficiaries of their career move, which amazingly usually involves telling working clinicians what to do. Not that I'm accusing Gawande of that, but some individuals closer to home, certainly.
Anyway, this preamble is to praise the benefits of long, hard won clinical experience, especially of the surgical kind. There is a significant difference between prescribing a drug - which could do harm - and opening someone up with a knife, which is intrinsically harmful before it gets better, even if everything goes well.
Is there a plausible alternative to working the hours? I think not. Don't get me started on the world of 'simulated surgery'.
All of which brings me to a fascinating interview with both Stephen Westaby (69), heart surgeon and Henry Marsh (67), neurosurgeon. Both have a public profile, both have performed thousands and thousands of challenging high end operations, for the NHS. With respect to the aforementioned competition, these are the guys that I want to hear from. They've also written books for the general public, as it happens.
There are numerous gems in the interview, here's some tasters:
HM: We have this very complex relationship with patients. It’s not one of straightforward altruism at all; it’s a very difficult relationship. You have to be both hard and soft at the same time. You certainly don’t want to be empathetic. If empathy means you actually feel what your patients are going through, actually . . . you can’t do it.
...the problem is you could spend the entire national income on healthcare and everybody still dies — there is 100 per cent mortality — so you have to decide somehow where to set your artificial floor on that bottomless pit.
...[When he was PM] David Cameron made this speech about we must have “zero harm” in the NHS, which struck me as the most incredibly stupid thing to say because it suggests that when anything goes wrong, therefore somebody’s to blame. The whole point about medicine is it often goes wrong. The decision whether to operate or not, to recommend an operation or not, is all about probabilities, and these are very subjective, difficult judgments. Everything we do is in the face of uncertainty and a lot of the time patients come to harm. It doesn’t necessarily mean that anybody’s at fault. So I thought that was a very, very naive and rather silly thing to say.
SW: The job is difficult enough without having the press and everybody else on your back. A British heart surgeon had the idea when he became the medical director of the NHS that surgeons’ death rates should be published and available for the newspapers. Let me ask you: which surgeons would have the highest death rates, the worst ones or the best ones? The best surgeons attract the worst patients like a magnet. So if you want to make your best surgeons defensive, you start counting the bodies and putting it into the public arena. My particular branch of the profession is now risk-averse. Fewer heart surgeons want to come to Britain to do heart surgery and the British especially don’t want to do heart surgery. They’re long operations, you can end up operating all night, every day of the week, and it’s taxing and it’s rotten when people die. It’s totally rotten to have to go out of an operating theatre and tell a couple of young parents that their baby’s just died on the operating table. It’s misery. None of us lose patients because we’re careless or don’t care. So I’ve seen my profession wrecked, I’m afraid.
HM: Forty years ago, the power structure in hospitals in this country was very simple. There was a senior doctor, a senior nurse and one manager, and basically the hospitals are run more or less by the senior doctors, for better or for worse. Now you have a whole series of competing pyramids. The management, the doctors, the nurses — more or less autonomous now — the other paramedics and physios and people like that, so there’s a real sense of nobody being in charge. I would go to work in the morning and I wouldn’t know what I was going to do that day because it all depends. Is there a bed? Is there an intensive-care unit bed? Is there a bed on the high-dependency unit? You have to negotiate with each of these individual power structures, it’s deeply chaotic
...Another example is that, after the Stafford scandal [over nursing care] and the Francis inquiry [into it], the General Medical Council wrote to all the doctors saying that when a mistake is made you must apologise and then it said that this is usually the duty of the senior clinician; in other words, whoever makes the mistake, muggins here has to go and say sorry. And then thirdly it added that for an apology to be meaningful, it must be genuine. If the GMC can’t see there’s a problem here — if an apology is compulsory, how can you force it to be genuine? Well, the answer is that it is genuine if the senior doctors have a sense of authority, if they feel they’re trusted and then they do feel responsible for what happens in their department.
Just superb, and not calculated or self-serving, simply real world experience of something very important. Westaby's line "The best surgeons attract the worst patients like a magnet" is very very true.
I'm also ending with a bit of biblical advice, Jeremiah 6:16 - put yourself on the ways of long ago and enquire about the ancient paths: which was the good way? Take it then, and you shall find rest
Trainees, your aged consultants will guide you in 'the ways of long ago'. Catch them before they retire.
Friday, 22 September 2017
The earthquake dislocated my hip replacement
When I was training, one of my distinguished bosses, an academic, used to tell me about one of his trainers back in the 70's who used to listen to the occasional patient in the clinic who'd not had a good outcome. He'd acknowledge their unhappiness, and indeed, empathise very effectively. When the frustrated patient eventually left the consulting room, he'd turn and face his registrar (my boss) and say sadly: "funny fellow that".
The moral of the story - as it was emphasised to me - was never blame the patient.
Own your own mistakes and bad results. Be brave, dig deep. Good advice, I suppose.
Later, as my boss approached retirement, he'd show me an X ray - often of a knee replacement who'd got some residual pain - and say something like "I can't see much wrong with it. He's a strange fellow though. You never succeed with people like that"
For any one case he may have had a point, but he'd forgotten his own advice. Never blame the patient.
So blame can be an issue. Not in the medicolegal sense, more in terms of peer respect and apportioning embarrassment. Maybe that patient fell because your hip replacement dislocated, rather than your assertion that it dislocated because they fell. We're only human after all.
So in the spirit of making excuses for cock ups, I give you a short video of a handy set of excuses for the next time you have had a hand in a surgical complication. One of them will apply, I'm sure.
The moral of the story - as it was emphasised to me - was never blame the patient.
Own your own mistakes and bad results. Be brave, dig deep. Good advice, I suppose.
Later, as my boss approached retirement, he'd show me an X ray - often of a knee replacement who'd got some residual pain - and say something like "I can't see much wrong with it. He's a strange fellow though. You never succeed with people like that"
For any one case he may have had a point, but he'd forgotten his own advice. Never blame the patient.
So blame can be an issue. Not in the medicolegal sense, more in terms of peer respect and apportioning embarrassment. Maybe that patient fell because your hip replacement dislocated, rather than your assertion that it dislocated because they fell. We're only human after all.
So in the spirit of making excuses for cock ups, I give you a short video of a handy set of excuses for the next time you have had a hand in a surgical complication. One of them will apply, I'm sure.
Saturday, 16 September 2017
Parachutes and the pelvis
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| * |
When the acetabulum fractures, the femoral head may have been halfway across the inside of the pelvis before it bounced back to where it sits on the X ray, to give one example. The injury is everything that got damaged then, not just what that 2D X ray shows. The average pilon fracture is equivalent to a small explosion in your ankle.
Most of this less obvious damage is soft tissue of course, hence the appeal of Oestern and Tscherne's slightly clunky classification of soft tissue injury, as a counterpart to Gustilo in open fractures. It seems fairly accurate, but does anyone actually use it?
A lot of pelvic ring fractures and related injuries are essentially internal dislocations of the pelvis through the symphysis and SI joints. They spring back usually, even the vertical shears to a large extent, but can you imagine what it's like at the moment of injury?
Well, imagine no more.
A big hit at the moment is Admiral William McRaven's very short and readable set of life lessons, expanded from his speech to graduates at his alma mater, the University of Austin, Texas. Rest assured, it's not a mindfulness manual. McRaven was the chief of the US Navy SEALs, and ran the operation that took out Bin Laden.
In fact it's not unlike Leo Gordon's matrix lessons, a staple of this blog.
The more general point that McRaven is illustrating with the following excerpt is that we all need help sometimes, and success in something is rarely down to ourselves alone. He describes his very tough rehab after what I think was a very bad 'open book pelvis', which happened in midair. Honestly. His description is pretty vivid...
....the book is genuinely worth reading. This particular episode confirms what we don't know from discharging people three months after injury, but one does rapidly learn doing medicolegal reports - all trauma has rehabilitation challenges, and many injuries leave you with lifetime symptoms, long after your injury has officially 'healed'.
Wednesday, 13 September 2017
Celebrity orthopaedics: Gabriel Batistuta, Marco van Basten and a disquisition on pain
Here's a scary description:
I left football and overnight I couldn’t walk. I wet the bed even though the bathroom was only three meters away. It was 4am and I knew if I stood my ankle would kill me.I went to see Doctor Avanzi (a world-renowned specialist in Orthopaedic trauma) and told him to cut off my legs. He looked at me and told me I was crazy.I couldn’t bear it any longer. I can’t put in to words just how bad the pain was.
I chose the right leg (to be operated on) as the doctor couldn’t do both.I didn’t care. My problem is that I have no cartilage or tendons. My 86 kilos are supported by bones alone. That’s what generated the pain.
And here's the author of that description, in action, wrecking his ankles, for our benefit...
Batistuta was probably the best striker of his day, and one of the best ever. If I can quote from the well known biting South American striker of today, Luis Suarez:
The ultimate? Gabriel Batistuta. He was a spectacular No 9 - great at finding space, shooting from outside the box, good in the air. He was always a reference for me and I used to watch the way he played. He took free-kicks as well. I don’t get to take them here! (laughs) but I’d copy him and watch videos of him all the time.
I agree with the sharp toothed Uruguayan. Not only was Batistuta an awesome player, he was a modest appealing person, who always looked super cool. He scored 300 club goals, and 56 for Argentina in 78 games, which is better than Messi.
However, he was wrecking his ankles. He had numerous steroid injections to get him through, and they probably didn't do him any favours in the longer term.
The assessment of pain severity is one of the hardest things in orthopaedics - one man (or woman's) agony may be another's "well it hurts but I try to ignore it", and yet it's the basis on which we offer complex operations with significant complications.
Most surgeons would recognise the claim "I have a very high pain threshold, doctor" as probably meaning that the opposite is true. For what it's worth, I never use the VAS 1-10 scale. A waste of time. However, Batigol's description is pretty good, as is (most of) his understanding:My problem is that I have no cartilage or tendons. My 86 kilos are supported by bones alone.
It sounds to me like he had an ankle fusion, not, note, an ankle arthroplasty. He had " two screws surgically placed into his ankle to help alleviate the pain and support his movement" and the outcome? "Since I’ve had the screws put in, I’m much better now than I was three years ago.”
"I left football and overnight I couldn’t walk", rings true. Batistuta actually had a long career, 1987-2005 at the top level. I've seen quite a few professionals with completely wrecked knees play into their mid-thirties by limiting training, watching their diet, NSAIDs and probably most importantly, great positional sense. They run about that bit less. When they stop playing though, it goes downhill quickly.
Everyone thinks of knees, with ACL's and menisci, when considering sporting injuries, but ankle problems prematurely wrecked the career of all time Dutch great Marco van Basten, although worringly, he blamed the surgeon . He also appears to have had a fusion, he certainly had bone fragments removed from the joint, back when the unnamed maligned surgeon was trying to salvage things. When the weight bearing surface area is as small as it is, then you know that's going to be associated with major problems. I've done hips and knees on relatively youthful ex-footballers, who still play in kickabouts with no problem. Ankle fusion is not that good, but it's not bad either.
In case you're wondering how good van Basten was...
Here is van Basten's description of his pain. Not dissimilar to Batistuta:
After three years of pain I wanted a normal life again. Just imagine feeling pain every minute of the day, somewhere in your body. And that for three years! It dominated my life. From my ankle the pain bounced back into my whole body. As long as there's still hope you can still recover, you're willing to accept the torture, but after so much treatment and so many medical experiments I finally realised I was running up a dead end street.
And the outcome?
It all goes to show how lucky we are that knee and hip replacement are so good. These other procedures don't really come close, but it's all about the pain.
I chose the right leg (to be operated on) as the doctor couldn’t do both.I didn’t care. My problem is that I have no cartilage or tendons. My 86 kilos are supported by bones alone. That’s what generated the pain.
Batistuta was probably the best striker of his day, and one of the best ever. If I can quote from the well known biting South American striker of today, Luis Suarez:
The ultimate? Gabriel Batistuta. He was a spectacular No 9 - great at finding space, shooting from outside the box, good in the air. He was always a reference for me and I used to watch the way he played. He took free-kicks as well. I don’t get to take them here! (laughs) but I’d copy him and watch videos of him all the time.
I agree with the sharp toothed Uruguayan. Not only was Batistuta an awesome player, he was a modest appealing person, who always looked super cool. He scored 300 club goals, and 56 for Argentina in 78 games, which is better than Messi.
However, he was wrecking his ankles. He had numerous steroid injections to get him through, and they probably didn't do him any favours in the longer term.
The assessment of pain severity is one of the hardest things in orthopaedics - one man (or woman's) agony may be another's "well it hurts but I try to ignore it", and yet it's the basis on which we offer complex operations with significant complications.
Most surgeons would recognise the claim "I have a very high pain threshold, doctor" as probably meaning that the opposite is true. For what it's worth, I never use the VAS 1-10 scale. A waste of time. However, Batigol's description is pretty good, as is (most of) his understanding:
"I left football and overnight I couldn’t walk", rings true. Batistuta actually had a long career, 1987-2005 at the top level. I've seen quite a few professionals with completely wrecked knees play into their mid-thirties by limiting training, watching their diet, NSAIDs and probably most importantly, great positional sense. They run about that bit less. When they stop playing though, it goes downhill quickly.
In case you're wondering how good van Basten was...
Here is van Basten's description of his pain. Not dissimilar to Batistuta:
After three years of pain I wanted a normal life again. Just imagine feeling pain every minute of the day, somewhere in your body. And that for three years! It dominated my life. From my ankle the pain bounced back into my whole body. As long as there's still hope you can still recover, you're willing to accept the torture, but after so much treatment and so many medical experiments I finally realised I was running up a dead end street.
And the outcome?
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| Remember kids, low impact activities are best when you're old |
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