Chapter 1 Your First Three Years Chapter 1: Your First Three Years YOU want me to do WHAT? “I made it. My dream has come true. Now there is no one telling me what to do. Finally!” I remember that feeling well. The big day arrived! It was my first day in practice of orthopaedic surgery. I had been through four years of college, four years of medical school and six years of residency. That’s a lot of delayed gratification! Doctors are very good at delayed gratification. For young doctors starting out, that’s an extra 10 years of de- layed gratification while your college classmates are out working, traveling, making money, and starting a family. All while you are killing yourself with very long hours and very low pay for your educational level. You feel deprived. To make matters worse, throughout your entire residency, your attending physician, (your boss, who you may or may not like or respect) has been telling you what decisions to make with pa- tients, how to do the surgery, and even, at times, how to behave. You are tired of it. Your residency has ended and you are finally going into practice where you can be your own boss. Now, you have that indepen- dence you have been pining for for years. Finally. But moving from residency to practice was not the utopia of independence I had imagined. 5 Part 1 | You What?! My First Day in the Office My first day in the office was exciting. I was confident, but ner- vous. I knew the orthopaedic stuff. It was everything else I didn’t know. Here’s how things went down. Patients can show up with anything because I am the new guy. I don’t have any of my own patients and I am the path of least resistance when they call. Patients are great. But... How do I actually do this? What hospital do I go to? What doctors should I use for consultants? Who can help me with these things? I don’t want to bother my partners with these trivial things. The Nurses Are Your Friend The nurses! They can help me with these things. And I learned a very important lesson right out of the gate. It was July of 1980 and I had just started my internship. The nurses in the Surgical ICU had been very nice, very helpful (probably because I looked to be 10 years old). I was writing my notes and the nurses were bustling around doing their ICU tasks when all of a sudden, the neurosurgeons barge into the ICU on rounds and immediately start barking orders. This group was a notorious bunch of jerks and very quickly re- inforced that impression. Suddenly, all the nurses disappeared, frantically busy with tasks that took them as far away as possible from these schmucks. I remember thinking, “There is a lesson to be learned here!” I’m convinced that a lot of doctors are mean to everybody they work with because they try to make themselves feel bigger by belittling those around them. Probably because of insecurity. 6 Chapter 1: Your First Three Years I have said for years that the best reflection of a person’s char- acter is how they treat the people around them that they think can’t do anything for them. Lots of people are nice when there is something in it for them. Be nice to the nurses. Don’t piss off the nurses. They will do their jobs as nurses because they are professionals and they care about the patients. But, if they don’t hate you, they can make your life much easier. Treat them decently and with respect, because a lot of doctors don’t. My First Surgery Patient “First day in the office. This is what I was meant to do. Bring them on!” On my first day, Mary showed up in the office with her daughter Joan. (I am very good at remembering names.) She had a bad broken wrist that needed to be fixed. I recommended that she have an external fixator placed in surgery that week. “I got this!” Then I thought, “Let me check with the attending physician be- fore we get it scheduled.” Wait a minute, there is no attending! I am my own boss! Suddenly, anxiety and doubt set in. I’ve been waiting all this time to be on my own and now it’s here. Is this the right thing to do? Then, there are all these questions from my patient. “Is that the only way to do it?” “No ma’am.” “Is that the best way to do this?” “I believe so.” ”Pins in my wrist?” “Yes ma’am.” “Are you old enough to do this?” (“Of course, I am!”) “Yes, ma’am, I am a board eligible Orthopaedic surgeon.” (What I didn’t say was this is my first surgery on my own.) 7 Part 1 | You What?! She went on and on and I patiently answered her multitude of questions. She was a real worry wart. We finally agreed to get the surgery scheduled for that week. “THEY WHAT?” I can’t believe these people are really going to do what I recommend. Astonishing! And now, Mr. Big Shot, Dr. Independent... I now have all these questions. This is way hard- er than I planned! All the little details that go along with surgery were always somebody else’s responsibility during my residency. Now it’s all mine! Thankfully, that’s when the nurses kicked in. “Here are the pa- pers you need to fill out.” “I’ll call Sylvia to come get it sched- uled.” “Here is the phone number for the rep for the external fix- ator that the other doctors like best.” The nurses are your friend. So, we did the surgery. And with external pins in her wrist, it was painful, for both of us! She had lots of questions. Every time! But everything worked out ok. She (and her daughter and grandson and other family members) came back to see me a number of times over the years and we made a real connection. I like to think of it as a musculoskeletal family practice. In fact, 30 years later when Mary fractured her patella (kneecap), she and Joan came back and they wanted me to do her surgery. Pretty cool! As I was starting my practice, I realized that, despite the fact I had been training for six years, I didn’t know everything! (I Didn’t?) One of our faculty at the University of Florida Ortho- paedic Residency, Dempsey Springfield, warned us we wouldn’t see everything in residency and what we were there for was to learn how to think and use the principles of the musculoskeletal system and surgery to develop an approach and handle the prob- lem. He was a great teacher. 8 Chapter 1: Your First Three Years I knew right away I needed some advice. But that can be hard to admit. It takes a strong ego to become a surgeon. I’m supposed to be this hotshot new partner with new techniques and ideas. I don’t want other people to think I don’t know what I am doing. It’s embarrassing, as well as damaging to my ego. This is why a lot of young surgeons seem arrogant. Some of them really are. But some of them just don’t want to look like they don’t know what they are doing. If a nurse mentions some- thing that might help, she is likely to get her head bitten off with a sharp, “I’m the doctor here. I don’t need any advice from a nurse!” Or, if a nurse dares to say, “I have seen Dr. Barnett do it this way,” she could be slapped with a terse, “Well, Dr. Barnett is not here now, is he?” Only someone “realistically confident” can accept advice, particularly in the operating room. Ask for Advice The secret is to “Get a guy.” (Good advice for life, as well.) Find somebody you can go to who understands young people don’t know everything. Go to a quiet place, away from everybody else, where you can ask questions. Find someone who will give you good advice and won’t blab to everybody. Greg Munson was that guy for me, even though we didn’t do the same type of surgery. Often, the medical issues are not the difficult ones. It’s the other things, like how do you handle the difficult patient or what consultant should I use? You may need help with political issues (local MD stuff, not Republican and Democrat stuff). Another great question is “Who can I trust and who should I watch out for?” 9 Part 1 | You What?! There are always people to watch out for. Some are just not good people. You are going to have to learn how to deal with them. The bad behavior of doctors has been tolerated for way too long, especially in the OR. Find out who the worst ones are and stay clear of them as best you can. Oh, and don’t become one of them! 10
Chapter 1 Your First Three Years
Chapter 1: Your First Three Years
YOU want me to do WHAT?
“I made it. My dream has come true. Now there is no one telling me what to do. Finally!” I remember that feeling well.
The big day arrived! It was my first day in practice of orthopaedic surgery. I had been through four years of college, four years of medical school and six years of residency. That’s a lot of delayed gratification! Doctors are very good at delayed gratification.
For young doctors starting out, that’s an extra 10 years of de- layed gratification while your college classmates are out working, traveling, making money, and starting a family. All while you are killing yourself with very long hours and very low pay for your educational level.
You feel deprived.
To make matters worse, throughout your entire residency, your attending physician, (your boss, who you may or may not like or respect) has been telling you what decisions to make with pa- tients, how to do the surgery, and even, at times, how to behave.
You are tired of it.
Your residency has ended and you are finally going into practice where you can be your own boss. Now, you have that indepen- dence you have been pining for for years.
Finally.
But moving from residency to practice was not the utopia of independence I had imagined.
5
Part 1 | You What?!
My First Day in the Office
My first day in the office was exciting. I was confident, but ner- vous. I knew the orthopaedic stuff. It was everything else I didn’t know. Here’s how things went down.
Patients can show up with anything because I am the new guy. I don’t have any of my own patients and I am the path of least resistance when they call. Patients are great. But... How do I actually do this? What hospital do I go to? What doctors should I use for consultants? Who can help me with these things? I don’t want to bother my partners with these trivial things.
The Nurses Are Your Friend
The nurses! They can help me with these things. And I learned a very important lesson right out of the gate. It was July of 1980 and I had just started my internship. The nurses in the Surgical ICU had been very nice, very helpful (probably because I looked to be 10 years old). I was writing my notes and the nurses were bustling around doing their ICU tasks when all of a sudden, the neurosurgeons barge into the ICU on rounds and immediately start barking orders.
This group was a notorious bunch of jerks and very quickly re- inforced that impression. Suddenly, all the nurses disappeared, frantically busy with tasks that took them as far away as possible from these schmucks. I remember thinking, “There is a lesson to be learned here!”
I’m convinced that a lot of doctors are mean to everybody they work with because they try to make themselves feel bigger by belittling those around them. Probably because of insecurity.
6
Chapter 1: Your First Three Years
I have said for years that the best reflection of a person’s char- acter is how they treat the people around them that they think can’t do anything for them. Lots of people are nice when there is something in it for them.
Be nice to the nurses. Don’t piss off the nurses. They will do their jobs as nurses because they are professionals and they care about the patients. But, if they don’t hate you, they can make your life much easier. Treat them decently and with respect, because a lot of doctors don’t.
My First Surgery Patient
“First day in the office. This is what I was meant to do. Bring them on!”
On my first day, Mary showed up in the office with her daughter Joan. (I am very good at remembering names.) She had a bad broken wrist that needed to be fixed. I recommended that she have an external fixator placed in surgery that week. “I got this!” Then I thought, “Let me check with the attending physician be- fore we get it scheduled.” Wait a minute, there is no attending! I am my own boss! Suddenly, anxiety and doubt set in. I’ve been waiting all this time to be on my own and now it’s here. Is this the right thing to do?
Then, there are all these questions from my patient. “Is that the only way to do it?” “No ma’am.” “Is that the best way to do this?” “I believe so.” ”Pins in my wrist?” “Yes ma’am.” “Are you old enough to do this?” (“Of course, I am!”) “Yes, ma’am, I am a board eligible Orthopaedic surgeon.” (What I didn’t say was this is my first surgery on my own.)
7
Part 1 | You What?!
She went on and on and I patiently answered her multitude of questions. She was a real worry wart. We finally agreed to get the surgery scheduled for that week.
“THEY WHAT?” I can’t believe these people are really going to do what I recommend. Astonishing! And now, Mr. Big Shot, Dr. Independent... I now have all these questions. This is way hard- er than I planned! All the little details that go along with surgery were always somebody else’s responsibility during my residency. Now it’s all mine!
Thankfully, that’s when the nurses kicked in. “Here are the pa- pers you need to fill out.” “I’ll call Sylvia to come get it sched- uled.” “Here is the phone number for the rep for the external fix- ator that the other doctors like best.” The nurses are your friend.
So, we did the surgery. And with external pins in her wrist, it was painful, for both of us! She had lots of questions. Every time! But everything worked out ok. She (and her daughter and grandson and other family members) came back to see me a number of times over the years and we made a real connection. I like to think of it as a musculoskeletal family practice. In fact, 30 years later when Mary fractured her patella (kneecap), she and Joan came back and they wanted me to do her surgery. Pretty cool!
As I was starting my practice, I realized that, despite the fact I had been training for six years, I didn’t know everything! (I Didn’t?) One of our faculty at the University of Florida Ortho- paedic Residency, Dempsey Springfield, warned us we wouldn’t see everything in residency and what we were there for was to learn how to think and use the principles of the musculoskeletal system and surgery to develop an approach and handle the prob- lem. He was a great teacher.
8
Chapter 1: Your First Three Years
I knew right away I needed some advice. But that can be hard to admit. It takes a strong ego to become a surgeon. I’m supposed to be this hotshot new partner with new techniques and ideas. I don’t want other people to think I don’t know what I am doing. It’s embarrassing, as well as damaging to my ego.
This is why a lot of young surgeons seem arrogant. Some of them really are. But some of them just don’t want to look like they don’t know what they are doing. If a nurse mentions some- thing that might help, she is likely to get her head bitten off with a sharp, “I’m the doctor here. I don’t need any advice from a nurse!” Or, if a nurse dares to say, “I have seen Dr. Barnett do it this way,” she could be slapped with a terse, “Well, Dr. Barnett is not here now, is he?” Only someone “realistically confident” can accept advice, particularly in the operating room.
Ask for Advice
The secret is to “Get a guy.” (Good advice for life, as well.) Find somebody you can go to who understands young people don’t know everything. Go to a quiet place, away from everybody else, where you can ask questions. Find someone who will give you good advice and won’t blab to everybody.
Greg Munson was that guy for me, even though we didn’t do the same type of surgery. Often, the medical issues are not the difficult ones. It’s the other things, like how do you handle the difficult patient or what consultant should I use? You may need help with political issues (local MD stuff, not Republican and Democrat stuff). Another great question is “Who can I trust and who should I watch out for?”
9
Part 1 | You What?!
There are always people to watch out for. Some are just not good people. You are going to have to learn how to deal with them. The bad behavior of doctors has been tolerated for way too long, especially in the OR. Find out who the worst ones are and stay clear of them as best you can. Oh, and don’t become one of them!
10