Orthopaedic art: the ARCP**

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.

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.

...oh dear

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 B12 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?

Classifications are often rubbish

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

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

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

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

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

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

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

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

Heraclitus and the European Working Time Directive

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


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


Front Page of BMA News:     

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

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

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

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

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

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

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

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

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

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

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

Naaman orthopaedics: avoiding the complex option

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Alt.orthopaedics: 10 things I hate about you

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

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

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

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

So, in no particular order:

1. Inappropriate familiarity

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

Not good.

2. Obsequiousness.

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

Too much. Way too much.

3. Telling the surgeon how other people do it

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

But...

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

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

4. Tiredness

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

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

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

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

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

5. Economy with the truth

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

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

"Why are you late?"

"I was at the trauma meeting"

"I didn't see you there"

"I was on the ward"

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

"...er...12.5"

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

6. Picking on underlings.

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

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

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

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

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




7. Not visiting the bedside.

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

Read the post.

8. Complacency.

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

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

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

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

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

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

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

10. Ingratitude.

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

Not bad, eh?

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

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

b. Disappear into private practice.

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

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

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

Old farts strike back: surgery and bible edition

...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.

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 surgical ego

You probably need to have a degree of egotism to be a good surgeon, albeit one that is cloaked with a true essential for surgical practice: humility.

Not an easy balancing act. We all meet surgeons who have an excess of the former. I doubt think that I've ever met one who had an excess of humility (myself included, he added humbly).

Anyway, our patients and their complications will help provide the latter, hence the well known perils of schadenfreude.

I give you the following short video from Steve Martin's The Man With Two Brains to illustrate the problem.




 Indeed the whole film is something of a surgical primer, and is one of the more accurate representations of neurosurgery that I've seen. The little girl in this clip is at least an ST2.

The 654 year old surgeon

The oldies we quote are usually Hippocrates, Galen and folk like that. Here is a new one for me:

Guy de Chauliac makes some good points. It gets a bit tricky towards the end for some surgeons, perhaps. He appears to have been an early proponent of simulated surgery or skills labs, according to Wikipedia:

 "It was seemingly from books that [Chauliac] learned his surgery.... He may have used the knife when embalming the bodies of dead popes, but he was careful to avoid it on living patients".

Dead popes can't be easy to come by.

Bearing in mind the bafflingly poor knowledge of anatomy in UK undergraduates now, he makes another observation:

"A surgeon who does not know his anatomy is like a blind man carving a log"

I've assisted at operations like that.

Probably not peer reviewed. 

Orthopaedic heroes: the sage of Oswestry

Back in the day, about the time when the FRCSOrth examination changed from being voluntary, with a less structured format, to compulsory (though even then it was still a moderately agreeable experience), there were relatively few examination preparation courses. This was the mid 90's, and the main course, I would say, was the one run in Oswestry, overseen by a relatively small group of surgeons, one of whom was David Jaffray.

He was an eye opener to many of the attendees, for quite a few reasons. He had an unreconstructed North East Scottish accent, an unusually informal approach to meeting strangers ("is NAME REDACTED still ******** NAME REDACTED?" he immediately enquired when learning which hospital we'd been working in), a very caring attitude to trainees and patients, and he was an awesomely good teacher. Quite superb, and very funny.

An example might illustrate some of this,  I think I remember it accurately.  He'd been up for a job in the university department of orthopaedics at my hospital, quite a few years before, as Senior Registrar/Lecturer. He came up the day before, to have the standard look round, and try to meet people (still essential, by the way). In the course of this, he began to feel that he didn't particularly want the job. He probably hadn't met the cream of the department, to be honest, but I knew exactly what he meant. The trouble was, he was manifestly the best candidate, and was almost certain to get it offered to him. Backing out at this point was considered very bad form, and difficult to explain. As he put it "I realised that I had no choice. I had to sabotage my own interview". The next day dawned, and the interview panel was the usual mix of university, management, potential NHS colleagues, an external and so on. The questions began, and it came to the turn of the extremely famous and acerbic professor of general surgery, representing 'undergraduate education'. "Mr Jaffray, tell me, what would you suggest to improve our undergraduate course in orthopaedics ?"

I will pass you over to DJ's words, which I still recall: "This was my opportunity, I had to act fast. I looked at him and said firmly 'abandon it!' " This apparently did not go down too well.  "It did the trick. After that I had no chance".

Perfect. And there are lots of other similar anecdotes .

I can't say I knew him really, but we had the odd contact about trainees. He was unfailingly helpful and completely up to speed on all aspects of training, as well as being very frank. Ask around, the man is a bit of a legend.

All of which leads me to the short memoir he put into BJJ News, which is a pure and perfect gem.

If you read this blog, you'll see that one of its themes is the value of listening to the wise older surgeons, many of whom are both highly rated as surgeon/clinicians but also funny, smart and charismatic figures. There are lots of fine surgeons about. There are probably fewer really gifted  trainers. There are even fewer who combine the two at a very high level.

The paragraph on the right is a tad pessimistic , and I can vouch from my own experience that being ...er...candid  (as opposed to confrontational) is often welcomed by senior management who may be as sick of the daft aspects of bureaucracy as you are. Meeting colleagues face to face is nearly always the best way of dealing with issues. Beyond that, the whole article is laden with  reflections, wisdom, humour and practical tips, culminating in a profound final bit of maternal advice.

Read and learn!

Old farts may be correct shocker!!

From a recent BMA News (normally awful), presented without comment, other than to say: good points, well made.

True dat

Our orthopaedic ancestors

Could you think up an operation like this?

There are an awful lot of very good surgeons about these days. And of course we all consider ourselves at least slightly above average - I know, a statistician's nightmare - but how many great surgeons, or surgical pioneers are there?

Answer - not many.

So when you meet these people, or more probably, when you work with one of their previous trainees, you should cherish it and realise that you are indeed the recipient of significant accumulated orthopaedic wisdom. It is a privileged position,

In my own case I worked with Colin Howie, who worked with Robin Ling (Exeter hips for young readers), and I learned a lot. I also worked with David Rowley, who worked with Reg "not quite a genius" Elson, who worked with the ne plus ultra of hip arthroplasty, Sir John Charnley. In addition, David Rowley worked with John Insall on developing the next stage of the enduringly good Insall Burstein knee replacement. These are not negligible figures. I learned hands from John Dent who worked with Harold Kleinert  and  Graham Lister. I worked with Jimmy Innes who'd been a colleague of Marvin Tile and Robert Salter. I learned  a lot of trauma surgery from Jeremy Martindale, who worked with Chris Colton and the whole AO group. My own AO course involved Alan Apley (possibly the most natural teacher I ever heard speak), Maurice Muller, Hans Willenegger, Tom Ruedi and many more. I'm old enough to have met and heard lecture Bernie Morrey, Emile Letournel, Allan Gross, Gus Sarmiento, Charles Rockwood, Reinhold Ganz (a legend), Derek McMinn and quite a few others.

None of this makes me as good as these guys, but they are 'names' for a reason. Of course, I also worked with several outstanding surgeons who may not be quite as storied, but are just as great as surgeons, mentors, colleagues and teachers,

My point is this - treasure such encounters and listen to the details, the 'small print' of their lives and careers. They are potential treasure troves that will benefit you and your practice.

Most recently I met Diego Fernandez, the multilingual Argentine working in Switzerland, now in his seventies, and still working hard. He was charming and friendly - not everyone of these big names is -  and gave a marvellous talk on his life as a surgeon. Clearly brilliant technically, the unspoken messages were: be humble, think laterally, retain an interest in general orthopaedics, commit to a problem case, and have other facets to your life - in his case, incredibly, ocean surfing, still. Also, don't retire if you don't want to.

I mention Dr Fernandez partly because of this recent encounter, but also because of his influence on my practice. Let's face it, most of our reading - BJJ, JBJS, CORR, JArthroplasty, J Trauma etc etc - contains papers of some interest, but only very rarely something that changes one's practice. At the end of this post is Diego Fernandez' outstanding and exceptionally original paper on correcting post-traumatic problems of the distal radius, and doing it properly (ie. anatomically). Simply outstanding, and I use these techniques to this very day.

Graham Lister's comments at Harold Kleinert's death are what we would all like to have said about us, as surgeons and trainers: he had a profound effect on me as a person, on my career, and on how I approach the many problems we deal with in our discipline.

Cherish your orthopaedic lineage!

!!!!!!???????

This may be a dying problem, particularly if the admonitions of GO ASYP are not heeded.

Have you ever been irritated by a differential diagnosis in the notes, for a basically simple clinical  presentation, such as chest pain:

?angina
??MI
??? PE
???? reflux
?????Boerhaave's
?????? Tietze's syndrome

I could keep adding. It tends to be less of an issue in orthopaedics, rather than acute medicine and general surgery, if only because it's hard to look past a broken femur.

That said, Leo Gordon provides some rich examples, noting the history of punctuation, and the philosophy underpinning this nonsense. More usefully, he suggests punishments for this terrible crime. If I may add a few musculoskeletal essay titles to make offenders think before they do it again:

Discuss the public health debate regarding osteoporosis

Discuss the suggested 'treatments' for osteoporosis, and the evidence for their use

Discuss the similarities between osteoporosis and wrinkles

Discuss Camilla Parker Bowles' public statements on osteoporosis

I could probably find some more. Unlike Leo Gordon, I have fewer problems with exclamation marks, they rarely seem to be used in orthopaedics and trauma. We are a phlegmatic, calm bunch, ordinarily speaking.

However, if electronic records really catch on, I expect to see emojis all over them.  Perfect for that dislocated hip replacement.

GO A S Y P

Here's an edited email from another specialty about a patient with an ischial pressure sore. There are no patient or doctor identifiers. The writer of the email had not seen the patient concerned.

Thank you for your email. I have discussed this with the registrar who received a phone call  from a Foundation doctor regarding this patient.

Note the sniffy tone. What was the F1 doctor meant to do? The specialty concerned refuse to carry pagers, and are routinely a hassle to track down. The point of all the specialties being under one roof - which is called 'a hospital' -  is undermined by such difficulties in access.

Advice was given with regards appropriate dressings, ensuring good nutrition (albumin of 21 is not optimised) and appropriate pressure relief with mattress, cushion, turning, etc.

As the ward nurses concerned said to me: "appropriate dressings and nutrition! Brilliant. We'd never thought of that". Furthermore, the patient was verging on being morbidly obese. Malnutrition was not an issue. Isolated albumin results are not the gold standard. This was an obvious 'end of the bed assessment' point.

He also made it clear that we do not routinely operate to close pressure sores, and would certainly not do so in the presence of osteomyelitis.

This was not requested. The specialty concerned are just one part of the appropriate multidisciplinary input the the patient needs (and can reasonably expect). A bedside review would be the obvious first step

I have reviewed the recent MRI scans, which show destruction of the ischial tuberosity and oedema of the surrounding muscles.

'destruction' suggests something dramatic. In reality it was typical superficial osteomyelitis at the base of a sore. The ischium was essentially intact. MRI is very sensitive and needs to be interpreted with care

He should continue with dressings and antibiotics. The pressure sore will never heal unless the osteomyelitis is adequately treated.

The first bit is misleading,  he definitely needs an operation, which is why the second bit is true. Established osteomyelitis is not treated by antibiotics without surgery. If there's pus, let it out (the old ones are the best).

As it turned out, the pressure sore was excised and the osteomyelitis debrided back to healthy bone, there was plenty of soft tissue to allow a tension-free closure, so there were no secondary soft tissue reconstructions needed. This was exactly what could be expected from even a brief visit to see the actual patient. 

Hence the title, GO A S Y P  or 'goasyp' to keep it catchy. Go and see your patient.

This is not picking on any one specialty - we are all capable of making this mistake. I don't, to give a common example, think you can properly assess an acute abdomen without a bedside assessment. In that example and in others more orthopaedic, like possible compartment syndrome, it may easily need several such visits. That's your job.

Once the problem has been referred to you, it becomes to a variable degree your patient. Act accordingly. When was the last time you let Kwikfit sort out your car over the phone?

Being easily available (why do people not want to carry their pagers - mobiles are no substitute?) makes a huge difference and will enhance your reputation.

This is not just  kind and humane - the patient always appreciates a bedside visit - but how the hell can you make a key decision without all the relevant facts? You can't, at least not consistently. Relying on data from your work PC instead is part of what I call Google Medicine (more another time). Anyone can look stuff up. It is not equivalent to taking a history and examining your patient. How could it be?

Not only is this advice good for the patient, it is good for you too. It will protect you when if, one day, there is a clinical mishap because of advice given over the phone or by email, though there had been nothing stopping you from actually doing what every doctor since Hippocrates has been routinely taught.

GO A S Y P !!!

....old school (in every way). Note that the surgeon is at the patient's bedside.

The Germans have a word for it

um....nice screws

There is an orthopaedic 'walk of shame', more literally a walk in the old days before digital X rays, when one had to go to the front of the room in the morning trauma meeting to put up the latest X rays of one of your hip dislocations. Every man/woman and his/her dog will then opine confidently on impossible-to-verify topics such as "your cup is too anteverted on that X ray". Their faces betray no hint of sympathy for your pain, and indeed that of the unfortunate patient. Disappointingly, there may be seen traces of joy. Dislocation, being so blatant on X ray, is probably the best example of this meme.

Thanks guys, I never knew you were all so expert on this.

However, they will regret it.

Many years ago, one of my bosses who was an erudite and witty man, and something of a Germanophile, introduced me to the now ubiquitous subject of schadenfreude. I have seen countless examples since then. If guarded against, it induces the salutary virtue of humility, something all doctors, especially surgeons, should cultivate.

Schadenfreude is a human response, but also a human failing. As Leo Gordon tells us in his vivid example below:

The gods of surgery giveth, and the gods of surgery taketh away.

You have been warned.

Surgery is a serious business

I was searching for a suitable metaphor to encapsulate certain aspects of surgical training, particularly - as in orthopaedics - those areas that require the use of potentially injurious high tech equipment.

I think I've found it.

Enthusiasm alone is no substitute for adequate training, and if trainers lack interest in their trainees, failing to assess their capabilities and not showing the necessary respect between colleagues, bad things can happen....

The metaphysics of nursing (part 1)

I am very specific in my clinical instructions. I frequently write them in by hand on the ward round, always in theatre, the drug kardex etc. I speak to the relevant staff. I don't rely on people reading my mind, or following "that's what he always does". There are always important exceptions cropping up: if they already take aspirin I don't want them on rivaroxaban and aspirin; if I very occasionally want 'none weight bearing' I make it clear.

But...

....after a complete, documented and thorough ward round I will frequently get bleeped 10 minutes later to be asked if a patient can mobilise. I will find patients being sent home on subcutaneous heparin injections - which I never do. The wrong consultant's name will remain above the bed despite daily requests to change it. There are many, many examples.

This is one of Leo's funniest matrix lessons, he really gets going in the second half. It touches on metaphysics and welding. It is also entirely true.

The Surgical Gods

Cancel this case!

Much as I would like to think otherwise, I am not a surgical god. In fact, I don't know any, but they do occasionally get in touch. This is a genuine warning in practice, call it the subconscious if you will.

Any surgeon who's done enough operations will be aware of a rare feeling that something isn't right. You want to feel this before you start the case.

I can't put it any better than Leo Gordon. There are lots of orthopaedic examples as well as generic ones. "Why am I removing this humeral shaft plate?" is one that springs to mind.

Cancelling a case is not the worst thing in the world.