Welcome to the upper hand where Chuck and Chris talk hand surgery.
We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.
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Oh, hey, Chris.
Hey, Chuck,
how are you today?
I am well, how are you?
I'm doing very, very well. It's a little, you know, Today is November 15, then we're still in the midst of the pandemic and things are going in the wrong direction in St. Louis. I don't want to be a downer. So we don't want to talk too much about this.
Yeah, you did open up a couple of weeks ago with the election and then pivoted quickly into the podcasts or into the into the pandemic. So yeah, total win.
All right, well let's go, well let's stay happy here. No pandemic talk, no cancellation of elective surgery talk. We're gonna jump into our podcast without further ado.
Well, yes. So there are obviously many things to be grateful for. And we're grateful for our listeners for really giving us energy as we do this. And this is one that, I have some feedback that came from the survey. It says here, thank you for your efforts in producing this podcast. Taking call as a junior resident is one of the more intimidating tasks that I
have undertaken. Knowing that I've heard about something or that I can put a name to something help with, that helps with many of my upper extremity consults. I like hearing about your experiences with diagnosis and physical exam. For example, it can hurt when mashing on someone's scaphoid fossa, and that's totally normal. If you're mashing it probably will hurt.
I love the word mash. I love that.
Oh, yeah. Oh, yeah. Well, thank you to the anonymous person who filled out our survey for obviously filling out the survey and then also for giving us that wonderful feedback, I hope that your calls as a junior resident go well, I remember those days not so fondly.
Absolutely. I think mash is a southern term. And I'm a southern boy. And I do like that it brings back shades of Alabama for me.
Well, any good cases recently, Chuck?
You know, I've had a couple of interesting, similar cases, which are failures of CMC fusions in young patients. And so first of all, let me just say, because I, this is somewhat controversial. I'm a believer in the CMC fusion, I think it can be an outstanding option in the right patient. And for me, the right patient is a younger patient. And what does younger mean? I don't know, less than, younger than me, less than 50
I was about to say.
It means someone who is you know, as my patients like to say, you know, I use my hands a lot. One of my favorite patient comments. Yes, thank you. We all do. But someone with intensive hand activities, especially. But I think it's a great option. Do you use the CMC fusion routinely?
I do, I tend to follow the standard kinds of indications, people younger than Chuck, and people that do heavier types of activities, whether that's for work, or when I ask them the types of hobbies that they like to do. You know, I know that, you know, the, there are some studies demonstrating that grip and pinch can be quite well restored after arthroplasty or, you know, LRTI type options. But I do think it makes a lot of sense in the right patient, you know, the non union rate is real. And
that's what scares me. You know, so, in a paper coming out of here even demonstrated that a couple of years ago, so I mean, how do you mitigate that risk?
Before I answer the question, which is the important question. I give patients and I'd be interested to see what you tell patients, I tell patients, two things in warning about this procedure. Number one, you will not be able to put your hand flat on the table. If you say that in advance, it's a non issue, because they can come close, but they can't quite get their hand flat on the table. And the second thing is even less of an issue. It can be tricky to put
your hands in gloves. But other than that, I don't get complaints about this procedure.
Do you think that it takes a long time to get over this surgery and we've talked about the thumb CMC arthroplasty, you know, LRTI in various iterations, and perhaps we don't tell people how long it truly takes. You know, some patients have told us six, nine months and we usually tell them three. So what do you tell people about the recovery after an arthrodesis?
I think that's one of the benefits of an arthrodesis. It is absolutely a faster recovery when compared to an LRTI. Now, you could argue that other trapeziectomy combined procedures, such as an internal brace may be a quicker recovery. But I think if you get to three months after a fusion, patients are generally healed, strength is recovered or nearly recovered and they're back to doing everything. So I think it's a pretty fast recovery.
Now are you immobilizing for six weeks after the fusion to allow the fusion body to set up?
I'd probably go a little shorter than that. But yes, I think the hardware and we'll get to that is part of the issue. And I do tend to go a little more slowly and don't get them into therapy too quickly. Getting back to your question, I think the key elements to this procedure are one really getting good cancellous bone exposure. And I did these two revisions in the last three weeks, and neither of them had complete cancellous bone exposure.
So you were still looking at cartilage?
I was still looking at cartilage or that subchondral bone, you know, when you take off the cartilage, sometimes you think you're done, but you're really not. You need that sub cortical bone gone. You need the yellow, hopefully yellow, cancellous bone which is just sitting there waiting to heal.
What side was the was the issue on? On the metacarpal side or on the trapezium side?
So on, there was a like a T plate use on one of these patients, there were staples used on one of these patients. And on both of them. Preparation was okay, I wouldn't be overly critical the previous surgeon but it wasn't perfect on either one. And it was on both sides
On both sides. You know, because I think that one of the challenges is that obviously metacarpal is a much bigger bone. When you're doing the the fusion surface preparation. Trapezium I mean, on some of these patients that you may run out of bone pretty quickly.
You can so it's so much easier to prepare the base of the metacarpal I like to create that in a little bit of a cone shape, and I try to create a little bit of a cup shape from the distal aspect of the trapezium, but the preparation of the trapezium is just more difficult and you need to be meticulous. I do add distal radius bone graft to most of these because it's right there and it's simple to get and it does fill in the any gaps you may have. And then the hardware
you know, pins are fine. A typical plate like a T plates probably okay. There are specialized plates and I have no relationship with Medartis whatsoever. But they have a really nice plate design for CMC fusion, which I use in both of these last two cases. And it's a game changer.
Yeah, I think you know, beyond that specific plate, having a two column type plate is really important. And obviously you want locking options to see how much you can you know, especially on the trapezium, it's easy to run out of real estate. Ever use a headless compression screw?
I've revised headless compression screw cases, I just don't buy that you have enough trapezium. I just find I think you can get away with it sometimes, but I think you can get burned with it sometimes as well, and sta- I'm not a stapler. I recognize some people love staples for four corner fusions. And for this, I'm not against it, but again, it has to be set up to succeed.
Yeah. Well, so thank you for sharing that. Chuck. If there's anybody that wants to put in any requests, you know, for listener grab bag, feel free to email us handpodcast@gmail.com. Otherwise, you're gonna just keep getting pearls from Chuck. And then of course, please go and do our listener survey. You'll find the links on our social media accounts on Twitter, we're @hand podcast. And we'll also have it at our our website, theupperhandpodcast.wustl.edu.
The chance to win the coffee mug, the coveted coffee mug for the December drawing is is coming up.
It is and we are excited to draw hopefully a domestic listener. But hey, whatever it takes.
I love the international listeners. I don't know about you. I love that. Thank you for anybody that's listening to us across the world. Chuck doesn't appreciate you but I do.
I love you just like I love our domestic listeners. I just don't like mailing you mugs.
Oh, come on.
Alright
The Grinch is already here. It's not even December yet.
So listen, so people ask partners ask why I like Twitter. I like Twitter because I have a medical Twitter and I have a personal Twitter and they're for very different purposes on my medical Twitter, I usually just listen or read and sometimes I get exposed to things that I would not otherwise be exposed to and our topic for today is exactly that. So in 1999 in the journal clinical cancer research, which I honestly have never heard of
That doesn't get in your mail box?
It does not, I struggle to read the journal of Hand surgery
Come on QXread.
True, but a well known cancer researcher and department and university leader named Joseph Simone wrote an article called understanding academic medical centers, Simone's Maxims and when someone blurbed about it on Twitter, I was intrigued and intrigued enough to go pull the article and I shared it with Chris and we thought it would be an interesting article to discuss.
First off before we get into the article, I 100% agree with you that I learn a lot on Twitter from other fields. And you know I pick up a lot from the field of general surgery because they're obviously doing a lot of work on social media. And there are a lot of interesting concepts with regards to leadership, and then even some of the research topics that we like to explore in terms of new methodologies that you can pick up on Twitter. So that's one of the main reasons
why I like it. And I also honestly will have learned about, you know, big randomized trials published in like the Lancet based on Twitter. So, kudos to everybody who's sharing good stuff on Twitter. Thank you.
Yeah. And the other thing I read a lot about on Twitter, and again, I've been exposed to interesting articles is in the field of field, I don't know if that's the right word, but diversity, inclusion and social justice, there is great work and that some of that gets propagated on Twitter. And it really helps to open my eyes in a way that in my normal daily life, I may not be exposed.
Yeah, it's always good to have that extra exposure. So let's get into discussing Simone's Maxims. I think the first Maxim that's listed here is truly interesting. It's a little awkward to have this discussion in front of my vice chair. But institutions don't love you back.
So well, hold up, can I give a little background?
Sure
You're, you want to jump into it. And I do, too, because it's super interesting. So this is an article and I think you can pull it for free. So anyone out there and we'll put a link in our in our show notes, there actually was a book written. So this article's from 1999, there was a book written in 2012, which I probably will buy, which is the same idea, but it's updated. So this is old. This is 21 years old. But it has absolutely stood
the test of time. And the author just shares his thoughts about academic medical centers. And so some of you listening are like, Well, I'm not in academics, why should I keep listening? And I would just say that I think this is fascinating. You may listen to this conversation. And you may think, thank God, I'm not at an academic medical center. Or you may think, Hey, this still applies to me, because all of us deal in some form or fashion with bigger institutions today.
Yeah, I think that's 100% relevant, and there are going to be many listeners who are saying, I'm glad I'm not those guys.
So
But you'll probably find some relevance for sure.
For sure. And I definitely did. So yeah, first of all, institutions don't love you back. And they're, that is the most important thing, I think, in this manuscript. I mean, it is really true. And the line that I like, which is, which is pretty clear, is that institutional leaders must make decisions that are not personal, but usually have positive or negative personal consequences. So institutions have to think
about the bigger picture. And I think it's really fair and fair or unfair, it's just it is what it is.
One of the, you know I, I think that this is a really interesting part of the paper. And the sentence I underlined a few sentences down is, one must keep in mind that institutional relationships are really with persons who can and sometimes do
love you back. So if you think about, you know, what you enjoy about coming to work, and you know, it's really the people as opposed to saying I'm affiliated with so and so institution, because if, you know, if it was just the institution without the people, it would, it would be probably an empty existence.
I that is exactly right. And I and I, one of the later points is that leadership matters. And I think if you have an effective leader, whether that's in your academic institution, your private practice, or whatever, then there are personal relationships. So we don't want to be too negative as we started the show by saying, I think it's just a reality, you know, you have to advocate for yourself, and understand institutional
priorities. So Ryan Calfee recently suggested that I read the infinite game by Simon Sinek. And he's a business writer, he's written some really good stuff, I hadn't read this particular book, the infinite game, essentially, contrary, and this is a good read so far. It really contrasts the finite game, which is like a game of football. Or it could be Chuck Goldfarb's career versus the infinite game, which are games that are not won and lost and are played over a longer period
of time. So institutions think about infinity, Chris and I, you know, because we're human, because this is our job think in a more finite way. So it's just a really interesting context.
Yeah, I think that's a good way to put it and, you know, not being in a, any sort of leadership role and not being part of, you know, the bigger thoughts of an institution and I have a hard enough time, you know, putting one foot in front of the other on some of these days, so.
Absolutely, I like this. What they called a variant of this maxim is that institutional reputations, and those of its departments and divisions change long after the time of their successes and failures, individual reputations change more quickly. And we've seen that in real life, and I'll be very personal here, is that our department, and I can thankfully say in the past, had a reputation for being somewhat malignant for residency training, and lo- it took a long
time for that to go away. And that was a negative reputation. And we had to work really hard. We don't have that reputation anymore. We shouldn't have that reputation because we're not, but those kind of things for better or worse are hard to change.
Well, how do you change it then?
I think It's A about, you know, reputations develop for a reason, and maybe not always fairly, presumably with a little bit at least some degree of truth. And so I think you first have to recognize that, you know, there is or potentially is an issue, correct the issue double down on correcting the issue. And then you have to be patient as hard as that may be.
How long do you think that it? You know, the, the arc of time between when it was recognized that, you know, we have this reputation of being malignant in residency training, to when you feel like the page turned? Like, how long did that take?
You may laugh at me and really think I'm old, but I would say 10 years. 10 years before it was not an issue that we felt like we had to say something about during residency interviews, and we were malignant. When I was a resident here, we were malignant. And again, we have doubled down it just, we were not malignant for many years before that reputation went away.
Gotcha. Yeah, reputations are, are hard to adjust. And I think that, you know, that's one of the challenges of being a leader and knowing when you have to change something, but having the patience and then having constituents that are going to be patient enough.
Right, absolutely. And you got to make sure you're heading in the right direction. And we'll get to some more of that. I like this next one, just because this definitely applies to anyone and everyone, it talks about institutional committees. But this applies to any committee one is on, any board one is on. It consists of about 30% of members who will work at it, despite other pressures and work, and 20%, who are idiots, status seekers or troublemakers and the rest are somewhere in between.
Yeah, I was going to say what happened to the rest of the people I was I read this line a few times trying to figure out what the other 50% of people were
They're just there. But I think the key point here, which really resonates with me, is that the line that most successful committees have hardworking Chairmen who prepare themselves and the members before the meeting, call meetings only when essential, and engage members in a productive manner.
So how do you run an effective meeting? Because I think that that's something that is really challenging to do.
Totally agree. And I do think and first of all, I take pride, I run a lot of meetings now. And I think the first, the first and most important thing about being seen as somebody who runs an effective meeting, is finish your meeting on time, come hell or high water, finish your meeting on time, and people know that when I run a meeting, first of all, I do prepare, and I always have an outline for a meeting. And always keep your
remarks short. And try not to just talk at the committee, but meaning is about Yes, communication to the committee. But hopefully it's about getting back information from the committee. And so the preparation and the timeliness to me are the two most important things.
Has it become that much more challenging in the pandemic environment?
It is, the loss of the personal touch, I guess? The fact that you can call a meeting at any time is really challenging. But the fundamentals still apply.
Yeah, I think it's I think engagement is harder in the current era. I mean I'm not involved in nearly as many of the leadership things as you are in running meetings. But I think that even trying to run my lab meetings, you know, everybody, because we're not present in the same room, it's harder to be present, you know, in a greater sense, and getting people engaged on zoom and saying, hey, video on etc. Like, that's hard.
That is a really important point to me. And it's interesting, our hospital and our department have different cultures, department meetings, almost everyone has their camera on. Hospital meetings, they don't I always put my camera on unless I really am not engaged. But that's the first that's the first do and the other part is be a be a good participant. And so it's so tempting to answer email when you're in a zoom meeting. And sometimes that's the right thing
to do. Because it's just not a meeting that you need to be an active participant in. But I don't know, you And ideally, you're not multitasking.
Yeah, I think that it's it's much more tempting to do that. In the current era. And I'll be honest with you not to for leadership stuff, but even for like if there's a grand rounds that I really need to I want to watch and know that I'm going to be tempted to do email or something else, I actually get on the exercise bike and have my tablet pulled up in front of me and just bike so I
have nothing else to do. Like my hands aren't free that I can get on my laptop and actually, like try to do emails or whatever, so.
Yeah, that is great. We had a great Grand Rounds last week, which was on microaggressions. It was really one of the best grand rounds in my 20 years at WashU. And I had, you know, many emails I needed to address, it was a fight not to multitask. And I'm so glad that I did and I got so much out of that grand rounds. I think whatever it takes for you to focus is you got to do it.
I did that one for the bike. I got more out of it because of it.
Do you think it was it was as good as
I thought it was fantastic.
Yeah, it was really good. All right. leadership. Leadership does matter is the bold in the article. And I like that and I like one of the sentences that I underlined. Is that even though its effectiveness might not be apparent in the short term.
Yes, I think that one thing that I'm trying, I'm starting to realize now, it's leadership and the appearance of leadership are two different things. And I think that we, each of us has different expectations of what a leader should, how they should act, and what things should look like. And everybody interprets that differently, which I think is it makes it hard as a leader, because you know, you you have, you have to satisfy so many different constituencies with different expectations.
So let's have a brief and we can use this article to help. Let's have a brief conversation about leadership. And I've mentioned this before, and we absolutely need to need to focus one episode. But Jim Collins writes so many great business books, but his description of leadership and what he called the level five leader was so
important. And I think, to me, that probably is one of the most fundamental things, it's not specifically referenced in this article, but a leader who credits others, a leader who does not be need to be in the limelight, a leader who allows others to grow. Those to me are just so important.
Yeah. So I mean, I think that, you know, one of the challenges as a leader, beyond that is even, you know, do they understand what the people they are leading are going through?
Yes, especially, I mean, this is, my gosh, I mean, we talk about this all the time for leadership in our department, you know, what we are going through in this pandemic is a stress to our work lives, our home lives, like we've never experienced, any of us have ever experienced. And it's really indescribable. And I don't know, when we will, you know, when the pandemic's over, we're still gonna be dealing with the ramifications of this
time. And I think recognition of that, trying to address it, even though we may not have an answer. It's just really, really important.
So my memory of Collins's writings might be a little bit off. But you know, he talks about that level five leader who has characteristics that you described, but then there's that level four leader who leads because they want to be in the spotlight, and they may be a very effective leader. But what separates the person who is out there for for this, you know, for the limelight for the bravado compared to a person who is leading in the way that you described.
I think, and I haven't read the book in many years. But I, the point to that I have taken away is that, you know, there is something lost if the leader has to be in the limelight, development of those beneath that person, shared accolades, there's just something lost if it's all about the leader. And again, as you said, you can be a very effective level four leader, but I don't think you can truly hit the high mark and business performance is correlated with
those level five leaders. And I would certainly, you know, echo that.
So one of the things that Simone writes about in here is that a leader should articulate a consistent simple public vision. And this vision must be backed by public acts. And but it's sometimes smaller acts that are more valuable. So how do you interpret that?
Leadership is complicated. And that concept of having a simple message is really important. And it may not be a message that is, like, Oh, my God, you know, you're not supposed to get tingles when you hear the message. But if it said over and over and over, I think it starts to resonate. And so, you know, making a difference in our community or making a difference in the lives of our patients, expanding our reach, those are kind of things that are pretty simple and easily
understood. You know, you have a bigger vision statement and mission statement, but a very simplistic message, I agree is really important.
Do you do you, do you think that a lot of people yearn for the big Jerry Maguire type speech? That probably just dated both of us when I made that reference.
Oh, it's a classic isn't it? I think it is. Um, yeah, but I don't know, I think you can be a super high level leader and not have that capacity. I mean, a good leader has to be forward facing and has to be able to, to rally the troops so to speak, but I don't know that it, you know, a department leader needs to be like a football coach. I mean, it would be great if we were.
Maybe if you were paid like a football coach.
True, true. I liked the concept that one of the flaws of choosing academic leaders in particular, is that it's based on a bygone era. And we'll get to some of the eras that I thought, era being era that are pointed out here, bu it writes choosing leaders i not a precise science, but i surprising how often managemen skills, interpersonal skills a d experience are undervalued. I hope that's changing. becau e traditionally in big aca emic centers one thin was prioritized and that is NIH grants.
Yeah.
I hope it's changing. I don't know if it is completely.
Yeah, I think I think there are some institutions that are just going to be stuck in needing you know, that that marker of credibility. But I think that that era probably has passed where, you know, you can rely on an NIH funded scientist or clinician scientist to be, you know, the the absolute best person in these other domains that you talk about that are probably more important.
Right, absolutely.
But there's one more thing in this section, I thought that was really interesting. I mean, you know, in terms of the critical skills, I mean, he points out here scientific taste versus accomplishment. And I thought that was a really intriguing part of it. I mean, a keen sense of excellent versus average science, as opposed to the ability to run one's program
successfully. So if you're going to be a leader, you know, a department chair, does it matter that you are a fantastic scientist, or can you pick out the people that are doing good science and are going to advance the field and get them on your on your team and your department?
Yeah, I would strongly argue that as important as it is for that department chair, to be a scientific leader, it is far more important that that chair, have the capacity to hire the right people. And that's what Richard Gelberman taught me, and taught all of us that recruitment, to me is the, excuse me the single most important skill that any Chairman needs.
What about retention?
Retention is the second most important.
1A and 1B.
Yes. But if you if you create, you know, one of the things is just having a department where people feel like, wow, I'm in a department heading in the right direction, doing the right things. And while there will always be reasons for people to leave, reasons that you can't deal with, if you have a department heading in the right direction, where it feels good to be in the department, that takes care of a lot of the retention issues, I think.
Well, that's one of the reasons why I came here. And one of the reasons why I stay is that, you know I, no ties to St. Louis, no ties to Wash U, you know, I was coming as a fellow when I started looking at the
job. And to me, it was, this is something special, this is something where you can be a part of something and you know, one of the things that I want, you know wish to preserve here at Wash U is making sure that it stays a special place so that it brings more people here who want to be part of that, regardless of where they come from, and you know, whether they have any ties to the area.
I think that's right, and you had to hit it on the head. That's why I'm here too before I probably said it a little bit wrong. In this paper, it says in recruiting, first class people recruit first class people, second class people recruit third class people. And again, the point is that you're going to make mistakes in the recruiting process, because it's imperfect. But you got to put in the effort and the time to get as much due diligence as you can to fill the department with the
right kind of people. Because if you have people in the department who have one skill set or two skill sets, but really have other issues, interpersonal issues, or they put themselves first to the detriment of their partners, those kind of things can be deal breakers for the department.
Yeah, and they may be tremendous in other capacities. But you know, if they don't fit well, and this comes up a little bit later, you know, you know, he thinks that the, the philosophy of recruiting the best athlete is a stupid oversimplification in his words. And, you know, there have been times where, you know, you're like, wow, we should really get this person because they look like, they look amazing. But I mean, are they gonna fit here?
I think that's right. And it is, you know, you want every partner to be perfect, you know, to be a great clinician to be, you know, that's the floor, you got to be a great clinician, but you also want to be a great researcher in whatever domain and a great educator and a leader. But if it's going to be to the detriment of others. I just don't know that it's worth it. I mean, I think it can be too much.
Yeah, and chemistry is obviously a very delicate thing. And you spend a long time getting that chemistry just right, and also establishing a culture in which everybody can thrive. And the last thing you need is, you know, somebody coming in and, and disrupting
that. And, you know, one of the things that we often think about is sports, you know, and not sports medicine, but sports in general, where you have the disruptive hotshot wide receiver who the coach decides to bring in and you know, is that going to work? Or is it not? And chemistry is a really challenging thing.
Absolutely. I want to mention one thing, before we go on, we still should talk about the job. But I like this line that in academic institution, muck flows uphill. And I can absolutely state that I agree with that completely. And whether whatever type of environment you are in, and whether it's a big issue or a little issue, I don't think it's practical in 2020, to think these things are going to go
away. There's too much attention paid to interpersonal interactions, and there's too much attention to pay to all aspects of the care we provide. And so I think the leaders have to get the facts. Get it get as many people on board as possible and address things rather than hope they disappear.
Well, you know, you have the unique experience of taking over the number two spot in the department what it's been 18 months now maybe?
Going on, yeah.
Yeah. And then in an environment where there's a lot of muck with COVID, so.
There is.
A lot of challenges there. I mean, has it has it gotten that much harder in this environment where muck is everywhere?
You know, I think it's tricky, because and I think this will resonate with the listeners, you don't want to be a leader that is constantly putting out fires, because that's no way to lead. And you shouldn't expend your energy doing that. And so that's either a reflection of challenging department personnel, a challenging culture, but somehow another, you know, the leader needs a vision of where the department should be going, and hopefully spending energy on
that. not putting out fires. But yeah, we have a lot of fires. Yeah,
Well then how do you, so then who should be dealing with fires? I mean, how do you? How do you find the right structure to do that? Because it's something that you obviously don't want to spend too much energy on. But there can be some delicate things to delegate there.
Yeah, I don't, I don't know that you can delegate a lot of that. I think that's exactly right. Our department is going through a phase where we are transitioning to an increased role for division chiefs, just because we've gotten so big. But that's not easy. That's not an easy change. And so I still think department leadership has to own
a lot of this. But it's again, it goes back to getting the right people on the bus with a with a culture, and a vision that resonates and people who really see things the same way to the greatest, you know, degree possible?
How hard is it to drive home vision to people? I mean, does this need to be something where you know, you have retreats of the sorts, obviously, in a socially distanced manner or remote kind of thing? But I mean, is that the best way to drive vision home to people? Or is it through other ways? Is it one on one meetings and that kind of thing?
I think we had a retreat. I don't know how long it's been at least a year ago, maybe it was last January. And I got so much positive feedback, everyone gripes about finding four hours on a Saturday to sit and talk about something that doesn't directly affect their clinical lives. But it was a great, well you know it was great. And I think we were planning to have more of those. I think that's great. And it's just the constant messaging, and and signaling, kind of who we are, throught the type of
conferences we have. It's just, it's kind of all of leadership actions, whether they are allowed or not send a message, all the choices we make send messages, and those messages are heard, whether we think they're being heard or not. You know, one thing, this article talks about job changes. And one of the things in academics is we are constantly fighting the perception that the grass is
greener. The grass is greener in private practice, or the grass is greener in another job, and especially in COVID, because we're dealing with, you know, financial issues, which are real, and huge. And now, as we potentially are walking into another shutdown, those issues are going to raise their ugly head again, and the grass is not greener. You know, for us, we are very, you know, I try to
share this message. I know for a fact, by looking at different private practice jobs in our community and academic jobs around the country, we have it really good, but it goes back to your question, how do you make people truly understand and appreciate that?
Well, I hope you have the answer to that, because you're probably gonna have to use some of that skill and muscle in the coming months, you know, with, you know, the financial aspects are going to be turned upside down, probably. And, you know, that's where a lot of people's true colors show is when you know, you're dealing with that kind of thing.
It is for sure. All right. So we've been going at this for quite a while, I would like to and we can talk about a few more issues. But I think one of the most powerful parts about this was the section entitled success. And I like it because I'm a history buff. But why don't we just alternate, and basically, Simone described, essentially four overlapping eras relevant to academia. And it's really interesting. So the first is the the Oslerian era
from 1900 to 1945. And this is when medicine had a long way to go. And leadership was dominated and I quote, by diagnostic skills, anatomic and clinical pathology, and public health. There weren't a lot of academic positions. They weren't paid particularly well. But those clinicians, were giants and were respected. And they set the, they set the standard and institutions that had those physicians really became the place to seek medical care.
Well, I mean this, it says here, this was the era of the medical renaissance man or person, superb clinician, investigator and teacher often well read.
Yeah, and it was a man. Yeah, I mean, yeah, we had a hard time saying that yesterday. Yeah. It's fascinating, fascinating. What was the next era?
So the NIH rapid growth era, 1945 to 1970. And that saw the NIH when it was the premier place in the country to train, not just to do research, but people went to the NIH to train and then it when when there was a diaspora of people who left the NIH centers, it really demonstrated the value of the NIH in pushing the envelope in terms of research and particularly funding.
Yet and it says here, NIH grantees became kings. And there's still some of that today, but not to the not to the same degree.
Well, you didn't finish the sentence here. So it says they became kings often allowed to distain clinical or teaching duties because they were an important source of prestige and dollars for the institution
It's true, and there are some holdovers that we see still older, almost always older. And again, they are all men that still walk around with that mentality, but it's become a dying breed.
Yeah, and I've heard, I've had, you know, several people of different generations tell me that, you know, once that happens for you, it is a big leverage point, like, you know, in terms of, you know, I know that there are people, even in our institution that have used it to, you know, you know, shop around a bit, and they talk a little bit about looking at jobs and stuff in here, but.
Yeah, for Absolutely, it's still mat- don't get me wrong, it's still matters a lot. And NIH dollars matter far more than other dollars. I mean, DOD dollars are great, just not the same. The next era, the third era was the medicare/medicaid era, from 1965 to 1990. And this saw academic structures, I'm sorry, sorry. So academic centers restructure to increase the newly available clinical revenues, that allowed cost shifting, to support
research and teaching. And so this is when academic medical centers became clinical hubs. And it became important to treat lots of patients to bring in money to support the other missions. And while this era allegedly ended in 1990,
I'd argue it's still going on,
absolutely, still going on. And still super important to what we do, although then we have the final era,
The for-profit era, and, you know, the dominant forces with the greatest impact on their missions for good or ill, are Managed Care Health Systems and the pharmaceutical and biotech industries. You know, I'd argue for these two eras that we've described, the medicare/medicaid era and the for-profit era, you know, our salaries are paid by our clinical care, not by anything else, you know, it's the care
that we provide. And when I was looking at positions, and I wanted to spend a substantial amount of time doing research more than most, it was essentially, you know, many people said, Alright, that's, that's your call, because that's a financial liability for you. And, you know, we don't want you costing us money, but you know, you're gonna lose some money, too. And I think that that's the way that most people look at research nowadays, is that it's
a personal choice. It is, you know, there's a lot of opportunity cost economically for that. And, you know, that's a decision you have to make, and how do you prioritize it in your life?
It is, it's really tough, it's tough for departments, you know, department can support some clinical research positions. But ultimately, the department has to be financially viable. And the deans and the leaders of these academic institutions understand that. And so it's a balance right. And certainly at our institution, we do absolutely prioritize changing the field of orthopedics through
research. But Washington University also realizes you have to be clinically productive to help pay the bills.
Yes, becoming even more challenging in current environments right?
That is true. And the you know, the article ends with the statement that academic medicine is a noble calling. And certainly, I think you and I agree with that. It's funny, when I was a resident here at Washington University, one of my attendings said to me, you know, always remember, this is a job, this is just a job. And while that is the opposite end of the spectrum of being a noble calling, sometimes that I mean, obviously, it's still residence, it's been 25 years and I still remember that
statement. And I have to remind myself sometimes that it is still a job. But I think of the life I lead of work being you know, my work, taking care of patients and hopefully changing the field of orthopedics, it's more than a job, but there's still, that still some what rings true.
You know, and when, you know, the challenges that when it's more than a job it becomes a slippery slope, because all of your identity becomes tied to how things are going at work at times. And I think that, you know, obviously, some of us do it better than others in terms of, I don't think the right word is compartmentalizing, but integrating things better. Because, you know, let's be real, physician suicide is a real problem, and mental health issues in physicians are real
problems. And I think that if we tie our entire lives to our calling, job, profession, you know, you have a string of tough outcomes, and that can really sting.
For sure. And you know, the burnout is also the expression that obviously you and I've talked about before and it's so incredibly relevant. So you have to achieve balance and it is a noble calling, but you can't forget the other stuff because remember how we started this that academic institutions don't love you back. Anyways, for those of you who have not heard of this, again, we'll put the reference in our show notes.
It's worth the read. If you're in academics, if you're not in academics, I think it's just really interesting and well said.
Yeah, thank you for pointing it out and for for sharing it, and I look forward to perhaps learning some more lessons from the updated version.
Absolutely. All right. Great to see you as always
Do it again next time.
Hey, Chris, that was fun. Let's do it again real soon.
Sounds good. Well, be sure to check us out on Twitter @handpodcast. Hey, Chuck, what's your Twitter handle?
Mine is @congenitalhand. What about you?
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