Welcome to the upper hand, where Chuck and Chris talk hand surgery.
Chris Dy :We are two hand surgeons at Washington University in St. Louis here to talk about all aspects of hand surgery from technical to personal.
Charles Goldfarb :Thank you for subscribing wherever you get your podcasts.
Chris Dy :And be sure to leave a review that helps us get the word out.
Charles Goldfarb :Oh, hey, Chris.
Chris Dy :Hello, Chuck. I have decided I need to say that differently because my current resident Dr. Paul Inclan has started to mock how I greet you in the podcast.
Charles Goldfarb :Lord knows what he says about me.
Chris Dy :He walks in. He's like, Hey, Hey, Chris. Hey Chuck
Charles Goldfarb :Fair enough.
Chris Dy :So Paul, you've gotten your wish you now have your second shout out on the Upper Hand.
Charles Goldfarb :It's like our call sign though.
Chris Dy :I know right? I think it is.
Charles Goldfarb :You got to do it.
Chris Dy :So that came up today during the case, which was really interesting. I had, I had a list the surgical list recently that had, it was about-it was nine cases and half of it was re- you know, standard anesthesia. And half of it was wide awake. And you can guess the better half of the day in terms of entertainment value.
Charles Goldfarb :I'm sure I can. Can you share?
Chris Dy :Oh, yeah, one of the patients. She actually gave me permission to give her name, but I won't for obvious reasons. She is the one who walked into my clinic was like, Yeah, I like your podcasts. Can you do my carpal tunnel?
Charles Goldfarb :Oh, you told us about that.
Chris Dy :So she she comes in today as sweet as pie and we, I do her block and we get her back into the operating room. And so of course, Dr. Inclan is ribbing her about the podcast thing and she's like, Well, you know, I listened to the podcast and I knew that he was the one I wanted to have to do my carpal tunnel and Paul was like you sure it wasn't Dr. Goldfarb?
Charles Goldfarb :She chose wisely.
Chris Dy :No we had a we had a nice day in the operating room and it was fun. We had a patient who also chose to bring his own music to the OR which we made a little exception to the rules. I hope nobody from BJC is listening to this. But it was what was going to help calm him down and it made me realize the calming power of music.
Charles Goldfarb :Absolutely. All right, I have got three quick reviews to share. And one Fun fact.
Chris Dy :Oh boy, here we go.
Charles Goldfarb :So here are the reviews. One said 'just found your podcast love it. I listened while riding my bike. You have bettered my hand surgery practice while maybe slowing my Strava times'.
Chris Dy :Who was that?
Charles Goldfarb :Good! That's Steve Huish from Bountiful, Utah.
Chris Dy :Oh, wow. All right, well, sorry about the Strava times I know how hand surgeons are a bit competitive on that platform. So
Charles Goldfarb :Yeah,
Chris Dy :Good for you.
Charles Goldfarb :Here. Here's another one which is great podcast, the three E's. Now I have the three A's, which I quote all the time, but the three E's are entertaining, easy and educational. So that is super nice.
Chris Dy :Thank you so much.
Charles Goldfarb :I know is it worth mentioning the three the three A's? You and I talked about the three A's? You know, three A's?
Chris Dy :We Have, Yeah. What is it? Available? Affable and Able,
Charles Goldfarb :correct and the most important?
Chris Dy :What was that?
Charles Goldfarb :And the most important one is
Chris Dy :Oh, available. Without, without a doubt, and I think, you know, I mean the three A's still totally apply. You know, it's the moment where you're seeing like, for example, trying to build a Plexus practice. It's seeing all of the, you know, seeing a lot of the non op stuff in the very beginning. Yeah, I know, I probably don't need to see a lot of this stuff. But it does help me develop rapport with Referring, referring surgeons helps me develop rapport with patients and it helps me hone my exam and understand natural history. So I see a lot of stuff I probably don't need to see as a surgeon. But, you know, it's that availability that leads to that kind of stuff.
Charles Goldfarb :You know, that's a really interesting point. I think all of us, especially, I'm not picking on anyone, but younger surgeons really expect to step into practice and be busy initially. And, you know, it's just a process, you have to put in the time you have to make the connections. It used to be that doctors did two things and we're actually gonna have a podcast about parental influence. But as I-when I was growing up, my dad used to talk about it, he met other physicians, by taking care of patients through the ER. And that's how we get his name out there and then in the doctors lounge, and we do a lot less of both of those in 2020. Yeah,
Chris Dy :yeah, well, especially that second one with the old COVID
Charles Goldfarb :Even without COVID, hanging out in the doctors lounge, not so much.
Chris Dy :Yeah, I agree with you on that. And, you know, it's I think culture has become a little different too in a lot of ways, you know, even outside of medicine, people just aren't as you know palling around as much in terms and some of that might be, you know, geographic and regional, you know, so I grew up on in Florida and then I moved to New York. And there was never like this down homey, kind of, quote, Midwestern hospitality field around everywhere, so I don't know what it was like in Alabama.
Charles Goldfarb :Yeah, well, I'll tell you what it was like in Alabama was, you know, certainly, you know, at Christmas time, my mom and my siblings and I used to drive around and hand out Christmas gifts to everyone who ever referred patients because that was the culture. And I you know, we never paid for our, you know, if I went to the doctor, it was always complimentary. And just all these things have changed and Those, even those little acts those build the inter physician community and some may view it as inducing referrals. But others just think of it like my father did is a way to say thank you for great relationships and referrals and the ability to take care of other doctor's patients.
Chris Dy :I think that you we have a lot of trainees listening and I agree with you 100% is that you have to put in the work to get to get referrals, especially if you're trying to build a niche practice. But if you're trying to build a practice in general, you do have to put in the work. Now the work is different if you're in an academic practice, and you're in, for example, like I was the seventh hand surgeon joining a group. Whereas if you're in a private practice in a smaller group, and you're one of maybe two hand surgeons or you're the only hand surgeon it's just different kind of work, but nobody really is going to step into a practice where all you do is operate and see patients that have been teed up for surgery.
Charles Goldfarb :You know, I totally agree. You know, Charlie Eaton said something really interesting that resonated with me. It's only, and I've been in practice almost 20 years. And only recently do I not worry so much about the ups and downs. But Charlie said, he'd been in practice for a while treated a lot of rheumatoid patients. And then all of a sudden, he stopped getting rheumatoid referrals. And he was thinking, what did I do wrong? Who did I make mad? You know, is there a new surgeon in town? And really, it was about the disease modifying antirheumatic drugs, but so focused on the changes in referrals. I used to do that all the time. I'd have one slow week in the OR and be like Oh, my God, who did I make, mad? It's just fascinating.
Chris Dy :Yeah, I mean, I think that we rely a lot on referrals more than we know. And I think to be honest with you, being at a university makes that process a lot easier in some ways, but I definitely appreciate the people both on the primary care side as well as you know, the other surgeons who send people for nerve specific things and it honestly it just makes it so much more fun when you recognize names and you know, ask patients to say hello to people, that kind of stuff.
Charles Goldfarb :Yeah, and I know you do a good job of sending on the appropriate paperwork, making sure those referring physicians are in the loop so that, you know, they just want to know the patient's well taken care of taken care of in a timely fashion and we can check those boxes. You know, pretty easily. I think.
Chris Dy :I learned it from you.
Charles Goldfarb :I don't know. Alright, one more review, actually.
Chris Dy :Yes. Okay.
Charles Goldfarb :So I was emailing with a fantastic hand therapist at Texas Scottish Rite, named Amy Lake, and we were talking about other things and she said, I discovered your podcast and I had so much fun listening to you guys. But what I really loved was Macy, the therapist. Can you give me her email address? I want to catch up with her on some stuff, which was hilarious so
Chris Dy :that's awesome.
Charles Goldfarb :Yeah, I loved it. And so I hooked her and Macy up by email, which is really funny.
Chris Dy :Oh, great.
Charles Goldfarb :That's my here's my fun fact. Before we jump into the show, Are we getting antsy? So, you know, we publish our podcasts on Buzzsprout. And that's a it's one of the if not the biggest, you know, podcast, I guess it's called publisher. And they, they, they were trying to give us some perspective on where we were in the grand scheme of things. And you know, I think we're doing great. We have almost 800 regular listeners. And that number grows pretty rapidly. You and I've talked about it. I mean, I remember when it was 400. And now it just keeps going up. It's near. It's around 800 now, and in August, we had, we had, we had almost 5000 downloads. And so what that means is we're in basically the top 2% of podcasts on buzzsprout.
Chris Dy :Wow, that's insane.
Charles Goldfarb :So thank you.
Chris Dy :Wow, thank you. Yeah, absolutely.
Charles Goldfarb :Yeah
Chris Dy :That's that's fantastic. And I know that a lot of our listeners are at different training programs across the country in practice. Both surgeons, therapists general orthopedists plastic surgeons. So, thanks for listening us. That's incredibly humbling. And, you know, we're nine months into this now and it's still fun. So hopefully, we'll continue going.
Charles Goldfarb :Alright, let's jump into it. I think we have a cool topic.
Chris Dy :Yeah, so we've been, we spent the last three episodes talking about Dupuytren's disease, so we thought it'd be good probably to bring it back to a topic, a little broader scope. So I've always admired you as somebody who is incredibly organized and efficient. I mean, I think if any of the res-if you asked any of the residents who is the most efficient attending, at least on the hand service, and maybe for the entire department, your name comes out of everybody's mouth. And it's clinical efficiency, academic achievement, you're publishing papers, you're vice chair to the department, excuse me, Executive Vice Chair, or execu- is it executive to the vice chair,
Charles Goldfarb :administrative assistant to the chair
Chris Dy :but But how do you organize your day? You know, and how do you organize your to do list and this can be-we were-I was looking through the Harvard Business Review email a couple weeks ago and there's really interesting article came out about to do lists. And we'll jump into the article itself in a couple of minutes. But tell me how you just think about from a very executive level task function. How do you go through your list and how do you organize your day of things to do or week too?
Charles Goldfarb :Well, first of all, thank you. I do take that as a compliment. I do take pride in being efficient and that is outside the operating room, inside the operating room, in clinic. And I can always learn so maybe some listeners have tips that they have found are helpful for them. I think my two pearls are and they're not unique by any stretch of the imagination is one I use my email as a to do list. And I'm pretty obsessive. I get a lot of email, but that is one to do lists to the extent that I will sometimes email myself with things to do and that includes patient calls and so I either deal with something right away or I save it to deal with it and then move on. So my email is my ultimate to do list. But the second thing I do is when I
Chris Dy :before you go before you go to that second one, how often does Chuck Goldfarb get to inbox 0
Charles Goldfarb :Oh God never zero chance zero chance of zero.
Chris Dy :I think I and the rest of our listenership feel better now we can all exhale.
Charles Goldfarb :Yeah, I think my goal is if I end the day or midway through the next day, I have less than five emails remaining from the day before that's a win.
Chris Dy :That's still pretty amazing. Because I had definitely stuff parked in there from a few months ago that and I do the same thing in terms of my to do list. So
Charles Goldfarb :but I do try to deal with everything that I can before I go to sleep and that's what gets hard and becomes a bad obsessive compulsive trait, because certainly there's some things that can be left to the next day. And what I've done I've set myself up that people expect a rapid response. And that's good. You know, that's definitely good. But it creates this hamster wheel effect, which is really hard, hard to maintain,
Chris Dy :but do, do you ever feel like you know, because we're in the culture, you know, currently in 2020, where you know, work life balancing, or work life integration, depending on how you think about it is paramount to everybody. And we're trying to avoid working too much, I think. Do you ever feel like if you send out an email, quote, outside of business hours, that you are either A) assume- you know, set-setting the expectation that the recipient will then respond in a you know, outside of business hours and B) are you modeling behaviors that perhaps we shouldn't be modeling?
Charles Goldfarb :Both statements are true. And I am guilty as charged, and I don't have great balance. And just ask my wife, as you probably know, I do feel like I find time For my family, but I don't have balance. I don't. And I've thought long and hard about the culture of the institution where you work. And, you know, if I were to change institutions, for example, and went to an institution where that was not the culture, could I adapt? And I think the answer is yes, I could. And I'm not blaming my current behavior on anyone other than myself. But it's a problem. Like it does breed an expectation of rapid response. And you have to be strong in who you are not to get caught up in that.
Chris Dy :Are you a big believer in one touch email, as they say? Like do you quickly process something, fire back a response, get it out of the inbox?
Charles Goldfarb :Yeah, but not to the extent where it's a crappy effort. You know what I mean? I don't want to just get it out of my inbox and back into your inbox. I don't believe in that.
Chris Dy :So you're not sending anything half baked, you
Charles Goldfarb :don't play hot potato with email and I do try to just answer Question and move on and and what I do, what does frustrate me? And maybe you feel the same way is when people do that to the extent that they superficially read an email, and just respond to be done with it missing some of the point or missing the deeper message that gets frustrating. I hope I'm not guilty of that.
Chris Dy :Yeah, and but you know, to, I think writing email, and this isn't me nothing new to a lot of people, especially those that have spent any time outside of medicine, but I think writing an effective email is a skill and sometimes an art and the last I, as now somebody who is responsible for a research team, I hate long emails, you know, and getting updates that are excessively long can be, I just won't, I won't read it, and then I won't respond because I don't like you're saying I don't want to happily read an email and miss the point. And, you know, a lot of times when those long emails are written, you know, they tend to bury the lead. So you know, unless you're going to use some formatting To draw out the things that I need to read, understand, respond to, just makes it harder and then it just gets pushed further down that moving in basket or inbox list. You know?
Charles Goldfarb :Yeah, that there is a great deal of truth in that. So you want to write an efficient email that is, you know, answers all the questions and says what needs to be said in as few words as possible? And I've been noticing in my, recently, I don't know if it's COVID or I'm tired or what but I've noticed grammatical errors in my email, which I'm blaming on spellcheck. I don't like that like I think it's just it's not, it's not okay. Like I think we are judged by things like email and so we, it's important to do well at least that's how I see it.
Chris Dy :I agree with you entirely. So I'm dying for for Goldfarb efficiency. Tip number two.
Charles Goldfarb :So I think when I have stress, and I don't mean again, my wife may disagree, but I don't think I get stressed very often. When I have stress, it is Because I feel like there are too many things that are expected of me in a short period of time. And so this is again, nothing novel. But when that happens, I write things down. I don't do it electronically, I write down my to do list. And in doing so, it just takes the burden off of my shoulders. And there's nothing that feels quite so good. Call me what you want as crossing through a to do list when you've done an item. And doing that manually. And I think it de stresses me. it organizes me, it helps me prioritize. And so I like the handwritten to do lists on occasion. I don't live with one but on occasion.
Chris Dy :I use the handwritten To Do List especially on academic days. When I know that I have a block of time to carve things out. I've tried to learn what I can and cannot do on clinic days and OR days with reasonable expectations. But the handwritten to do is still is a mainstay for me as well. Even I mean, I'm still like even going The grocery, if I don't write it down and physically cross it out, I'm gonna miss something.
Charles Goldfarb :totally true.
Chris Dy :So this HBR article was interesting and the author is Peter Bregman. And he was talking about, you know, days where he was just wondering where the day went. And while he thought he had a good day, he just wasn't as productive as he wanted to be. And he says here, he said, I considered and rejected some popular solutions, trying harder. So perhaps that's not really a reasonable way to go about it, but the other one is working from a long to do list. And he rejected this idea, and I'm interested to see what your thoughts are, but it says here, too many options can lead to procrastination. And there's some other research on this. If shoppers are faced with too many choices, they're less likely to buy anything at all. So it's like seeing that long to do list and just throwing up your hands and saying, I'm gonna go watch YouTube.
Charles Goldfarb :No doubt. 100% true. And so the benefit I think you and I have over people in the business world is most of our to do's are tangible. And so it is complete this abstract or get this presentation ready for submission, or, you know, write the paper or edit the paper. For me, those are mostly tangible, and where I fall down, is saving time to think deeply about issues. I don't, though, there's no time allotted for that, despite the fact that we all know that's incredibly important. So for me, I don't mean to get off on a tangent for me that happens when I'm exercising, or at other times, it doesn't happen with a block of time scheduled in my day. I wish it did.
Chris Dy :Yeah, I think that's one of the things that has been challenging with COVID. For me personally, you know, I specifically have protected academic time because I was told by mentors along the way and then realized how right they are that you need time to think so I do block off time for that. Of course, an opportunity cost in other ways for other things I could be doing. But trying to work from home that's been challenging on academic days, mainly because you just don't have the same time to think because you're not in the environment where at least I'm used to thinking. And then also, it's like, you know, while I can get a lot of things done, if the kids are around when I can work on them, I do because I do like seeing them, you know, during the day, that kind of thing on those academic days, but you just don't get the headspace to think and that is so important.
Charles Goldfarb :Absolutely. I think that is genius to say that trying harder is not the answer. I mean, my God, I don't think anyone listening to this podcast would say that I just need to work a little harder. That's not our problem in medicine. With whether you're a therapist or a student or a physician, I don't think that's the problem for most people. It's carving out time to do the things that you need to prioritize. I would say what I and I felt this today a little bit. If I'm not clear about how to spend my time, if I find myself with a block of time, it is easy to make email your priority. And I'm really good about trying to answer email in a timely fashion. But if email becomes the focus for an afternoon, that's a waste of time. total waste of time and so I'm not one who checks it twice a day. I check it throughout the day answering those that can be answered, but email can't be the focus or else it just feels like a lost day.
Chris Dy :That is the hamster wheel.
Charles Goldfarb :That is the hamster wheel totally agree.
Chris Dy :So Peter Bregman's solution was the quote one thing, so he would take a Goldfarb esque long to do list and write everything out. But then he would get a clean sheet of paper and write down one thing from that long list that you I guess you wanted to prioritize it, right? Something that was, you know, accomplish something you could accomplish. So instead of saying, write this chapter for so and so book, it's write the first page of the introduction for the chapter, whatever, and then put away that long list. And then don't look at it again until you finish the quote one thing. What are your thoughts on that?
Charles Goldfarb :I think it's fantastic. I don't know that it applies to us necessarily. Certainly, I have have to prioritize on on a busy weekend, unfortunately, with the X number of projects that need to be done. But my to do list is, I think, and this sounds stupid, I feel like all the things are important. And if I could only pick one, I don't think things work that way. In my world, I think it's a great concept. And so for me, it's probably not picking one but it's about prioritizing and when I have to think bigger or differently, so for example, we in the department of orthopedics are kind of trying to reestablish a culture and a priority around our APBs and How do we do that? I've been talking to a lot of people looking at schedules, trying to get an organizational structure talking to other departments where maybe it works better. And that's the thinking part. And that's the communication. Those are the kind of things I like. And so what I can't let happen is get caught in the mundane and not do something like that, which gives me energy. Those kind of projects give me energy, whereas answering email and the mundane take energy away.
Chris Dy :Are you thinking Are you thinking about this while you're on your rower? Is that like, No, no, no, I'm asking in seriousness Is that the kind of, because I remember when I was a resident, I would run and that time I was training for the marathon in New York and I would just be running laps in Central Park. And I came up with some really good research ideas, just running because it was like the only time I had that headspace at that point in my life.
Charles Goldfarb :I think exercise is a great time for something like this and a couple other projects I have going on like revamping the APP program actually find time at work to think about it. But big ideas yeah are around exercise. here's a here's a little bit of a thing though. I don't play basketball anymore because my knees are not what they used to be. And then
Chris Dy :I heard I heard you can ball though, Chuck
Charles Goldfarb :Many would say it's a good thing for basketball that I don't play anymore. But the thing about basketball for me and I know there are listeners that this will resonate with, is basketball is different than running. When you're running you're alone with your thoughts and you can accomplish things or space out or listen to a podcast or whatever. When you play basketball, you can only do one thing is think about basketball.
Chris Dy :Or or the second thing is not tear your Achilles when you're playing basketball in your 40s and 50s
Charles Goldfarb :if you're thinking about how to tear your Achilles, you should not be playing basketball. But it's the absence of thought in basketball, which was the joy for me. But no, it's absolutely on the rower, on the bicycle. You know, running is a great place to think for sure. For sure. What tips do you have? Like, what, what what efficiency tips, make your day better.
Chris Dy :Um, I think about chunks of my day. And I think about the chunks that require more thinking and less thinking. I try to block meetings into certain timeframes. And I try to avoid having a morning of meetings that are spaced an hour apart and you just can't get into any sort of rhythm of doing any work. I'm guilty, especially in the pandemic of not setting aside enough time to think for you know, if I'm right now I'm dealing with a lot of journal revisions. And it's easy to just kind of go, you know, point by point on responding to reviewers. But then if you don't really let them read the reviews and try to understand kind of what the reviewer was saying the big picture that may or may not be explicitly stated. You're going to miss the boat when it comes back to having them review it again. And I mean, I'm learning more and more by experience, read rejection, how much the peer review process is sometimes and I hate to say it anybody who does reviews is an absolute crapchute. Something that can depend on you a lot of it can depend on who's reviewing and what kind of experience they have and what kind of biases they may or may not have. It makes it makes it hard. So I think having the time to step back, really slepping sink in and then try to craft a response is super important. So making time for things like that, and not just jamming it into 20 or 30 minutes between, you know, back to back meetings, I think has been really helpful. I agree with you that you know, to really have to really move something forward, you need to have the time to think and I've heard other people say you know, if you really want to have a serious research program, like a dedicated research program where you're shooting for grants all the time, you need a day because inevitably there will be a lot of creep from your clinical schedule into that day. And it's hard to fend that off. Because as clinicians, surgeons, therapists, we all want to see patients, take care of people. And it's really hard to say no to stuff. And of course, you know, especially in my stage in my practice, I want to say yes to everything I can. But it's just making sure that you don't lose too much time. That because that's the real danger.
Charles Goldfarb :I think there's a lot of really critical things you said in that. In that soliloquy. I think you
Chris Dy :I broke our one minute podcast rule.
Charles Goldfarb :No but it was all good stuff. I think you're right. I mean, I still love taking care of patients. In some ways. It's both the most satisfying and the most straightforward part of our practices except a part of our lives except when it's not like the joy we get and take care of patients. For me has never left and I I fight the administrative creep Not to mention the research creep in my life to maintain The the focus on patient care. The other thing you said, which I think is really, really important is the concept of how do you respond to review, it's a little tangential, but it gets to the point in in review response, just like in life, you can respond and check the boxes, you know, point 1, point 2, point 3, and maybe even get your paper accepted. But if you don't really absorb the comments, you miss an opportunity to make your paper better. And that's the same thing with emails and everything we've been talking about. So it is we are all on a hamster wheel, but you can't let it change how you approach tasks throughout the day. Some of them need to just be checkboxes but some of them require more than that.
Chris Dy :100%. And so you like doing the crossing things off of the to do list. This is something I'm guilty of. Do you ever do something that is productive but wasn't on your to do list and then kind of write it on there and the cross it off afterwards? Because I did something I did that review or that journal even though it wasn't something I was supposed to do, I was productive.
Charles Goldfarb :I have never done that. But that's another pearl.
Chris Dy :Oh I've totally done that. I don't know if it's a pearl, but it's a it's a pitfall for sure, because you weren't doing this stuff was actually on your list.
Charles Goldfarb :I love it. Um, I hope our viewers you know, we keep asking, not our, our reviewers, our listeners that we keep asking for a more interactive approach. And maybe that's on Twitter, but share some thoughts with us. We'd love to hear from you.
Chris Dy :I agree with you, and I think that this is an area where we can all get better and all learn from each other. And maybe I'll try this. You know, this one thing to do list, but I feel like I would burn through a lot of paper. I hope that I'm burning through a lot of paper, at least that means I'm doing something.
Charles Goldfarb :Right. All right. Thank you for joining and talking and this was interesting. This was fun.
Chris Dy :Okay, all right. Well, we'll do it again soon.
Charles Goldfarb :All right. Have a good one.
Chris Dy :You too.
Charles Goldfarb :Hey, Chris. That was fun. Let's do it again real soon.
Chris Dy :Sounds good. Well, be sure to check us out on Twitter at hand podcast. Hey, Chuck, what's your Twitter handle?
Charles Goldfarb :Mine is @congenitalhand. What about you?
Chris Dy :Mine is @ChrisdyMD spelled d-y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
Charles Goldfarb :And remember, please subscribe wherever you get your podcast
Chris Dy :and be sure to leave a review that helps us get the word out.
Charles Goldfarb :Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time