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 :We want to thank you for subscribing wherever you get your podcasts. And please leave a review. That certainly helps us get the word out. Oh hey, Chris.
Chris Dy :Hey, Chuck, how are you?
Charles Goldfarb :I'm very well thank you and yourself.
Chris Dy :I am well, I'm a little more focused and we decided to get it together and do this in the office as opposed to battling children that are waking up.
Charles Goldfarb :Yeah, there there are more battles and more challenges at home that is for sure. The quiet of the office does bring some advantages.
Chris Dy :Absolutely. So you know, how has your week been?
Charles Goldfarb :You know, it does feel like things are getting back to normal. So we're recording this on June 25. And I know each part of the country is very different than I think every part of the country is a little worried about what the future will look like. But in St. Louis, despite the rising tide in Missouri, St. Louis has been pretty good. And so I've been pretty busy clinically. What about you?
Chris Dy :Yeah, it feels closer to normal. I mean, I think it's really interesting, no matter what your ideology or beliefs are, if you watch the news, it looks like you know, every state is very, very different. So it's hard to get a true view of what the country is going through because every state's its own microcosm.
Charles Goldfarb :Yeah. And there's this there's this looming sense of negative anticipation to again what the future holds, but all we can do is provide patient care until we might be restricted again.
Chris Dy :Well, I think one thing that we're really grateful for is that we have so many people that are listening and leaving us some really nice reviews.
Charles Goldfarb :Absolutely. We appreciate it and we want to hear positive and if you have constructive criticism too. We'd love to hear that as well. Let me share one- I actually don't have quite the whole thing, but it's really we really are grateful for this. It says 'As a veteran hand therapy professional, 30 plus years, I've enjoyed listening to this fantastic and engaging podcast. I've learned tons of tips and tidbits to incorporate into my clinical bag of knowledge. I'm sharing this podcast with all my hand peeps', and it goes on from there. I liked a couple of things about that. One, it's nice to know that our podcast is indeed resonating with hand therapists who you and I have spoken about and feel strongly about our relationships. And two, I love that this is a person of my vintage and, you know, we all listen to podcasts and hand podcast together
Chris Dy :Was it was it the veteran part of the Peeps part?
Charles Goldfarb :And the 30 years. All of it so so that's really nice. And again, we were are always interested in thoughts and suggestions. So thank you. Thank you very much. I guess one of the things we had talked about doing regularly which we've started is talking about an interesting case. Did you do anything super interesting this week?
Chris Dy :I did. But I'm afraid to say adventure outside of hand surgery. You know, one of the one of the fun parts of being here Wash U is being able to work with colleagues in different fields and having the peripheral nerve hat in our department means that I get to do all sorts of interesting cases with the sports folks. So I collaborated with two of our sports partners recently, for a case that was really interesting- huge fluid mass or bursa from the ischiofemoral space, and they did an ischiofemoral debridement, as well as an intra articular procedure using a scope for the hip. And then I had the opportunity to decompress and dissect out the sciatic nerve, which I love doing. Happy to report the patient is completely neuro intact, but I love serving that role for our colleagues so they can do their thing. And this bursal sack was just really interesting. So, that's a fun part of the job.
Charles Goldfarb :You know, I like it how you say it was an opportunity. Take taking the positive high road
Chris Dy :I probably learned that from you.
Charles Goldfarb :You know, I also serve that role with some of our sports partners when they are treating chronic hamstring abortions. And I don't know honestly, I've never had this conversation with anyone. I serve the role as being responsible for freeing the sciatic nerve to allow a more seamless and safe repair of the chronic hamstring rupture. So, those cases are not usually particularly fun, and can be a little harrowing, but I think it serves an important purpose. And it's nice collaboration.
Chris Dy :There are three things that make a difference there. One is chronicity of injury, which leads to the you know, the amount of scar that might be around a nerve, how far it's attracted back to. The second is the habitus, a patient that can change the game and the third is whether your partner insists on doing avery aesthetically pleasing gluteal crease incision versus the peripheral nerve preference of going longitudinal, but you know, I guess I'll do whatever they want. It's just a little bit more challenging sometimes when you when you go through the very aesthetically- pleasing incision
Charles Goldfarb :You nailed it on all three points. That is exactly right. And I am, I do have a little embarrassment in admitting that the sports or just may have a better sense of aesthetics than us but trasnverese gluteal crease incision is torture.
Chris Dy :Yeah, it really is. But I mean, I get it. I understand. There are some cases where I tell them from the beginning, we are not going transverse. So today we're going to talk about teaching in education. That's one of the reasons why we're both here at Wash U in St. Louis, great legacy of education in our Department. So I thought maybe to kick off the conversation, can you tell me a bit about how you were taught as a trainee.
Charles Goldfarb :Yeah, so it is one interesting point is that, we have a little different experience. I did my residency training here at Washington University, and I went away for fellowship. And then I came back, where as you know, were else were for your residency and were here for your fellowship, and you stayed. You know, I think things are different, not to say better or worse today, compared to when I trained. I started my residency in 1996. And I finished my fellowship in 2002. And it was, first of all, I was fortunate to have really great mentors, folks that continue to impact my career and decision making and that I still turn to for advice. And Richard Gelberman was certainly one of those. Peter Stern was certainly one of those Paul Manske, who unfortunately is no longer with us, was another one of those. And those are probably the three strongest mentors, but in every field orthopedics, there were mentors that affected me and the way I think about teaching. So that's a broad introduction, what about you- how do you think about it in a big picture standpoint?
Chris Dy :Yeah, I think the, the mentorship model is really important. And the ability to take something from every person you work with, even if you don't think you're going to be able to, you know, so because there's some there's a certain point in your residency where you're like, well, I'm not going to do this and you can- it's easy to and tempting to check out. For example, you know, I had a spine rotation pretty late into my residency and I, you know, it was not something I was interested in doing. I was clearly going into hand and didn't know I was going to be a peripheral nerve surgeon and looking back at that experience now, I wish I had scrubbed more ACDFs. I wish I wish I had seen more cervical spine surgery so I had a better I would that would help me so much more now. I would have paid more attention in clinic. So what I tell the residents that come through is okay, fine. You've already differentiated you're going to do sports or going to do joints, let me teach you some things that are probably going to be pertinent to you and your career, I'll take that step. But then I also want you to think well, how can I learn from this particular procedure or this, this type of patient in clinic? So I try to have them meet me halfway on that because there is stuff that I think you can learn from every rotation.
Charles Goldfarb :Now, no doubt that that's true. Yeah. When I think back to my own training, it's interesting what I remember as impactful. And what teaching techniques affected me most. It's not to say that I've incorporated all of them. But undoubtedly the ones I remember, most were, I guess, put me at a level of stress, right? We all know that there's a level of stress where we learn maximally and if you're below that level of stress, you probably don't learn as well as you should. And if you're above that level of stress, then then it becomes a negative. And two folks really impacted me amongst many, but one was Ken Yamaguchi for shoulder and the stress level that he created on learning anatomy, as a junior resident, was really impactful. And it was- I learned my anatomy, I'll say it that way. And I don't personally use that same strategy. But wow, it was impactful.
Chris Dy :So, I think we can only speak as orthopedic surgeons, I know some of our listeners are plastic surgeons or not surgeons. Do you think that the fact that most orthopedic surgeons have gone through some level of team sports, you know, do you think that drives this kind of environment of stress and, you know. Clearly stress is used as a motivator, throughout athletics, and in other environments as well. But do you think that that's why we default to that?
Charles Goldfarb :I don't know. I don't know. That's an interesting question. I haven't really thought about that way. But I don't know that we put residents in a similar stressful position today. I don't think that's that's some of that's frowned upon. Maybe or that's Chuck's interpretation of what may be frowned upon?
Chris Dy :Do you think that's the right approach? You know, the way that you were taught in terms of, you know, having you rise to the occasion?
Charles Goldfarb :I honestly think it is. I, as an educator, do a poor job of that. It's just not my m.o. I don't, I don't do a good job of raising the intensity level in the room, at least to my knowledge, you may tell me, I do, unknowingly. But that's not how I try to interact with trainees. Yeah, I mean, I think that it's probably in if you were to take a very high level view, it's probably the most effective for a high number of trainees, but I think for the trainees that it's not effective for it can be a disaster. And you're gonna, you know, it's one of those things where you can derail somebody pretty severely if you raise the temperature in the room that much. You know, and I think that, you know, as a former trainee of yours, the expectations were high because you held yourself to a high standard. I don't think that you necessarily made the environment about, you know, feeling afraid to not know anatomy or whatever. It was just it was a busy, busy practice. So, you as a trainee, you had to elevate your game to match where you were. And I think that's, that was my take on it as your fellow. Yeah, if we're not pushing trainees to elevate their game, then we're failing as educators. And there's stylistic differences and how that can be accomplished. There's different ways that we can, I guess you might say, put pressure on a trainee, whether it's reading X number of chapters or understanding the anatomy to the "T" and being able to recite that during surgery. I think those can be done in a positive way, in the negativism that may have existed in the previous surgical training eras is no longer acceptable. But you can still apply pressure in a strong learning environment I believe.
Chris Dy :I will say I think the most, you know, for better or worse, the most effective education experiences I had as a resident, I was afraid of being wrong. I was afraid of underperforming. And I think that's just I think my personality. You know, I've always I think, strived to be successful and wanted to get all the answers right. And I didn't like getting something wrong. And I think that, you know, I think back to me, the three most effective educators were Dr. Gelberman, Scott Wolfe, and Dean Lorrich. And I think that's because of my personality. I was always afraid of getting Scott Wolfe's questions wrong. And he really knows his stuff. And I wanted to make sure that I knew it too. But there was a point in every case where he would, he would get you and you just want to get as far down that road as you could. And it was almost the same thing, you know, in a way you're trying to really understand Dr. Gelberman's approach to anatomy and what he thought was important in what he was going to ask and all that. You know, I think a lot of these rotations that we talk about as you know as a trainee, there's what actually happens, and then what people think happens. And it's like a lot of these rotations, especially when I worked with the large HSS on trauma, there was this aura of the rotation. And it's almost like that aura made it worse, because you were always anticipating that something horrible was about to happen. And it masked, I think, his true dedication to the residency. Now, unfortunately, Dean died a couple of years ago. He was a monumental figure in the residency for better or worse, I think he was an incredible educator for many. But for some, I don't think that the tactics that he used were effective.
Charles Goldfarb :Yeah, and that's our challenge, right? As educators we have to understand how to get the best out of each trainee and that style. You know, most of us are set in our ways by the time we get to, you know where you and I are, especially me because I'm further down the road. But we have to show some flexibility because everyone learns differently. Now, I think the student or the trainee has to meet us halfway, you know, we can't be expected to 100% modify how we teach. But one great example that you mentioned is Doctor Gelberman's emphasis on just an absolute mastery of anatomy. And that fits with hand surgery because you have to know the anatomy to be really good hand surgeon. Other specialty, subspecialties may emphasize it a little less but I don't think it should be much less than any area.
Chris Dy :You know, I think to quote Scott, 'anatomy is power.' You know, you walk into an OR, if you know your anatomy, wherever you're operating, whatever kind of surgery you're doing, you will successfully accomplish your goals. In that case. Especially in than cases that don't heavily rely on the implants etc. So how do you approach teaching now? I mean, what's changed from, you know, when you were at my level or when you started in practice to how you teach things. Now, you alluded to one thing about, you know, recognizing that trainees are each different. I think that is one shift that's occurred even since I started training.
Charles Goldfarb :Yeah, my, what what I try to do and what may be perceived as my teaching M.O.,
Chris Dy :You're just siting and wondering how I'm gonna respond to what you say.
Charles Goldfarb :You're right, I am. You know, first of all, I think resources are different now. And that sounds lame, like, Oh, my God, I'm not saying it's so much easier now. But there are a lot of resources. There's a lot of video that trainees can access on surgical techniques. It's certainly easier to find online information. And so I feel less. I feel it is less necessary for me to give six articles or, or manuscripts (to read) for each surgery, which is kind of how I learned. So that's one difference that I say look- if you're having trouble finding something pertinent to this case, then let me know, I can absolutely point in the right direction or just email you a couple PDFs. But unless I hear that I assume the trainee is going to be able to take care of things. Is that fair?
Chris Dy :Yeah, I think it's fair. You know, but I also remember as a trainee spending, you know, and maybe this is my own problem, but spending so much time trying to find just the right thing to read. And then you realize an hour and a half later that you haven't read, and you are still looking for the right article. So, you know, I try to give trainees articles, but I think that sometimes they're what is appealing to them is going to vary based on their level of experience, their knowledge, and honestly, their interest. You know, recently received some feedback that maybe some of the readings I was giving were not pertinent to that level of training. So I don't know. I mean, I tried to help them by giving them reading. Because honestly, the stuff that I'm sending in this is stuff that I know and probably what I am going to be asking them about. But maybe that's not the right approach either.
Charles Goldfarb :Yeah, for me, it really is- an extern, for example, I would say, just do everything in your power to know the anatomy for each of the approaches that we're going to be doing tomorrow or whenever. For the residents. I don't really know that I care whether it's a junior resident or a senior resident. I don't think you need to be doing a lot of reading from the scientific literature, I think you need to get a couple of good chapters on top of the anatomy and just get it from that perspective. The fellows, I push harder, they need to understand the anatomy, they need to understand the basic textbook chapters that have been written, and then they need to take it one step further. That's my general paradigm.
Chris Dy :That you try to push trainees to read something for every case is that right?
Charles Goldfarb :Well, certainly that is the standard that I held for myself for several years in practice. I wish I could say I read something for every case today, its just not true. Certainly for anything out of the ordinary. I do. But yeah, every case carpal tunnel trigger, there is absolutely something that should be read. And that's not a big ask. And I think that's what we owe- ee owe that to our patients.
Chris Dy :Yeah, absolutely. And I think things like, you know, Peter Stern's Selected Readings provide a resource of just you know, once you're at that level where you're no longer reading about anatomy, you can find it an interesting article to read. And I also find that to be a good way to keep up on stuff myself is that once I've had a trainee for a while, say, Okay, look, you've read all the basic stuff. Let's find something new to read together.
Charles Goldfarb :That's exactly right. And one other teaching technique which I need to make a more formal part of my rotation is the- post case discussion, or rehash. And that can be general about cases that are you know, if you do a carpal tunnel, you do a carpal tunnel, but sometimes you'll see anatomical variants, but for me, where it really hits home, are cases such as a wrist arthroscopy with the way we reviewed an MRI preoperatively you do the case, and it is so important to go look at that MRI after surgery- to put it all together in your head. I think that that kind of rehash is really important.
Chris Dy :Yeah, I think it's beneficial for everybody involved. Right. Yeah. So, you know, I think one of the advantages that we have over our, you know, diagnostic colleagues in radiology and physiatry is that we get to see the anatomy. I mean, for me, I love it. One of my favorite things to do after a case is to look at the pictures that we took during the surgery and sit with the nerve study and say, Okay, did this match, did this not match- look at the imaging as well, because and I do that because I put together, for the more complex cases, I put together a little portfolio or PowerPoint of what we found. And if I don't do that right away, the quality of it is never as good. But putting all of that together really helps me get better, to be honest with you at looking at nerve studies, my clinical exam ahead of time saying, yeah, that absolutely matched or that didn't match. And I think that's an effective exercise.
Charles Goldfarb :Right. And so I think that, you know, there's a lot of reasons that you and I feel lucky to be where we are. And, you know, helping to educate a great, you know, group of people. One of the reasons is they push us, you know, there's no complacency. I can't go to the OR, and just say, oh, I'm gonna do this carpal tunnel on this wrist scope, whatever. I know that I will be pushed by the trainees, and that's fantastic. And the other is kind of, as you just alluded to, we have to get better. Right? There's it's so much more than what I learned 20 years ago, because it'll be apparent to those I work with if I'm not elevating my game, every day, every month, every year, whatever.
Chris Dy :Yeah. And so I think one one thing that's changed a lot that you mentioned in one area where I think we as a program can get better is how we utilize video. You know, I think that the generationally, trainees have changed and it's clear that you know, there's literature to support the assertion that trainees want to learn from video. And one of our former research fellows here at Wash U, who's now chief resident of Mount Sinai in New York, and is going to be one of Cincinnati hand fellows, Dan London, and he did a really nice study on looking at how to best structure video for surgical learning. And what's been your experience with either using video in your in your own learning or in how you teach.
Charles Goldfarb :I definitely can can be better so as far as how I personally use video, I access videos and I think the ASSH library is amazing. And you really have committed people that have provided videos of varying quality, varying lengths and varying in depthness, but I access videos from my personal learning only if I'm really extending myself a little outside my area of comfort. So I don't know a recent example but I don't access video very commonly. I do make videos like you do on occasion. But I have to say, I'm not personally aware of techniques and tricks and tips to, to help maximize that process. ] Making video can be really challenging, because, you know, like anything that we do we want to do as well, you know, so I played around with options in terms of, you know, recording what we do in surgery. I tried wearing a GoPro for a while, and it just wasn't what it didn't meet the quality standards that I wanted. And, you know, one person that has really pioneered in videos, Susan McKinnon, she's done an incredible set of videos, and I've talked to her about that and it took a lot of money. There is a lot of funding that came in from a patient of hers in order to set up those videos. And now now that that funding has lapsed, it's a lot harder I think, to keep that standard up. And you know, having watched her team put together those videos. It's really, really a lot of effort. But when it's done well, it's clearly a resource that can be used by generations of surgeons and, you know, number of surgeons internationally as well. Yeah, that's exactly right. And educating our international colleagues with perhaps fewer resources is incredibly important. And I will echo what you've said. When I have tried to put together videos, and we've done a few that I think are good. I've found it beneficial to use the Shriners Hospital resources and a videographer who is there. And that has been super helpful. It still requires time, time from me, and I have gotten good at editing podcasts.
Chris Dy :I'm grateful for that. I want to be on record saying that.
Charles Goldfarb :But yeah, I mean, editing videos is just a different challenge. I think if you do it enough, you get really good and quick at it, but it's still time. So money and time. Yeah, yeah. One thing that, you know, a lot of resources are now being dedicated to simulation. And before we dive into the simulation discussion, I think there's one technique or one facet that we really don't use that much that we shouldn't. That's cadaveric dissection. You know, I remember preparing for my trauma rotations with the Dean Lorrich, who, you know, was very much a anatomy master and very big on surgical technique for dissection. I mean, he did everything with a 10 blade and a freer, and no tourniquet, any of those. I mean, it was it was beautiful. So every time you operated with him, you wanted to operate like him. And that meant knowing the anatomy cold and knowing technically how to do the procedures. And I spent hours and hours in the cadaver lab practicing my approaches. We're fortunate enough here to have a great cadaver facility and the availability of cadavers to practice your approaches and really get good at them. But I don't go into the lab enough with the trainees. You know, I have built in academic time and when they're not obligated in other ways on my rotation, I tell them, you know, requested a cadaver and see if we can do some approaches together. I'll have them you know, get started, get everything dissected out, and then I'll do, I'll review it with them. Or depending on what point in the rotation we're in, I'll say okay, let's let's do this procedure together. This is how I do it another a nerve transposition. And I think that- it's a great way to spend time on the finer points without the pressure of being in a case and obviously having to move things along. No doubt. So super important point. And we are fortunate to at Wash U. to have great access to cadavers, and what a resource that is, my gosh, and we use those cadavers for anatomy once or twice a month for the hand service. We use it for arthroscopy skill development, and I think that's our primary learning tool outside of the operating room. And we have industry partners who also set up labs for us which is incredibly important. You know, one of my strongest memories residency was when I was a resident at Wash U. There were two hands surgery fellows, one for Richard Gelberman, one for Paul Manske essentially, is how it worked out. And every week there was an anatomy conference, and every week there was another conference. And the anatomy conferences, were - talking about pressure learning- were high pressure, I mean high pressure. And I had the opportunity to be the chief on Hand Service as a PGY4 and a 5 maybe that was remediation, maybe not, but, I like you just said, spent hours preparing to present from memory, a long list of data points. But I'll tell you what, I owned that anatomy. The anatomy dissection was excellent. And the presentation was to the point and wow, it was high pressure, but again, I remember it to this day, so the imprinting worked.
Chris Dy :So let me bring up something that might be unpopular. I mean, so I'm I've been here at Wash U. long enough to have been the fellow in the anatomy lab, it wasn't as high pressure i think is the setting you were describing. But still Dr. Gelberman was there. And you knew there were the Gelberman anatomy sessions and then the other faculty anatomy sessions and the tone was different. You know, you would prepare in a different way for the government anatomy sessions. And I'm grateful for that. But recently now, as as faculty, I've seen that the preparation has changed. There are some trainees that will just have the anatomy stuff printed out next to them. And we'll be looking at the handout and talking through the handout there. And there are some trainees that will still do the beautiful, I will call it a recital of the anatomy from memory and I can tell there's a difference and the ones that do the recital versus the ones that are reading off of the sheet in terms of what they know at least that moment. Do you think that we should be pushing them to be, you know, reading or to know stone cold from memory.
Charles Goldfarb :And this is exactly what I don't do well, I don't- if I were to cite my biggest teaching limitation is I don't do a good job, I think and putting people outside their comfort zone. And so I don't know whether I am concerned about the generational differences and whether that's okay in 2020, or whether it's just about me not wanting to push too much. I don't know the answer to that question. I think we are, in some ways doing them a disservice. Because they're not learning it clearly. They're not learning it as well, with with notes on the side, and, you know, we see it, we see it in the quality of the presentation.
Chris Dy :Yeah. You know, I remember Dr. Gelberman telling me in the last couple years, at some point saying they just don't know, as well. And speaking about trainees and, you know, made me feel like I was failing as an educator. You know, so when you have trainees in the OR- I mean, so do you ask them those kind of anatomy? factoids, you know, before I let you answer I'll recall a quote from Ed Athanasian, the chief of the hands service at HSS. Who said there's a difference between trivia and minutiae. You know, trivia is not important. Minutiae is detail, but it is important.
Charles Goldfarb :Absolutely. One of my, one of the ways I enjoy teaching is when there is an external, I don't like pick on externs and I make it a friendly banter, but I use the externs and asking questions, especially a good extern, and I ask them progressively harder questions. But we're asking the questions of the extern, but we're hopefully educating the room.
Chris Dy :Remember being a resident as a fellow being God, I have this medical student gets this question, right.
Charles Goldfarb :Isn't that the truth? It's never a situation where if they don't know- well I shouldn't say never- it's rarely a situation where I feel if they don't know the answer, then their involvement in the case, technically is decreased. But it might be a situation where the, if they're really not prepared and they really don't know the anatomy, then they're I do have to have a serious conversation. But thankfully...
Chris Dy :I'm going to push you on that I disagree. You know, if I ask a couple of questions at the beginning of the day to kind of see where their heads are at, where the temperature is, and you know, I get it, if you are post call, you didn't get a chance to review all this kind of stuff, fine, but you're gonna have a different experience in the OR. Because I remember not getting things right, and then not having the knife. And if you don't have that level of preparation, your involvement will be different. I will engage you in the case. But if you can't tell me what structure is at risk when we're starting with carpal tunnel, I'm not gonna let you make the incision, because you don't know what you might cut. You know, or little things like you know, I'll I'll ask them what they want to prepare because I never you asked you at the beginning of cases, you'd ask me what I read to prepare for the case, and I'll say, okay, mark the incision and if their incision is completely wackadoodle then you know, no, you're not doing the case at least this part of the case.
Charles Goldfarb :That's totally fair, that's highly appropriate. And that's the way we should react. Maybe my, my comment is colored by the quality of the trainees that we're able to work with, because I don't recall the last time I felt someone was not prepared. So what you said is accurate and fair. Totally.
Chris Dy :And it's in it's it's an uncommon occurrence. You know, and trust me, I don't like confrontation as much more than the next person. And I don't like being you know, making people feel belittled, small, you know, that kind of thing. But, you know, we're doing surgery, like surgery is not up to luck or chance surgery is about preparation. It's about putting in the hours of learning and, you know, this is somebody's life. And I think that all it takes is a couple of poor outcomes to, you know, jar you and reset you, you know, as a young surgeon. That being said, you know, our trainees generally are excellent, and that's not an issue pretty much I mean, every time.
Charles Goldfarb :Yeah, I mean, that's one message that we have to be consistent about. And I and again, we're blessed with wonderful trainees, but you can't ever lose sight of that fact that, you know, we are lucky to work in the field that we work in. And every patient expects and deserves the best we could possibly give and any expectation that because you're at a training program, you "get to" do something is not okay. I mean, you have to earn the right to take care of patients and you have to do it every day.
Chris Dy :Well, so how do you do that in the out in the era of duty our restrictions?
Charles Goldfarb :Yeah, I mean, I have to say when the duty hour restrictions first came out, I was really concerned about whether residents would have the time to read and the time to prepare, and I haven't seen that be a limitation. I don't know exactly what goes on at home and when residents aren't, you know, in front of me, I trust that the duty hour restrictions, are being observed. I know there's more help in the hospital to help minimize some of the some of that time consuming work that was required of residents prior to this era with the assistance of APPs, etc. I don't know, I don't see it as as, as having changed things fundamentally.
Chris Dy :I mean, all I know, I came up with the error duty hours, at least in theory, and, you know, I think our my residency I was, I think we were pretty good about duty hours, but I know that our residents work hard. And it's not not necessarily also the amount of hours it's the distractions. You know, when you have a resident who is being paged to do certain things for patients on the floor, in the ER, during clinic, during cases their quality of learning is going to suffer because of that. And that's reality. I mean, I dealt with the same thing as a trainee. But that's where I think that the quality of time that you spend preparing for cases and learning is so important. You can't- there should be no time wasted. You know, and that's hard because obviously, you know, you have to take care of yourself and the relationships in your life. And that can be really, really challenging in residency.
Charles Goldfarb :Yeah, couldn't say it better. That's exactly right. It's, you know, we in some ways are very fortunate as attendings. Because in a lot of situations, we get to really focus on the care at hand, whether that's in the clinic, or the OR and we don't get these distracting pages as often as the residents do, who are trying to manage our service in addition to to learning. So it's a great point.
Chris Dy :So, to wrap up, I mean, I think one big push in the era of you know, all the technology we have now and also, you know, knowing that duty hours are a concern, have you implemented any sort of simulation into your teaching?
Charles Goldfarb :I haven't I play with a few different simulators. And I've thought they were all really good, but honestly, nothing that I played with I felt was ready for primetime, aside from what we already mentioned, cadaver work and using arthroscopy as an example is invaluable and I can't imagine we'll ever do quite as well as we can in the cadaver lab for arthroscopy, for anatomy, whatever, but I have not. Have you had any experiences?
Chris Dy :I haven't. I mean, you know, I was working with one of our residents to try to develop a simulation and coaching protocol. It just became very challenging from a technical aspect, but I think it'd be great if we, you know, for example, using some technology like a GoPro or some kind of mounted camera, to film our residents doing dissections and then coaching them saying, alright, let's watch the tape just like you would any other athlete, you know, surgeons, dentists, are athletes in a sense, and being able to watch tape with somebody and say, okay, here's, you know, where I think you could be more efficient. Here's how you should change the angle of your scalpel. Here's how you should grab this tissue, or gently move this aside in this direction. I think having tape is an awesome opportunity. I don't think we're there yet to make it easy to acquire. But once that technology comes about, I think that's going to be a great way to simulate cases and to learn and when you're not in the OR.
Charles Goldfarb :I think that's incredibly important. So the coaching that you and I don't get. And it's rare that we have someone who can critically assess our skills. It's usually one of us if we're doing a joint case, but I do believe that technical education is increasingly a part of my role. And so I do ask questions about approaches and why we're doing a surgery, etc. But I do critique technique more and more. And I enjoy that. And I think it's helpful.
Chris Dy :Yeah, absolutely. I think placed in the right context, you know, the, you tell them look, I'm trying to make it better. And I think that, of course, you know, in the current era of how we speak to trainees, we have to give justification for why we're saying things. I mean, gone is the era of just throwing instruments and yelling at people. You have to provide context in order to be effective and you know, be a reasonable person.
Charles Goldfarb :Absolutely, absolutely. This topic is a fascinating one and one that we could spend hours on and maybe we need to re- visit it at some point. But this is a good foray into the educational process and how we think about them.
Chris Dy :Yeah, I think it'd be fun. We should have a guest at some point, you know, another, you know, somebody with a reputation as a master educator. So
Charles Goldfarb :That sounds great. All right. It's been fine. Thank you. Thank you for listening. You've made it to the end.
Chris Dy :Please keep in touch with us over social media, you can reach us @ handpodcast on Twitter. And my Twitter handle is @ChrisDyMD and that's spelled d -y.
Charles Goldfarb :And you can contact me at @congenitalhand.
Chris Dy :If you need to email us, please do its handpodcast@gmail.com.
Charles Goldfarb :Please subscribe wherever you get your podcasts.
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Charles Goldfarb :Special thanks for the amazing jazz music. It comes from Peter Martin. And remember, keep the upper hand and come back next time.