Christian Gerber, MD, is Professor and Chairman Emeritus of Orthopaedics at the University of Zürich, Switzerland. He was educated in Switzerland and France and did a shoulder fellowship with Dr. C. A. Rockwood in San Antonio. He was president of the European Society for Surgery of the Shoulder and the Elbow and Swiss Orthopaedics and is a four-time Neer Award, Kappa Delta, and Steindler Award-winner with a main interest in clinical and experimental research on rotator cuff disease.
My philosophy as a teacher, physician, and scientific contributor
Effective leadership is putting first things first. —Sean Covey [CR]
Everyone has a Cartesian coordinate system in which they move and that defines where they stand. My Cartesian system is called “the pyramid” ( Fig. 1.1 ). The pyramid summarizes all my principles of reasoning, decision making, and conduct. It has determined my thinking and acting during my career in relation to students, residents, faculty, administration, and government. It is so simple that it can easily be communicated to everybody, and it can be used by everybody to assess their own behavior and the actions of others.
This is the decisional framework of conduct. If any question comes up, it is translated into the question, “What is best for your patient?” If one of the solutions considered is best for the patient, no further evaluation is allowed; neither orthopedics nor institution nor ego is considered. The case is closed. This approach is axiomatically based on the assumption that what is best for the patient must be best for our human and professional cause. It is incredible how many decisions can be reached at that level and unreal how many discussions, committee meetings, and administrative burdens you can eliminate if you categorically refuse to consider any other level. However, be prepared that obstruction may ensue despite having acted in the comprehensive interest of the patient. Having the strength, courage, and discipline to not negotiate your decision may be much more demanding than reaching the decision. [CR] If at level P there is an answer, no task force is created, no study group is formed, and no consultant is hired.
If two or more solutions are apparently of equal benefit for the patient, the challenge is for orthopedics (O). The need to step to the next decisional level means that we do not know what is best for the patient. This is conceptually unacceptable and represents a formidable research question. A study must be planned and executed, and when the results are available, the question can be answered at P, the first decisional level.
If your study of the literature does not allow for reaching a decision, which may happen in questions such as, “Which is the better thromboprophylaxis regime: A or B?” and current research does not allow you to objectively prefer one over the other solution, only then is the institutional (B) level decisive. (Note: My institution is University Hospital Balgrist (B); for readers, this would be your institution, or “I.”) This very often means: Which one is less expensive? Which one creates a smaller administrative burden, and so forth?
Only if there is no best solution for a patient, no possibility to advance orthopedics, and no preferable solution for the institution, can you do what you personally prefer. I have never gotten to that level, but I have also never negotiated this principle of conduct.
However, I can imagine a problem at the bottom of the pyramid: What do you do in the theoretical situation that a faculty member annoys you to the extent that you know that further collaboration will not be possible for you? This is clearly a problem at the ego (E) level. To reach your decision, you must exclude creating a problem at the P level. You must be able to guarantee that the replacing person is as good a solution as the person who you would like to replace. If you can safely say that your alternative (who is not just a potential candidate, but a person who is committed to taking the job) is better for your patients, you are free to act. If the alternative is “as good,” you must consult level O, and if your current collaborator contributes more to orthopedics than your alternative, you must look for another alternative.
If the hospital administration or the board of your institution comes up with a proposal, you will not be able to stop it because you think that it is stupid and will not work. However, if you can document that the project is against the best interest of the patient, it is dead. Nobody dares to publicly go against the interest of the patient. If you are in doubt, be it in any teaching, clinical, scientific, or administrative situation, consult the pyramid. It will reveal the priority.
The question is whether such a simple drawing can influence a whole organization and become part of its culture. When a resident came into my office to ask for support for a research project, my administrative assistant asked him, “Do you have a first and family name of a patient who would benefit from the potential results of your study?” The resident said, “Well, not really, but…” She sent the resident back to redesign his project to document that the study could at the very least be of interest for the field of orthopedics. If the orthopedic resident proposes a study that he would find interesting, he has inadvertently inverted the pyramid, starting an activity that was in his and not in the patient’s interest. He must learn to put first things first.
Although principles of learning, teaching, examining, or operating vary from institution to institution, principles of conduct do not. They are the essence of education and must be transmitted in the earliest stages of the career. [CR] Those not adhering to basic principles of conduct may still become “successful,” but they will ultimately fail because they will never become men and women of value. [CR] I have considered adherence to the principles summarized in the pyramid as a law of conduct. For students, residents, faculty, and myself, I have never negotiated their content. [CR]
What to look for in a future resident?
Most people say that it is intellect which makes a great scientist They are wrong—it is character . —Albert Einstein [CR]
Residents, faculty, students, and scientists encounter each other, usually first within a teaching (hopefully not “training”) program. [CR] However, this is when the most decisive period for our ultimate value for society is behind us. Indeed, character-forming years precede orthopedic residency and possibly medical school. When teachers encounter students of orthopedics, they must find out how to motivate them to discover the irresistible curiosity and commitment to hard work and the willingness to improve during their whole lifetime. To be able to transmit the necessary enthusiasm and to transmit the passion to pursue, we must remember what led us to choose our profession. Was it in our genes? Was it because our parents were orthopedic surgeons? Was it because we admired the social recognition of doctors or their cars, yachts, houses, or mansions? When our children play tennis, they “are” Roger Federer, and if they are left-handed, they “are” Rafael Nadal. Who did we want to be when we were children? Wasn’t it the desire to be the person who was responsible for the smile of a child who had been debilitated but was cured by an orthopedic procedure? [CR] Our careers most probably started with such a dream and ended in the determination of what we were going to do. [CR] Most children and adolescents, admittedly or not, have role models, be they movie stars, sports idols, or doctors. In college and medical school, we continue to excel in fields with teachers we admire. These role models are critical because they represent our inspiration to become a doctor and a better person. Therefore teachers have an important role to play before they encounter medical students or residents. As physicians, at any moment of our lives we have the potential to serve as a role model, to let other people dream. [CR] Our greatest legacy will ultimately be that we have unknowingly motivated a young unknown who became the person to contribute more than we ever will. [CR] Should that be so, it was well worth it. [CR] However, it is our choice whether we are the role model for the next generation.
Later, some of us have the privilege to be involved in the selection of residents. For the choice of younger collaborators, we all have different criteria. Some have yielded good, some less good results. I have never been ashamed to include Einstein’s wisdom: “Not everything that counts can be counted and not everything that can be counted, counts.” [CR]
I have usually asked myself questions like: If I had a real problem, would I trust this person to analyze it? Would his or her curiosity win against an idiopathic disease? Is this person somebody who I would like to teach me in a few years? I know that previous performance is considered the best predictor of future success, but residents are above all future partners, [CR] and therefore I screen only for knowledge and skill but hire for curiosity, attitude, and traceable adherence to human values. [CR] During selection and education, I tried to make it crystal clear that character can never be replaced by knowledge or skill, neither in clinical nor in scientific activities.
We are not looking for future residents but for future contributors and role models. The key traits of character that I admire in role models are courage, [CR] honesty, [CR] and discipline. [CR] Courage is rare but indispensable to let honesty and discipline prevail against the daily pressures and outside influences. As mentors, we must select persons with character, and we must allow and support them in being courageous, honest, and disciplined. They will remember. [CR]
How to get the residents on the right track
Give a man a fish and you feed him for a day, teach a man to fish and you feed him for a lifetime. —Chinese proverb [CR]
If residents enter their educational program, it is critical that those higher on the academic ladder ascertain that the entering residents have the basic medical knowledge and understanding that is indispensable to integrate the allegedly ever-increasing but certainly ever-changing knowledge. If the residents do not have this basis yet, the educational process should provide this basis in a demanding but constructive and kind fashion. [CR] , [CR]
Some prerequisites for future excellence such as intellectual capacity or mere manual dexterity cannot be provided by an educational program; however, other crucial factors, such as attitude, mutual respect, patient focus, and common sense, can unquestionably be influenced and developed in day-to-day interactions between patient, resident, and teacher. The true value of a residency program consists of guaranteeing that patient, resident, and mentor are repeatedly in one room trying to understand a problem, showing how it would be best approached, and how the patient is informed and convinced to participate in the planned management. Residents should learn that often there is no right answer and that common sense is the strongest validation tool for a decision, but also for the validation of statements of teachers or authors, and a highly desired quality in an orthopedist. [CR]
Basic principles of transmitting and acquiring knowledge
There are mandatory bases for a successful and sustainable clinical and scientific career that are compulsory constituents of the educational program:
Knowledge of anatomy is the most important basis for our activity. It can be acquired by everyone if they are willing to do so. If they are not, then they must be eliminated from the program. It is out of touch with reality that some medical schools almost discard macroscopic anatomy. If residents come from a medical school that neglected macroscopic anatomy, they have a chance to become excellent surgeons only if the program provides them with this background. Knowing anatomy is the most relevant secret of excellence and the best liability insurance for an orthopedic surgeon. I have to confess that it took me years to recognize how important anatomy is. When—during my fellowships in Paris—I saw surgical giants such as Alain Gilbert or Alain Masquelet access the C5 and C6 roots in less than 5 minutes for plexus reconstruction in children, I understood that mastering three-dimensional anatomy is crucial to operating safely and expediently. I have also seen them operate in regions they were less familiar with, and the difference was astounding. “Dexterity” is usually nothing but a surrogate for profound mastership of anatomy. To date, I have never seen a proficient and elegant surgeon who was not an outstanding anatomist in the region he or she was operating. It is indispensable that somebody in the educational program is mandated to verify whether the residents have this basis and, if not, to bring them up to the desired level.
Detailed knowledge of anatomy is not only necessary to safely execute a procedure but also to make a structural diagnosis. The orthopedic student should recognize that anatomy has been the basis for the most relevant advancements in orthopedics to the end of the 20th century and integrate this fact into his or her career planning. Astute interpretations of simple macroscopic observations [CR] and not theoretical or experimental findings allowed for the discovery of femoroacetabular impingement and the development of surgical dislocation of the hip. Quantitative anatomic studies explain anterior or posterior shoulder instabilities and allow us to understand pathologies such as static posterior glenohumeral subluxation. All the tissue reconstructions after trauma or tumor used in orthoplastics are exclusively based on detailed, careful, macroscopic, and anatomic studies. We must gratefully accept that crucial discoveries will be made using molecular medicine but refute the concept that destructive surgery due to poor knowledge of anatomy can be compensated for by expertise in molecular medicine.
Textbooks are a basis. Computer-based, three-dimensional anatomy programs are invaluable innovations; but currently, cadaveric dissections are irreplaceable. Consulting Google is superficial and fugacious and may provide knowledge but not understanding. Mastering anatomy requires time, engagement, and repetition. We cannot teach anatomy; we can help orthopedic students to learn anatomy and give advice on how they can verify their level of knowledge, now and in the future. Without an exam, if the student can draw the relevant anatomy, the surgical site, the student is safe. If not, the student is uncertain and must go back to textbooks and to the morgue to deepen anatomic knowledge.
Drawing the anatomy of a region, surgical site, or procedure is an invaluable tool to successfully verify knowledge and readiness for surgery at any stage of one’s career. [CR]
Detailed knowledge of the anatomy of the entire body is impossible, but anatomy remains indispensable. Therefore anatomy is the basis for future orthopedic specialization, even though some institutions and surgeons believe that subspecialties are based on surgical methods such as arthroscopy, implant surgery (so-called reconstructive surgery), microsurgery, and maybe scissor- or scalpel-surgery. However, this is barking up the wrong tree. Specialization consists of compiling profound familiarity with all aspects of a joint or region—it means having much better than average knowledge of anatomy and pathology and skill in specific history-taking, experience in interpretation of the findings of correctly performed physical exams and knowledge of natural history and prognosis of all treatment options, and ultimately the capability to carry out the best-suited treatment correctly. The core value of specialization is that it allows us much more intense and regular contact with our only unerring teacher: the patient. [CR] It allows us to develop experience much faster because we see more patients with similar or slightly different conditions. Although not fashionable, experience is an absolute and invaluable key for judgment of clinical situations. [CR]
Patients do not come to get a total joint or an arthroscopy. They come because of a problem in a certain region of their body. The poor arthroscopist is quarantined in arthroscopic procedures, the arthroplasty surgeon is condemned to recommend an implant, and the scope of the microsurgeon will prevent him from being interested at all in this particular patient. Patients are like tourists who land in an airport, who know where they want to end up but do not know how to get there. Patients are like tourists who have a problem at a certain site and know that they would like to arrive at a cure but do not know how to achieve it. They come to us and ask for help and trust that we will bring them to the desired destination with the least possible risk and the highest reliability possible. They ask for direction and hire us as their taxi driver. Our knowledge, experience, and training are the tourist map which indicates the direction where we should lead our clients. If the decision is surgery, our scalpel or our arthroscope becomes our taxicab. If we are a brilliant taxi driver in New York, we may be unable to find the best, safest, and fastest route in Los Angeles or Seattle. If we believe that a shoulder is less complex for an orthopedic surgeon than the streets of New York for a taxi driver, or that it is easier to find our structures in a severely traumatized knee than to find the freeways of Los Angeles, we are mistaken and better think it over.
However, specialization is also much more than operating in only one region. Without acquiring additional and deep knowledge of anatomy, pathology, diagnostic criteria, natural history, treatment options, and rehabilitation, operating only in one region is what we call “spectrum limitation” and represents the audacity of doing harm but only in one region.
During early residency, the consultation of textbooks of anatomy and physiology of the musculoskeletal tissues can progressively be accompanied by reading true classics. If you are interested in joint replacement, John Charnley’s Low Friction Arthroplasty is an incredible masterpiece that will tell you how to argue in so many joint replacement situations. For fractures, Sarmiento’s Closed Functional Treatment of Fractures , as well as the Association for the Study of Internal Fixation Manual of Müller Allgöwer and Willenegger, are musts. Shoulder surgeons would do well to read Ernest A. Codman’s classic The Shoulder and maybe Neer’s Shoulder Reconstruction. Such books are not the latest source of knowledge, but they offer the combination of a solid base to start from and the motivation to continue, not least because we see that what great teachers knew and taught was not necessarily true. [CR]
Overall, it is a privilege to start one’s own career without the need to make all the mistakes that others have already made, [CR] , [CR] but it requires respecting that every generation has had great minds that deserve to be consulted. [CR]
If students of orthopedics have swallowed that they will neither be taught nor spoon-fed what they have to learn, and that their most important teacher is the patient, if they have emotionally signed that their principles of conduct [CR] are nonnegotiable, then there is only one last obstacle to overcome: there is no substitute for hard work. [CR]
How can residents optimally benefit from their educational program?
In the outpatient clinic
People’s minds are changed by observations, not by arguments . —Will Rogers [CR]
Work starts in the outpatient clinic or the emergency room. Do not forget: the patient is the teacher. Often the resident first sees the patient and then examines and presents the patient to an attending who decides. If we ask the resident what his diagnosis is, we commonly receive a list of possibilities or even a description of the findings. If then the attending examines and concurs, the resident’s reaction is, “That is exactly what I thought.” In fact, the diagnosis was possibly on the list. A resident should examine and make a judgment. He must write down the diagnosis before presenting the patient to the attending, and he must write down his treatment recommendation. He will be surprised how often he disagrees with the attending and must ask himself and/or the attending why his written-down diagnosis was wrong. He has to also ask himself whether his treatment decision was appropriate or would potentially have done harm. If a resident has a positive impingement sign in a painful shoulder and makes the diagnosis of impingement syndrome, but the attending identifies frozen shoulder syndrome, the resident asks, “Why?” The attending tells the resident that impingement syndrome never causes painful and limited external rotation of the adducted arm. In one minute, the resident has learned more than when reading a book. If the resident understands that performing an acromioplasty would have been disastrous, the next educational experience is realized. If the resident disagrees, he should not argue or accept the attending’s diagnosis, but instead go back to the literature, identify typically present and absent findings, and compare that to the patient. The patient will have the right answer. [CR]
The only complementary source to the patient is case-based questions such as in the study questions in the comprehensive review course of the American Academy of Orthopaedic Surgeons.
Physical examination has only one goal: it must identify the anatomic structure(s) responsible for the patient’s symptoms . As a rheumatologist, you can hope that your ingested drugs find the symptomatic area. As a surgeon, you will arrive in a joint and never find pain. You find structures, and you must know which structure is the suspect causing the symptoms because you may find numerous innocent pathologies. If you just treat what looks abnormal, you will fail.
The attending should accept only structural diagnoses. Scapular winging is not a diagnosis—the less experienced examiner may see a shoulder as in Fig. 1.2 and say that the patient has “winging.” Scapular winging should be replaced by long thoracic nerve palsy. Winging may be anything, whereas there is no reason for a long thoracic nerve palsy to allow lateralization of the scapula on the thorax and no reason to change the posterior aspect of the neck. Conversely, accessory nerve palsy does all of that. Although texts may be instructional, they do not approach the value of having seen the two patients in Figs. 1.2 and 1.3 . [CR] If ever upon reviewing the attending’s explanations or the literature, you find that they do not correspond to the findings in the patient, the findings in the patient are correct, and the literature has to be rewritten.
