Four major subspecialty service of UP-PGH Orthopedics which also parallels its pilars: Leadership and excellence in training, service and research

I just came back from an orthopedic fellow’s convention and the Ruby Anniversary (40th) celebration of my former orthopedic training institution. Aside from the maxed out celebration with former (tor)mentors and alumni, I got one serious question unanswered afterwards- What now?

Seeing the glorious past of an iconic institution, and sensing the current status of a top notch residency program, I am reminded by the vision and mission the department. The same vision and mission somehow answered the very question thrown on me by an alumni and mentor.

Where are you now in your orthopedic practice? Are you in pursuit of our department’s pillars of leadership and excellence  in training, research, and service?

A very had question to answer and I can swear I had to think deep enough into the recesses of my orthopedic practice to assemble my answer. There is no doubt in my mind the department’s alumni are in the forefront orthopedic’s training and service in Philippine orthopedics. What I saw and heard during our Ruby Anniversary partly reaffirmed this.  Well, I  ”rubbed elbows” and chit chatted with famous/celebrity/controversial orthopedic surgeons in the Philippines I listened to stories of alumni who practiced unknown territories where no other Filipino orthopod dare went into. In fact, almost every nook of Philippine orthopedics nowadays is led or being push up front by no less than the graduates of our institution, be it for excellence or some other things.

Research on the other hand, lags behind among these pillars that the department is excelling at. Such was an assessment by some former mentors and alumni, if we are to base it on the number of quality, evidenced based researches published on peer reviewed journals here or abroad. Sadly, such also applies to me. The last orthopedic related research I’ve done was six years ago and thats was during my residency training. In a community practice outside a training institution, the chances of you doing orthopedic research is practically nil. I blame it on nobody, but myself. During residency, we had this one common “Limitations of the Study” written in almost all our orthopedic research. It says “not enough study population”. Today, in my practice, that would still be a limitation. But many of former mentors mention this one reason:

“Many of our graduates outside a training institution don’t do orthopedic research anymore because research don’t feed mouths. Instead of providing money, you need money to do research. Research entails a great deal of commitment in terms of time, money  and effort. Commitment who couldn’t compete with the drive to earn money for living, comfortably”

Yes. I’m guilty too and these was an aye opener. At least now, I can set a direction to where my practice could focus more to improve service. Perhaps one day I can still live up to the expectations of my department’s vision and mission.  No it’s never late. Like what many have said, there’s so many areas to learn and research on Philippine orthopedics. Not many formal and evidence based researches have been done. Not many got published. That makes Philippine orthopedics still a fertile ground for research.

Copyright secured by Digiprove © 2011 Remo Aguilar

Our department has been conducting evidenced based journal clubs for its orthopedic staff since last year. We implemented a relatively standard, EBM style “format” of presentation that encourages thorough, analytical and critical thinking among our residents. This was also to prepare these residents for a better, EBM acceptable researches in the future. Indeed during the initial sessions of our journal club, we seem to have made a good impact.

After attending our latest journal club however, a few reports were drifting back and there’s still room for improvements. I’m not dampening the efforts of some residents in preparing their presentations. I can see potential in their reports. But a resident (you know who you are) simply made it appear he has been in the dark ages of EBM. His report pales in comparison to a known, acceptable format for a lively, critical and learning-conducive journal club reporting.

In this, many (if not all) of our consultant staff would agree. So I’m making some suggestions to improve some more our  journal club presentations. I know I may sound like a broken record but  consultants do feel sad when residents perform below their potentials .

To help you out, here are these suggestions.

1. Prepare ahead (weeks, not an hour!) of the journal club schedule. Think (or look back) for an case/problem/dilemma that affected you and your orthopedic training
2. Problems in orthopedics can be broadly classified into whether it is a clinical,  diagnostic, therapeutic, technical or surgical dilemmas, outcomes etc. Identify where your case/problems falls and then read the appropriate EBM guidelines in critiquing journals for those. Use them as guides.
3. Search for an appropriate journal. Appropriate means the journal relevance to your case/dilemma/problem/question. The journal should be able to make you decide for an appropriate EBM based action on your case/problem on hand.
4. Read first these general guidelines (I will enumerate them below) before during and after you read your journal. This will definitely guide you on sifting out weeds on your journal!
5. Make sure you can answer these questions and knew your journal by heart before even trying to write/prepare your presentation slides.
6. Prepare a 10-15 minute presentation that could answer these same general guidelines. Stick to the basic presentation format, slide color presentation and brevity of words.
7. Presentation should be concise, short but should answer all the relevant questions. Relevance should be at the first level. Cut those unrelated words and phrases and don’t mention or drag in concepts your not familiar with. This will save you (and us) a lot of time.
8. Wait for questions at the end of your presentations. Answer questions with first level relevant answers. Yes or no (or I don’t know) answers are pretty much better than strings of unrelated phrases.
9. Take note (or ask someone to do it for you)  of questions you haven’t answered. or suggestions for your improvement.That will actually gauge your proficiency and how well you prepared for this journal club.
10. Try to answer those unanswered questions in number nine after the journal club by either, going through the journal again and searching for appropriate material to read (books,journals researches etc). Just don’t leave any questions hanging for you and your colleagues.

I’m reprinting this outline from this journal and so all credits goes to the authors

• DESCRIBE THE CASE OR PROBLEM THAT ATTRACTED YOU TO THIS PAPER
• EXPLAIN HOW YOU CAME ACROSS THIS ARTICLE
• DESCRIBE THE STUDYAND THE RESEARCH QUESTION
• STATE THE IMPORTANCE/RELEVANCE/CONTEXT OF THIS QUESTION
• DESCRIBE THE METHODS BY GIVING MORE DETAIL ON THE QUESTION COMPONENTS
• STATE YOUR ANSWERS TO THE CRITICAL APPRAISAL QUESTIONS ON VALIDITY
• SUMMARIZE THE PRIMARY RESULTS
• DESCRIBE WHY YOU THINK THE RESULTS CAN ORCANNOT BE APPLIED TO YOUR PATIENTS/SITUATION
• CONCLUDE WITH YOUR OWN DECISION ABOUT THE UTILITY OF THE STUDY IN YOUR PRACTICE—RESOLVE THE CASE OR QUESTION WITH WHICH YOU BEGAN
• FINALLY, PREPARE A 1 PAGE SUMMARY OF THE OUTLINE ABOVE AS A HANDOUT

You can also freely download the file and reproduce or distribute them. Hope these suggestions will all improve our journal clubs in the coming months! I, for one will be expecting more from the presenter.

• Mark D Schwartz, Deborah Dowell, Jaclyn Aperi and Adina L Kalet. Improving journal club presentations, or, I can present that paper in under 10 minutes Evid. Based Med. 2007;12;66-68

I must admit.I’m a bit compulsive and freaked whenever a close person get sick or will undergo a surgical procedure.

In our family, I’m the only medically “knowledgeable” person. Being a  the medical guy in a family is a whooping responsibility.

Yes it is.

The three or four surgeries my mom and sis went through plus the numerous getting sick moments other family members experiences extract a heavy toll on my stress reserves. Of course my medical training helps, especially in the part where you plaster an emotionless face to keep a cool composure.  Yes,we play the hands of god to heal. For that, we need a calm, fluid, sewing, hands.

But this time, not even my M.D. training could ever down play such stress on my composure. Ironically, being an MD fine tunes your senses and pushes you towards compulsion to details whenever someone close to you get sick.

Why? Frankly, I don’t know.

As one good surgeon mentor told me before..

“you can never be a real surgeon unless you went through the knife yourself”..

Then suddenly it dawned on me. The closest thing for me to go under a knife until now,  is for any of my my closest people to go under the knife.  And that for the nth time, my mom would undergo one soon.

Her past surgeries were all emergencies. The decision making is emergent. The preparation is shorter and the options, close to nil.She’s left to a single emergent choice and then pray she’d wake up outside of the slim “margin for error”.

So you’d think  cataract surgery is minor. If you have seen how the almost blind, seemingly helpless elderly gropes in the dark while being carried to the OR, you wouldn’t think so. Better preparation, more choices and therefore less risks? Heavens no! With such wider margin for error comes the greater responsibility and risk of not missing any slightest detail. You bought only time to prepare, and therefore reduce the risks. But after that, it is still a surgery. If you miss something on the preop, given the longer preparation you have chances are the results would be a catastrophic guilt for the family. In a closely knit family culture of th e Filipinos, the guilt is pretty much an issue. And If your mom is on the OR table, everything is definitely “major”…

So never mind if my mom is diabetic with beginning retinopathy. Never mind if she has had 3 major surgeries before and countless other hospital admissions due to some sickness. Never mind she survived all of those. When your face by this same predicament and even on better circumstances, no surgery is still minor. Especially, if it’s your mom is on the receiving end of a surgeon’s knife.

So I go on with my usual compulsion to detail,  to my often obnoxiously redundant reminders of doing this and that pre-op. To most this might be an overkill. But If I were the patient, I’d love my surgeon to do so the same for me. Take the extra steps of care. That extra effort gives me a little security about my surgeons care for me.

This is one of the good  insights I learned from my mom’s procedures. You feel for your patients, you put yourself in their situation and imagine the best option your surgeon can offer. I always apply them to my patients. I teach this to my residents. Stressful? Yes it is. But who said the life of a surgeon is easy anyway?

So thank you mom. For undergoing the knife for me. You help mold a better surgeon.

(An update: I know my mom’s surgeon don’t read this write up, but I’m all praises for the guy. He didn’t just made an extra effort for my mom. Everything he did was a piece of his class. Masterful. Thank you..)

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.