If you’ve never been a patient with a serious problem yourself, you may not have considered this.  Having a medical problem not only drags down your body, it drags down your mind, too.  I’m sure someone taught you about it in medical school, but when we get wrapped up in the technical side of our profession, and it’s absolutely necessary that we do so, this is a lesson that some seem to forget.

Do you know people who are “buzz killers”?  Within a few seconds of being in their presence, you feel your emotional energy being drained and you can’t get away from those people quickly enough.  In contrast, those who are bright and energetic make you feel good and ready to tackle anything.

This is true in the doctor-patient relationship, and it’s serious.  I’ve been around doctors who act so down in the dumps that it seems that they are the ones who need help more than their patients.  Maybe they are tired from working so hard or maybe they are internalizing their worry about the patient, but they sure aren’t helping their patients tackle their problems.  Whatever the case may be, they are sucking needed emotional energy from their patients rather than filling their patients’ tanks with the fuel they need to deal with their problem.

I’m not suggesting that you not show concern.  To the contrary, I’m suggesting that you not only show concern for and interest in your patients, I’m suggesting that you be truly concerned and show it by transferring some of your own positive energy to your patients.

You can’t be silly or trivial.  That’s not what I’m suggesting.  It might take a little practice to find your own best way of approaching this and it’s hard to describe, but it’s about being positive and upbeat to the extent possible in any given situation.

Players play better for certain coaches.  You frequently hear about it.  I’ve seen it with teams that I’ve worked with.  The same players who were losing miraculously start winning.  Surely the reasons for the sudden success are many.  Maybe it’s conditioning or technique.  They’re important.  Without positive energy, however, I don’t think it happens.

Likewise, when you rod someone’s femur or replace someone’s hip, the technical aspects are critical, but that’s not enough.  You have to take care of the other physical needs as well, and I’m sure you do, but that’s still not enough.  You must also help that patient find the energy to get up and go again.  Equally as important, no matter how tired you are or what else is going on with other patients or in your life, you must dig down and find positive energy to share with your patient.

Many will dismiss this as insignificant and/or unrealistic.  I have no scientific studies to support it.  On the other hand, I have had many years of interaction with patients and truly believe that patients do better when they want to please their doctors.  It’s like a player wanting to please his coach.  You can’t fall into the trap of thinking it’s about you personally, of course, but if it’s useful to the patient, it’s certainly not harmful.

Worried that all of your energy will be drained by your patients?  Don’t be.  In fact, the gratification of seeing your patients happily improving or resolutely dealing with serious problems is in itself a source of energy for you.  It’s like heat reflecting off an object and back to you.  Try it.  You either already know that it’s true or you’ll be pleasantly surprised.

Dr. Hundley is a retired orthopaedic surgeon living in Wilmington.  He is the founder and president of OrthopaedicLIST.com a resource website for orthopaedic and other surgeons and related professionals.

From Plato and Aristotle to the present day, the wisest people who have ever thought about challenge and achievement in our lives and work have left us bits and pieces of powerful advice for attaining true success in anything we do. I’ve put these ideas together in a simple framework of seven universal conditions. Let me lay them out briefly and then we’ll look at each. Whether you apply them in your practice, in your life, or teach them to your patients, they can be very helpful for focusing on what it takes to reach important goals.

The 7 Cs of Success

For the most deeply satisfying and sustainable forms of success, we need to bring into any challenge, opportunity, or relationship:

(1) A clear CONCEPTION of what we want, a vivid vision, a goal clearly imagined.

(2) A strong CONFIDENCE that we can attain that goal.

(3) A focused CONCENTRATION on what it takes to reach the goal.

(4) A stubborn CONSISTENCY in pursuing our vision.

(5) An emotional COMMITMENT to the importance of what we’re doing.

(6) A good CHARACTER to guide us and keep us on a proper course.

(7) A CAPACITY TO ENJOY the process along the way.

There are certainly other concepts often associated with success, but every other one is just a version or application of one of these in specific situations. The 7 Cs give us the most universal, logical, and comprehensive framework for success.

(1) A clear CONCEPTION of what we want, a vivid vision, a goal clearly imagined.

In any facet of our lives, we need to think through as clearly as possible what we want to accomplish. True success starts with an inner vision, however incomplete it might be. The world as we find it is just the raw material for what we can make it. We are meant to be artists with our energies and our lives. And the only way to do that well is to structure our actions around clear goals.

(2) A strong CONFIDENCE that we can attain the goal.

Inner attitude is a key to outer results. Philosopher William James learned from championship athletes that a proper confidence should be operative in all our lives. In any new enterprise, we need upfront faith in what we’re doing. Sometimes we may have to work hard to generate this attitude. But it’s worth the work it takes, because it raises our prospects for success. The best confidence arises out of competence and then augments it.  It’s of course no guarantee of success. But it is among the chief contributors to it.

(3) A focused CONCENTRATION on what it takes to reach the goal.

Big dreams just lead to big disappointments when people don’t learn how to chart their way forward. Success at anything challenging comes from planning your path and then putting that plan into action. Gestalt psychologists teach us that a new mental focus generates new perceptual abilities. Concentrating your thought and energy in a new direction, toward a clear goal, you begin to see things that you might have missed before, that relate to the goal you’ve set. This focus allows you to plan and act, and adjust along the way. Even a flawed plan can start you off and lead you to where you can discover a better one. A focused concentration of thought and action is key.

(4) A stubborn CONSISTENCY in pursuing our vision.

The word ‘consistency’ comes from two Greek roots, a verb meaning “to stand” and a particle meaning “together.” Consistency is all about standing together. Do my actions stand together with my words? Do my reactions and emotions stand together with my deepest beliefs and values? Do the people I work with stand together? This is what consistency is all about. It’s a matter of unifying your energy and efforts in a single direction. Inconsistency defuses power. Consistency moves us toward our goals.

(5) An emotional COMMITMENT to the importance of what we’re doing.

Passion is the core of extraordinary success. It’s a key to overcoming difficulties, seizing opportunities, and getting other people excited about your projects. Too much goal setting in the modern world has been an exercise of the intellect and not also of the heart. Philosophers appreciate the role of rationality in human life. But we know that it’s not just the head, but also the heart, that can guide us on to the tasks right for us, and keep us functioning at the peak of our abilities.

(6) A good CHARACTER to guide us and keep us on a proper course.

Character inspires trust. And trust is necessary for people to work together well. Good character is required for great collaboration. In a world in which innovative partnerships and collaborative synergies are increasingly important, the moral foundation for working well together matters more than ever before. And good character does a lot more than just provide for trust. It has an effect on each individual’s own freedom and insight. Bad character not only corrupts, it blinds. A person whose perspective has been deeply skewed by selfishness or mendacity cannot understand the world in as perceptive a way as someone whose sensibilities are ethically well formed. Good character makes sustainable success more likely.

(7) A CAPACITY TO ENJOY the process along the way.

The more you can enjoy the process of what you’re doing, the better the results tend to be. It’s easier to set creative goals. Confidence will come more naturally. Your concentration can seem effortless. Consistency will not be a battle. The emotional commitment will flow. And issues of character will not be as difficult to manage. A capacity to enjoy the process is entwined with every other facilitator of success in a great many ways.

****

These conditions of success are all deeply connected. They constitute a unified framework of tools with which we can work our way toward the most fulfilling forms of achievement. They will help us to make our proper mark in the world. They will move us in the direction of true success. And why should we ever settle for anything less?

Tom Morris is the author of such books as True Success, The Art of Achievement, If Aristotle Ran General Motors, and If Harry Potter Ran General Electric. He writes weekly for The Huffington Post and can be found philosophizing on Twitter as TomVMorris.  He can be reached at TomVMorris@aol.com or through the Morris Institute.

Dr. Morris was kind enough to guest author this article for OrthopaedicLIST.com.

Lord, Thou knowest I am growing older.

Keep me from becoming talkative and possessed with the idea that I must express myself on every subject.

Release me from the craving to straighten out everyone’s affairs.

Keep me from the recital of endless detail.  Give me wings to get to the point.

Seal my lips when I am inclined to tell of my aches and pains.  They are increasing with the years, and my love to speak of them grows sweeter as time goes by.

Teach me the glorious lesson that occasionally I may be wrong.

Make me thoughtful but not nosy, helpful but not bossy.  With my vast store of wisdom and experience, it does seem a pity not to use it all, 

but Thou knowest, Lord, that I want a few friends at the end.

 [Published with permission from Dr. Steel.]

Howard Steel, MD is an icon in Orthopaedics and his inspiration goes beyond Orthopaedics.   Clinically he dedicated his career to children at Temple and the Shriners.  Educationally, he taught thousands of residents, medical students and junior faculty about surgery and life.  In 1970, he founded the Eastern Orthopaedic Association and was the Society President for the first two years.  He has hardly missed a meeting since.  Recognizing there is more to life than medicine, Dr. Steel donated funding (30+ years) for a “non-Orthopaedic” lectureship for many of the regional orthopaedic societies, the AOA and other orthopaedic entities.   Howard is funny, fun-loving and bigger than life.  

Comments about Dr. Steel by Judith F. Baumhauer, MD MPH, University of Rochester School of Medicine and Dentistry

            As a retired orthopaedic surgeon, I miss the hallway consultations where colleagues discuss cases while trying to determine the best course for our patients.  Fortunately I am still consulted from time to time and get to enjoy sharing ideas and opinions.

A few weeks ago I was called by a young surgeon who was perplexed by what would be best for his patient, an elderly, emaciated, osteoporotic woman with end-stage Parkinson’s Disease.  She had suffered a displaced, four-part fracture of her proximal humerus from a fall.  He had been taught that these need open reduction and internal fixation (ORIF) if the patient is to regain good function and felt obligated to offer that as a choice.  When so offered, she had stated that she did not want surgery but would think about it.  When he called me, he was dreading that she would call him in the next day or two saying she wished to proceed with ORIF.  How should he respond?

For me the answer was easy.  Treat her with a sling and swathe until the acute pain had subsided and then begin gentle range of motion exercises.  Sure, she would never regain function anywhere near normal but she could still use her elbow and hand to eat and for other similar activities.  Even better, she could bypass the possibility of anesthetic complications and surgical ones such as infection, blood loss, loss of fixation, nerve injury, and so on.

Being the one “in the trenches”, however, and having been taught that the proper treatment was operative, the decision-making for him was more stressful.  He felt that the right thing to do was non-surgical, but feared that that would not be acceptable morally and could put him at risk for a lawsuit.  That’s when I reassured him by saying, “It’s OK to do the right thing.”

I’ve always felt that decision-making is the most difficult part of orthopaedic surgery.  Sure, you must have a significant degree of core knowledge to understand the disorder and have an array of treatments at your disposal.  Probably the biggest decision is whether or not to operate and when if ever to do it.  If you don’t do surgery, how else would you best treat the patient?  If you do surgery, what is the best procedure?  If you run into surprises during surgery, what do you do then?  In every instance, the best decision is what is best for that particular patient at that particular time.  Sometimes, “doing the right thing” requires you to swim against the tide of current opinion and/or what you learned during your training years.  Over time, however, with personal experience and through seeing a variety of perfectly acceptable ways that our colleagues manage similar problems, we can and must learn to trust our judgment as to what is best for our patients.  Thus, no matter which way the fads are pointing at the time, when you include the patient’s wishes and do the right thing, it is always OK.  In fact, it’s more than OK.  It’s what should be done.

Epilogue:  In case you’re wondering, the patient remained steadfast and decided to not have surgery.  Had she requested it, I don’t know what he would have done, but I’ll bet he would have declined to do it.  Thus, although the whole conversation was moot it was interesting and will hopefully help him the next time he is conflicted by what he thinks he should do vs. what he thinks others would have him do.

Dr. Hundley is a retired orthopaedic surgeon with forty years of experience.  He is also a founder and the president of OrthopaedicLIST.com, a free and open-access directory of orthopaedic products and services that was established in 2003 and currently lists over 10,000 products and services for orthopaedic surgeons and related professionals.

barebones is the inspirational story of a bright, ambitious young man imbued with an iron will and an unwavering inspiration to benefit society through Medicine in general and Orthopaedic Surgery in specific.  This review is not intended to be comprehensive nor do I expect book reports to become a routine of the OrthopaedicLIST.com blog.  It’s simply that Dr. Sarmiento’s life history and his views are so interesting and compelling that I wish every orthopaedic surgeon and resident in training, indeed every physician in the United States, would read it.  As for immigrant physicians, Dr. Sarmiento’s story could well become their Bibles.

The story is well written and describes Dr. Sarmiento’s life and his family struggles when he was a young man through his medical training in Colombia to his orthopaedic residency in the U.S. as an immigrant who could barely speak English to his rise to prominence as an innovator, researcher, academician, and chair of three departments of orthopaedic surgery (two in the U.S. and one in Scotland).  Being elected President of the American Academy of Orthopaedic Surgeons, the largest and among the most prestigious of orthopaedic surgeon associations is evidence of the esteem by which he was held by his fellow surgeons.

As a resident in orthopaedic surgery in the late 60’s and early 70’s I well remember his innovative, dynamic treatment of long bone fractures as it rose to prominence.  I was fortunate to have received my training in a conservative program where the closed treatment of fractures was the first consideration and ORIF was simply one of the choices.  Moving from a long-leg cast to a PTB one for tibia fractures was a huge advance for our patients.

Dr. Sarmiento’s interest and expertise in the treatment of adult hip problems was not as well known, but he contributed significantly to that field as well.

The most compelling message from the book relates to Dr. Sarmiento’s observations of the changes in focus by some orthopaedic surgeons during his career.  Dr. Sarmiento was steadfast in putting the interests of his patients first and foremost while having to fight bureaucrats in hospitals and academic centers as well as politicians and observing and feeling the effects of powerful, fellow orthopaedic surgeons who put self interest before that of their patients and medical centers.

He also documents the efforts and effects of the powerful orthopaedic companies whose “good business” practices were not necessarily “good for patient” practices and believes that these companies have almost taken over the postgraduate education of orthopaedic surgeons.  He believes that the spiraling cost of medical care is one of the unfortunate side effects of that particular shift in source and surgeons practice “cosmetic bone surgery”, surgery that is not indicated for human function.

My only criticism of the book is that Dr. Sarmiento tends to paint our profession with a broad brush of negativity and, like most of us, is concerned that our medical profession will not continue to attract the best and brightest to become physicians.  Fortunately, the numbers and academic qualifications for those applying to medical schools have never been higher.  Hopefully those people will also make good doctors, a concern also addressed by Dr. Sarmiento.

I wish that I could require every orthopaedic surgeon, resident and practitioner, to read Dr. Sarmiento’s barebones.  As that is not within my power, I can only hope that this brief review will entice more to do so.

barebones.  A Surgeon’s Tale by Augusto Sarmiento, MD, Prometheus Books, 59 John Glenn Drive, Amherst, New York 14228-2197, www.prometheusbooks.com, Published 2003, 379 pages

Dr. Hundley is a retired orthopaedic surgeon living in Wilmington, NC and president of OrthopaedicLIST.com.

     Since for the first time I find myself with time in my hands I decided to dwell on exploring issues with which in the past I was involved to a major degree. Today I will discuss an issue where long-held, rigid adherence to an unchallenged tradition has forced me to challenge its validity.

My comment deals with the Colles fractures, which is one of the first subjects in orthopaedics we come into contact during our year of internship.  We learned about the ubiquitous fracture that affected a large number of older people and were told that its treatment was simple and the clinical results good.  All that was needed:  “closed reduction” and immobilization in a long arm cat for a few weeks.

It was not until late in my career that I first began to ask questions as to the etiology of the frequently observed loss of the obtained reduction. I had followed the gospel-like lessons we had learned from the British orthopaedist who forcefully stated that once the reduction had been obtained, the cast had to extend over the elbow, the forearm held in pronation and the wrist in a position of ulnar deviation and slight flexion.

One day, however, I suspected that the recommended position of the foreman in pronation in the cast was the guiltiest party. My logic was based on my understanding of the anatomy and physiology of the wrist. I reasoned that if it is true that muscles in order to function most effectively should be placed in a condition of tension then the forced pronation of the forearm would result in activation of the brachioradialis muscle, the only muscle attached to the distal radius, and in that manner recreate the deformity. The contraction of this muscle during flexion of the elbow could easily displace proximally and dorsally the distal radial fragment^{. 1}

I met with the neurologist who was performing electromyography and asked him for his advice and help. I brought him volunteer medical students and patients to have the studies conducted.  Without exceptions, every time the elbow was flexed the brachioradialis muscle contracted. In cadaver specimens, where we had created fractures that resembled the Colles fracture pattern, any pull on the muscle readily recreated the typical deformity.

Based on all that information we began to treat Colles fractures in supination and compared the results with those obtained when treated in pronation. The results were published, which indicated a lower incidence of re-displacement in the supination group. We went as far as developing a foreman brace that permitted limited flexion of the elbow, but prevented pronation of the forearm. It permitted limited flexion of the wrist but made impossible any radial deviation. ^{2, 3} I concluded that the classical position as described by Colles and faithfully accepted by the orthopaedic community was wrong.

At that time my career took a major turn toward Hip surgery following  a three-month visit to Sir John Charnley in England that resulted in my concentrating more seriously on total hip replacement and ignoring to some degree my interest in wrist fractures. I deeply regret the foolish decision since I am sure I could have been able to continue to devote time to both subjects simultaneously.

I vividly recall that during those days of romancing with Colles fractures I visited with some regularity local Nursing Homes where I followed patients I had treated surgically for various conditions. Oftentimes I took along with me one or two residents. During those visits I made it a habit to ask as many patients as possible if they had at any time in their lives sustained fractures of their wrists. As expected, many of them had. I saw many where a close look failed to indicate any deformity whatsoever. Other times I observed obvious deformities.  However, I have no recollection of a single patient who presented symptoms of osteoarthritis or complained of any serious clinical problems as a result of the deformed wrist.

No doubt, my mind was conditioned not to question the wisdom of Colles and consequently I had rigidly adhered to his well-intentioned but erroneous premise. I suspect we do this very often with many other pronouncements and treatment which overtime gain an odor of sanctity that precludes questioning. This is why I am such a strong advocate of conditioning residents to ask questions and to challenge virtually everything we teach them.

During the last two decades a great deal of enthusiasm has grown in support of open reduction and internal fixation of Colles fracture. The readers would not be surprised to hear that I have not surrendered to the new treatment modality. However, I trust I am smart enough to realize that the technique has made possible the attainment of better anatomical reduction and restoration of articular congruity and in many occasions is the treatment of chicer. 

        Approximately 10 years ago I sustained a comminuted, intraarticular Colles fracture with a severe dislocation of the radio-ulnar joint.  My hand surgeon fixed the fracture with multiple wires. When I woke up from the surgery and glanced at the radiographs I immediately commented “This will never work.” My remark was based on the recognition that the dislocated radio-ulnar joint had not been addressed. The surgeon had concentrated on reduction of the fragments in the best possible way, but ignored the dislocation of the ulna, which was the most important feature. Good fragment reduction in the presence of a dislocated radio-ulnar joint is not enough, particularly if the distal-lateral radial fragment has an oblique geometry. The reduction is easily lost when the brachioradialis contracts    . That was exactly what happened. Ten days after surgery new x-rays demonstrated the recurrence of the radial deviation of the held-together distal epiphysial bones. Soon after that I was back in surgery where a plate was used to stabilize the bony fragments.

My feeling regarding the closed treatment of Colles fractures may soon become meaningless since the current infatuation with surgery is displacing the nonsurgical treatment into the heap of history. Or maybe not. We should not be surprised if within a few years the orthopaedic profession will conclude that plating was nothing but a flash in the pan when the technique is applied to all displaced fractures and that plate fixation should be reserved for the very severely comminuted fractures with associated radio-ulna dislocation. We are already learning that the results from routine surgery are not any better than those obtained from manipulation and close reduction. Economics may the fact that triggers the arresting of the trend. Equal pay for the care of those patients may become the law of the land regardless as to whether or not surgery is performed.

REFEERENCES:

1. Sarmiento, A. The Brachioradialis as a Deforming Force in Colles’ Fractures Clin. Orthop. Rel. Res. 38:86-92, 1965.
2. Sarmiento, A., Pratt, G.W., Berry, N.C. and Sinclair, Wm. F. Colles’ Fractures – Functional Bracing in Supination. J. Bone and Joint Surg. 57A:3,311-317, 1975.
3. Sarmiento, A., Zagorski, J.B. and Sinclair, W.F. Functional  Bracing of Colles’ Fractures: A Prospective Study of Immobilization in Supination versus Pronation.  Orthop. & Rel.  Res. 146:175-187, 1980

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on OrthopaedicList.com and has guest authored a number of other articles for this blog.