HOW TO IMPROVE YOUR CLINICAL RESULTS
Joel M. Matta, M.D.
What is the formula for excellence in orthopaedic clinical practice? Certainly there is no set formula for all but I will give you my thoughts based upon what I have learned from others as well as my personal experience.
There are a number of ways that excellence can be measured but I think the most important is by the benefit we provide to our patients which is our clinical results. Top clinical results exist in many settings and are not necessarily related to the notoriety of the surgeon or institution.
My first recommendation is to pursue the type of practice you have a passion for. You should find your niche according to your interests and your abilities. Monetary reward will to a degree direct our activities however you sell yourself short if you place money first. In Orthopaedics we can have our “cake and eat it too”. Our position allows us to enjoy our work as much as sport, gain personal satisfaction and community recognition, and in the bargain also be well compensated. I think the key to all of these benefits however is our passion and commitment to our work. There are few careers available that combine the pleasure of both manual and intellectual challenges.
Though we are surgeons and the job we do in the operating room is probably most important we must also take pride in our one to one skills with patients. If the patient is able, the more he understands about his problem the better. Pre and post operative detailed explanations can help the final result. I also rely on patient information publications and my own web site to inform the patient and family.
In the acute high energy trauma situation be disciplined regarding the physical examination. The patient should be completely undressed and all skin areas visualized. As well as a neurological exam, palpate and move all extremities that do not have obvious deformity. Use x-rays liberally.
For the sub acute or chronic problem listen carefully to the patient. You need to always assume that the patient is telling the truth and is not crazy or a “crock”. There are many problems we don’t yet understand and everyone does not fit neatly into a category. Many old trauma problems such as mal unions and non unions require a unique solution that you need to invent. The extra time you spend in planning and consultation will make the difference.
At times we find ourselves at a loss with patients, particularly those with chronic pain problems who will often say “you’ve got do something” or “I can’t live like this”. The justification for surgical treatment however should not be based on such desperate reasoning. Surgery should always have a probability of success when undertaken. You may have nothing to offer the patient and in that case it is best to say so. In a few cases I have gone so far as to tell patients that they should quit seeing doctors before somebody operates. A large proportion of these difficult patients are chronic narcotic users. I believe it is our responsibility to limit prescription of these medications to acute situations or terminal situations such as neoplasm.
Be expert in interpretation of x-rays, CT and MRI. These combined with the clinical factors provide the main indications for surgery. Maintain indications for surgery and not just operate because there is a fracture. The integrity of you and our specialty suffers with application of faulty indications. Operating without the proper indication is not just unethical it is an assault.
Performing high quality Orthopaedic surgery is a goal we all aspire to. Within your chosen niche do everything you can to learn from the best. Read publications and texts. Attend courses. As we interpret medical data, large multi center studies can tell you the standard level of care that is present as an average across centers. Pay attention also to the results of experienced and knowledgeable single surgeon series. The large single surgeon series can represent the level of results that can be obtained with dedication to the subject.
Visit and observe patient care and surgery with the field’s best. Most orthopedic surgeons are open to this. A corollary to this is: learn and adopt the best existing techniques before attempting to modify or develop new ones. In learning a technique, the technique must be learned and adopted completely in order to expect the maximum benefit to the patient and in some cases to avoid disaster. As a resident in 1978 I attended my first Swiss AO Course. Upon returning home I was delighted to be presented with a tibial plafond fracture. I operated enthusiastically but as the months progressed I watched in horror as green bone fell out of the wound. I had learned how to plate and screw the bone but not how to make the proper incision and handle the soft tissues. Acetabular fracture surgery is successful by a specific combination of the table, patient positioning, surgical approach, reduction techniques and implants. I have quite a few visitors who wish only to peer into the open wound. Learn and adopt the best existing techniques in their entirety before attempting to modify and develop new ones. This knowledge will keep you from repeating the mistakes of past failed techniques and forms the basis of our technical evolution.
Is everyone created equal as surgeons? Of course not. Surgery is a combination of intellect and motor skill. I would say that intellect is by far the most important factor. Understanding the fracture before surgery, establishing a good plan including set up, approach, reduction and fixation strategies are the most important factors. Concentrate your plan more on how you will reduce the fracture rather than how you will fix it. Reduction is typically a bigger problem then placing the implant. For a given surgery, one of several implants may be applicable and your familiarity with a device may be the reason to use it.
I think that surgeons are often best judged not by a surgery where everything goes well but by how they react when things start to go wrong. I have witnessed “flails” triggered by panic with the situation going from bad to worse. The high stress of a problem situation should ideally trigger your mind to a higher level of focus to deal effectively with the unexpected problem. Experience and contingent strategies can help.
Following surgeries we need to critically assess the result. I would say that a minority of my surgeries are performed completely to my satisfaction particularly regarding acetabular fractures. I like to have a think after surgery in the presence of the post op x-rays regarding how things could have been done a little better.
How important is speed in performing surgery. At the beginning of my career I did not consider speed to be very important but I think it is an important factor though admittedly not the most important one. I think speed is a benefit in limiting tissue trauma and infection. It is also an economic factor for you and the hospital as well as one that limits the number of patients you can benefit. During my early years of operating acetabular fractures I was assisted for the first time by my chief, Gus Sarmiento on a Kocher-Langenbeck approach to a transverse plus posterior wall fracture. If you know Gus Sarmiento you know he is not particularly patient. Gus’s first words at the scrub sink, “Joel, how long is this going to take?”. My response, “Gus, relax and get ready for a four hour case.”. His response, “Four hours, I’ll give you 2!”. The case took 2 hours and the result was as good as my 4 hour cases and from that time forward similar cases took about 2 hours. On the other hand you need to take the time necessary to achieve the desired result. Speed is not a primary goal but should increase progressively with your years of experience. When you watch a good surgery go quickly you will not see particularly fast movements but rather well planned and effective ones.
As an orthopaedic surgeon you are the organizer and leader of the OR team. Regardless if you think that you are inherently organized or an obvious leader type this is your role. I don’t think that personal charisma or forcefulness is a prerequisite for leading an effective team. The factors I consider most important are planning, providing respect, education and encouragement for your team members and working with the team in a hands on way. The concern you show for the patient and the commitment you show for achieving an excellent surgical result will rub off. By all means don’t be the one who is responsible for delays or your tardiness and lack of efficiency will also rub off. Leading the team, trying to improve performance and efficiency is a job that never stops.
Surgical complications are inevitable and the indication for any surgery must be judged in relation to their potential incidence. When a complication occurs an honest discussion with the patient at an early time is essential. There is a tendency to feel guilt and a wish to avoid the inevitable discussion with the patient and family. It is important to use the word complication and confront the situation openly and directly. The patient will at least take comfort that you are still with him in his care and will do everything possible to take a positive course. Surgical wound complications such as hematoma and infection are some of the most difficult to face and potentially harmful to the patient. Three orthopaedic surgeons can look at a wound regarding infection and say no, maybe or yes. It is easier to pronounce a colleague’s wound infected than your own. Saying infection is present to yourself, the patient, and writing it in the chart aids in getting on with effective treatment.
The public often believes in the myth that miracles in medicine are the norm. The truth is that we treat most problems with significant limitations of our understanding and that we will look back at many of our current treatments as primitive. Getting good results following orthopedic trauma entails great difficulties. We therefore need to practice with honesty and humility.
I believe that a simple documentation system including diagnosis, treatment, complications and results is a big help in quality control. Simple data forms that can be coded in a prospective manner and entered into a computer data base may not add a great deal of time and expense. This information can guide the evolution of your practice methods. To improve results it is very important to have results to compare to. Changes to improve results are best addressed to groups of patients or fractures with a high level of bad results and/or complications.
I like to give credit to my mentors. In my own career my most important mentors have been Augusto Sarmiento and Emile Letournel. I take pride in my own contributions to orthopedic knowledge but recognize that the huge basis of my practice is what I have learned from others.
I consider health and lifestyle to be important in my performance as an Orthopedic surgeon. Some restraint with food and alcohol as well as exercise benefits you and your patients. I think a mistake most of us make is not taking enough time off. I once asked Harald Tscherne how much vacation he took. He answered, “Six weeks”. I said that must include your educational travel. “No”, he said, “six weeks vacation”. None of us would question Prof. Tscherne’s commitment or productivity.
You have carefully selected your career and have also passed an extensive training and selection process to be an orthopaedic trauma surgeon. The evolution of your practice toward improved clinical results will make it all the more exciting and rewarding.