This question was thrown to us by one former orthopedic mentor during our lively deli-beer-ations post surgery. The discussion came about as we were thanking them for extending time and effort to do an instructional course on their field of specialty. I added that these orthopedic courses should bring up the level of our general orthopedics training and entice some residents to go on a sub specialty training. I added that this is one of the training  thrust of our department  Commending our training program, he then posted these question to us:

1. Does your locality need  super specialist orthopedic surgeons? Do we have sufficient orthopedics cases to sustain this super specialist field?
2. How many (percentages)of these sub specialty cases are done by generalist orthopods themselves?
3. Having trained in a general orthopedics program, can do these cases even without sub specialty training?

The question went further into this. “Do you need a super generalist (should mean a generalist with a higher level of skills and expertise on all areas of orthopedics) or a super specialist (capable of doing rare cases but couldn’t do other general orthopedic surgeries) orthopedic surgeons?

The super generalist is commonly a product of an institution with a multi specialty orthopedics in place. The various sub specialty rotation gave these residents an “edge” receiving a “higher” level of training in all orthopedic sub specialties. Some institutions only have a few of these sub specialty training and thus a general orthopedic can only gain more skills by training elsewhere where a specific sub specialty training is available.

For sure, we wanted our program to produce better orthopedic surgeons, a super generalist in a sense. A generalist with a higher and broad level of skills not just in one orthopedic sub specialty but in all other as well.To do that, we need to complement our teaching staff with orthopedic sub specialist, a kind of irony but necessary step towards achieving this goal.

In just about a year and half of teaching orthopedic residents, I became interested in finding out which of the more familiar teaching styles works best for our crop of trainees. Honestly, I’m still continually experimenting.

The unique set up with which medical-surgical training programs thrive is continually changing. With the influx of medical information everyday, a program has to adapt to the call of time and for greater efficiency in preparing this ‘padawans into full pledged surgeons.It is not simple as it seems however since in this unique set up and unlike the usual academic, lab rat experimentation, a mistake might cost someone else life.

The “Master-Apprentice” method ( probably the more popular and is what I’m familiar with) involves  the “master” (attendings) showing the “apprentice” (residents) his way of doing things (skill) for a certain given situation or problem. Such teacher-student relationship is basically anchored on the assumption that the master is more experienced and adept than apprentice. This is usually an “I teach, you follow” approach to learning. One advantage of this approach is the specific skill imparted by the master to his apprentice for any given orthopedic problem. The obvious disadvantage is its limited applicability and the temptation to spoon feed a resident.

The rapid influx of modern technology and a deluge scientific evidence paved the way for a more radical, and holistic approach to learning in orthopedics. To the end of my training I was deliberately hammered by mentors to think rather than learn a specific skill, to criticize the validity of any information presented and above all, develop a logical framework for decision making process in any given orthopedic problem. Skills and techniques came in later as my mentors believe that modern technology will techniques change every 5 or so years. I am not an expert on education or teaching styles, but the latter method seems to work best for me. To my understanding, this sort of teaching style fall into the Socratic method of teaching. I’m really not interested into that. What I’m interested now is, if it’ll work too for my residents?

In every opportunity I have with our residents, be it conferences and pre ops, I focus on continually challenging their minds,  make them think harder, analyze a given situation,  criticize an evidence, present facts properly and then develop a sound decision making process. Obviously, I’m not a fan of residents trying to impress attendings with techniques and implants when he can barely utter a word on the biomechanics involved in those implants. Often, the common excuse for residents (this is awful) is the absence of patients  logistics and financial support common among government hospitals. I actually do not contest that. What we want for residents however, is to incorporate these specifics into his decision making process so he can plan ahead for his patients surgery Lastly, I wanted my residents to empathize with their patients. One common question I throw in during pre-ops is this

If you we’re the patient, what would you want your surgeon do to you?

 Usually this type of questioning gives the residents an idea as to the best option for the patient!

All of these teaching style have one thing in come though. To pass on knowledge to the new generation of orthopedic surgeons . In short, were training them to be surgeons not residents.

Will these teaching style work for our current residents? Personally, I don’t know.Not yet, but perhaps in the future.

I found this amazing animation about what orthopods do when patients sustain multiple fractures. Aptly titled “heal” and produced by genius animators of Ghost Productions, this high definition video was presented during one American Academy of Orthopedic Association (AAOS) convention and it awed a lot of viewers.

And even you tube visitors were equally amazed at the production. So go see for yourself!

One short note though, we do all of these with patient anesthetized! Helps allay the gory innuendos some may think about this orthopedic procedures!

One post operative, open fracture patient I’ve been following for weeks came to my clinic today asking me if I could remove his leg external fixator now so he can go to a “neighbor-recommended” bone setter that will “fast tract” his bone healing. A bit amused by his persistent pleadings (despite numerous occasions of explaining the need to maintain the external fixator for now), I chose another uncanny method to dissuade him.

I told him these:

1. that my own neighbor actually recommended a butcher to cut of his left leg and free him from all his temporary worries now.
2. a bone setter could not possibly do any bone setting at all because his once fractured bone, is aligned already and is showing signs of healing (2-3 cortices joined already). He cannot claim what nature does beautifully and without pain now.
3. I also told him that if the bone setter can attend to him 24 hours a day, answer all his questions via text message or calls anytime, stand on trial testifying for his “serious physical injuries” charged against those who mauled him, and then take it on stride that his services may be for free, then he can go to that bone setter now.

That bone setter lost one more patient today.

(Disclaimer: All names and characters in this story were deliberately changed to protect the privacy of the patient concerned. If you felt the story was referring to you or someone you know, you are wrong.)

“Hepe, you might want to go the ward now.” The nurse on duty ‘s voice on the phone, sound a little bit gloomy. I just came down from assisting a junior for an OR that extended to almost 12 midnight and I barely touched “the bean bag” to rest. My team wasn’t on duty that night.

“Bakit hepe?” (Hepe, is our pet calls for male residents and male nurses in the wards, sort of brotherly respect). “Nag code si Nanay Delia..Ikaw yung hinanap nya…” For a moment, I don’t know what to think of or how to react to this news. I immediately ran to the wards and joined the code team doing ACLS on Nanay Delia.

Just 5 hours ago Nanay Delia and I are happily exchanging goodbyes and hugs in what supposedly a very heartwarming patient-doctor relationship punctuated by a successful OR procedure. To thank me, she insisted I’ll take a gift wrapped Pierri Cardin hankies and neckties fresh from underneath her pillows. To Nanay Delia, I was her savior-son. To me, she was a motherly patient I can never forget. I am her surgeon.

“She what???!!!”

I first met Nanay Delia in the outpatient clinic two weeks before this incident. She was this jolly faced 56 years old lola with a very happy disposition and a charming talker. Without make up but only the ever infectious smiles you see in your grandma’s face, her wrinkles in the forehead looked like lines of happiness. Needles to say, resisting her motherly charms is totally futile. Unable to walk because of nagging pain in her right hip, she was totally unfazed by her predicament and was in fact very much hopeful she can walk again.

“Sa tulong at galing nyo doctor!” Nanay Delia was proudly chatting with some patients at the end of the clinic room. She was already infecting the whole OPD team with her crazy punchlines and contagious laughter. We can’t help but be swooned by her charm.

After examining Nanay Delia and her xrays, a decision was made to have her right hip replaced (a procedure known as Total Hip Arthroplasty) to ease out pain and make her ambulate again. I asked her and her son who was assisting her to come back next week for admission and OR.”Talaga duktor? Makaka pamalengke pa ulit ako??!” Everyone in the clinic saw the face of Nanay Delia lit up. She is over flowing with joy giving hugs to all the members of my service. A gesture that touched everyone in my service. Nothing extra ordinary, but a gesture in the right timing and execution, will melt the hearts of stone cold surgeons that we are. “Nany Delia just smooched us all!” Said one of my juniors.

Our arthroplasty service see quite a number of outpatients everyday . Believe me, Nanay Delia seem to be an epitome of hope among these poverty stricken and ill patients. In this institution, residents spend hours and days haggling for funds and implants among sponsors, philanthropist and politicians(with their CDF),so that these patients can have their OR, free.We were able to get funds for her implants, and since the surgeon, anesthesiologist and procedure itself is free, Nanay Delia will be operated with minimum of expenses.”Hay, salamat talaga duktor!”

Nanay Delia passed the cardio-pulmunary clearance and labs easily. The internist classified her “low risk” for this surgery. So the next week, I saw Nanay Delia happily sitting in one of our ward beds. A number of bantays and ambulatory patients were already crowding near her bed. I can even here the laughter and giggles these people made because of Nanay Delias funny stories and punchlines. She was the center of attention in our wards because of her friendliness, jolly type personality and talkativeness. She even talk loudly with patients on the other end of the ward, at least 10 meters far from her bed! “Kung tayo nga na infect ni nanay, mas maganda tong mga patient natin masaya din!” I jokingly told my service.

When Nanay Delia saw me and my team coming for the ward rounds, she shouted: “Shhhhhhh! Tahimik na tayo, nandyan na ang mga gwapong doctor natin!” She was gesturing her companions to keep quite but I still could here giggles from the other beds. “Nanay, napasaya mo ata ang buong ward ah!!!“

I talked with the cardio fellow and seek out another CP clearance, this time asking for repeat ECG and echo cardiogram. This premonition somewhat baffled me also. She was already cleared for OR twice and I was still asking another one. Obviously the fellow hated me for that, but I got what I wanted. Nanay Delia was cleared for OR. Nothing in the repeat labs picked up anything suspicious. Getting the final pointers and go signal from my consultants, I scheduled the OR in two days.

Talking to Nanay Delia about the procedure, the risks, the benefits and preparations, we were all set for the OR. If there was one happiest person involve in this procedure, she was Nanay Delia herself. She was so happy and proud that at some point, we heared her overtly exaggerating our scalpel wielding prowess that I can only sigh in disbelief and smile.

It was not my first THA as a resident and I have planned for this procedure several times In all of my previous surgeries, I have been chided for being too detailed on preparation and precautions to the point of obsession. Nanay Delia‘s case was no special procedure and she too did not escape my obsession to preparation. Ironically she was a symbol of hope for most of our patients admitted to the wards. Her happy disposition is so infectious that my service actually felt the outcome of her surgery will be the barometer of how good our delivery of service was. “If this procedure will have a glitch, we will be devastated. So lets make this again, our best!” I pleaded my team.

It was an uneventful OR indeed and the most satisfying one, finishing faster than we expected. Nanay Delia tolerated the OR well and we were so admiring of the outcome of the procedure. The planning paid off and more. Everyone in the OR team had a pat on the back and even Nanay Delia, who was mumbling my name under anesthesia.

The next day when I made my rounds, Nanay Delia was already sitting at her bed, her eyes glowing in joy. “Dok!, salamat po sa inyo. Maraming salamat talaga!” Coupled with a hundred more praises and exaggerations, I can’t help but gave her our “akbay barkada“, a gesture we made to our nicest friends. She was already inviting me to her upcoming birthday and the christening of her grand son, to which I would be a godfather.

“Nanay, you still have to start your hip range of motion exercise so that by tom, I can teach you how to walk with quad crutches.“I deliberately changed our topic of conversation.”Yes doc” was her smiling reply. I just shrugged my head. But deep inside, I was extremely please at the sight of one very happy and satisfied patient.

The next rounds she was motioning my team again to her bed. “Kain tau dok!” “Mamaya na po Nanay after ma dress natin yang sugat nyo and maturuan namin kayo ng quad crutch ambulation.” Teaching Nanay Delia ROM exercise was no sweat at all. She was even proudly showing off to us that her hip pain is gone. I was just smiling at her antics. “Hinay-hinay lang nanay!” I told her, she will be discharged tomorrow, once I inspected her wound and assessed her fit for home ambulatory rehab program.

That discharged never happened.

“Another epi please!” I was shouting while doing chest compression(CC). I am perspiring heavily since nearly doing CC for almost 10 minutes already. I’m still dazed as to what has happened but I’m racking my brains at reviving Nanay Delia. “Why was I not informed immediately about this?!” I was shouting already. “Hepe, ginigising lang si nanay nung bantay nya for meds nung napansin di na pala humihinga. Before natulog yan nakipag kwentuhan pa sa mga katabi at tawa ng tawa. She was asking for you and looking for you at may sasabihin daw.”

It was a massive MI according to the IM in the code team. “How can that be?” I said, Nanay Delia was cleared two times before this OR! Even the 2D echo did not pick up anything! It is frustrating to look for impossible answers. The obvious reason was, I, my service became attached so much to Nanay Delia. Nobody was expecting this event to happen because everything went well and she was one hundred percent happy just before sleeping. She never woke up to walk again.

When the IM declared Nanay Delia dead, I was still shocked and dazed. I was literally angry and frustrated at the same time. “Why did this happen? Was there anything we could have done that might have save her life???” I can see Nanay Delia‘s smiling face in my mind.

I mustered enough courage to talk to the family gathered around her bed. I offered my best consoling words. I almost cried when each of the family member hugged me. “She was asking to see you before she slept, doc. She was very fond of you.” I was in the OR

I excused myself and hurriedly left for the call room. I sat in one corner staring at the blank wall. I am looking at nothing. I still couldn’t believe what has happened. Nanay Delia and that this whole procedure meant nothing. I wanted to cry, but I couldn’t. I don’t know where to get my tears..I just sat there and wanted to cry but couldn’t…I was crying dry…

In my most isolated and stoned cold medical life, . I am hardened by pain and several deaths to our patients. I have trained myself to get detached and not be affected by emotions. I was trained to empathize, not sympathize.Yet, every time something like this happened, I felt it is easier to just cry and make ease the burden of guilt. It feels lot lighter and starting again, becomes easier.

But tears never came.

Perhaps, it was because Nanay Delia‘s jovial face smiled on us every time. That for a short time, we were able to make another patient happy and satisfied with what we can do with our god given knowledge. That we learned from this mistake and that she gave hope for our other patients. More importantly, Nanay Delia taught us all that happiness is a constant state of mind. And you need no superfluous things or event to enjoy it. No excuse.

I cried dry…