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, you changed your Hey, Chris a little bit.
I know just shaking it up.
Yeah, okay. You know, you probably got some some got some grief from one of your many fans.
No grief. As of the intro, I don't want to shake it up too much. Because this is our call sign.
Have you and Jake been signing autographs together now like is that like a limited edition basketball I can find somewhere.
If only I think both of our dreams were NBA and mine was shattered years ago. And his has been shattered more recently.
It's crazy how opposite the ends of the spectrum we are with our kids, because yesterday I took Rafi my five year old down sledding down a hill for the first time ever. And he loved it. He was fearless. And it was you know, a sizable kind of Hill. But it's definitely a different experience than having your eldest in college.
You know, I'm taking a lot away from the pandemic. I'd like it to be over. But I know it's continuing. And one of the things is, and others have noted this on social media and different places. But the gift of spending time with our kids, has been really remarkable. Jake's gonna have been home for four months in the middle of his junior year before he heads back in February. Even my girls, I mean, the limited social opportunities for both of them
in high school. We've just spent a lot of family time together. And we've gotten into a routine, which is, you know, pretty good. And I think we'll look back in 20 years, hopefully and say, Wow, that was really an amazing time.
Well, you know, like you mentioned, when we had Amy Moore on the program, you know, that email from the dean saying, you know, you're gonna remember the people you spent these times with, and I think that is a silver lining that we can capture. I mean, one thing I've noticed about my own schedule is how much less I'm traveling, which in turn has led me to be, you know, pretty busy clinically, which I'm sure makes you happy as our Executive Vice
Chair. But then also, it's it's more time at home with the family, which has been really, really nice, you know, because, you know, last year would have been a year where I was kind of globe trotting for the government scholarship. And I still can't even do that. This year, well, not as of yet. And probably not for at least six months or so.
Yeah, it's super interesting for those who travel for work, obviously, far beyond medicine. But, you know, I'm going to look forward to that first quote, unquote, normal meeting, and POSNA is still on the books for early May, I just do not believe it can happen, especially when with what is happening with this variant strain, or strains, plural. I, you know, when there's a normal meeting, and I think we're probably looking at 2022. before that happens, it'll
be fantastic. Getting back to once a month travel, which was sort of my routine feels really distant to me, and I don't know, it'll be interesting to see if we go back to the way things were done before.
Well, it'll be nice for some meetings not to have to go in person. You know, I think there are some committee meetings where you do need the camaraderie for certain things. But there are other meetings, which probably are better off just, you know, accepting a remote type platform and everybody's so comfortable with,
with video now. You know, two of the places I was supposed to go on my government scholarship, were Brazil and London and given the COVID strains, I don't know if I'm going anytime soon.
Well you can go but we may not welcome you back.
Well, yeah, I'll have to take a lot of time off of work. When I come back.
It is the other interesting meeting, like I work with the American Board of orthopedic surgery. And we have an annual meeting about question development and the like. And this really young
Chuck is the mean guy that writes the questions for the board's guys.
I'm the guy who tries to put as many sports and congenital questions on there.
I won- I wonder who the first author on all the papers.
Come on. Anyways, those meetings in person are dynamic and interesting. And the people in the room are fantastic. I'm going to do one, I think next week or the week after, virtually, and I just can't imagine it's gonna be very satisfying. And so that kind of meeting while it could be done over zoom, I don't know that it should be over zoom. So those are all things we have to work out.
Yeah. So what's been going on in your clinical practice anything any good cases recently.
I have had a really interesting case. And it's interesting, not only because of the case, but because of an epiphany I had during the case and to some this may sound lame to others it may sound interesting, but I'll just share so yesterday I had my first what I consider fully normal day since before Thanksgiving, in that I was operating in our own operating rooms, I had my usual two rooms, and it was a
pediatric day. So I did some congenital in the morning and I transition to some teenage or sports-like cases in the afternoon. And one of my cases was a proximal scaphoid, proximal pole scaphoid nonunion that was quite old. And on X ray and CT, the viability of the proximal pole was questionable. But given the patient being a high level athlete being that, you know, the options are limited, I thought
reconstruction made sense. I had several conversations with the patient about the options, including a more localized vascularized bone flap, versus a distant bone flap, and we elected to proceed with a one two, distal radius, bone flap. And by CT, the proximal pole appeared to be volarly migrated. And so what I guess what I'm getting at before it, rather than describing the CT as a markedly displaced, non union.
So a displaced and possibly non viable proximal pole, so a displaced non union with a, you know, questionable status of the proximal pole.
Right, right. And so, you know, again, the distant bone flap was an option, a salvage procedure was an option. But after a lengthy discussion with the patient we elected to proceed with, as I described, and started the case. And technically, you know, the approach and all that was just fine. And then we get down in the proximal aspect of the distal fragment was, was relatively healthy as one might
expect. And we curated that got back to good healthy cancellous bone, scaphoid was flexed, which we don't always see with a proximal pole, which was interesting. But it was able to be reduced, no problem after I did a little work. And the proximal pole was very hard to access, but also had bone attached to it, which did not look unhealthy. And so I proceeded with harvesting the bone flap, and had a nice pedicle. And then is where the struggle began, in that I was having trouble obtaining a
reduction. And I think there are various different approaches, you know, some will work many hours on a case if they think there's hope in achieving the goals. And certainly, if there's hope we should always continue working as surgeons to achieve our goals. And I tend to be one of those surgeons who will really do everything in my power, but I my decision making tends to be somewhat more rapid. And I was almost at the point where I said, I cannot obtain an
anatomical reduction. And when I make that decision firmly, because I've given up on everything, I move on. And I was going to accept a less than anatomical reduction, and with the hope that it would heal but didn't feel really good.
So before it before you tell us the rest of the story. Can I ask you a couple of questions, just rapid fire ones. So what was your surgical approach here for for this? Were are you coming from dorsal, were are you coming from radial? You know, to get that one-two or were you coming from volar.
So dorsal radial incision, which gave me access to the proximal pole, the scaphoid, and the flap. Again, relatively straightforward for the flap, it was just between the first and second dorsal compartments for the approach to the scaphoid I transposed the EPL. Ultimately, I brought the flap under the second compartment and under the EPL, to bring it in proximity where it needed to be.
So then with your, with your assessment of the proximal pole, and putting aside the reduction, how do you assess viability of the proximal pole in surgery?
I don't personally believe that letting down the tourniquet is super helpful, because I don't believe that truly determines viability. So for me is is there sufficient cancellous bone on that piece. And if there is then I consider it potentially viable.
Do you do anything to kind of stir things up, you know, put a K wire and fenestrate it, you know, quote, microfracture it?
Whether the k wire or fenestration was intentional or not, I definitely did that. I did curette, I did curette though-
Got it.
just to get rid of any corticated bone.
And then the last question before you give us the conclusion. Were you always that type of surgeon who says you know what, you know, like as you described, when you cannot you feel you cannot get an anatomic reduction in this particular case, say, you know what, I did everything I could I feel like I'm plenty capable, and it is what it is, or did you evolve to get there?
I believe I'm a meticulous surgeon. But as I mentioned earlier, I believe that my decision making may be more, not decision making, but my conclusions may be more rapidly obtained than others. I think I've always been exactly that way. And I think that's something that we are either born with or not, not not that is good or bad. And I certainly wouldn't criticize someone for using a greater length of time to come to certain conclusions.
I think that's always how I've been again, for better or worse.
So give us the conclusion.
So and I don't know that there's any lessons in how this worked. But ultimately, I was able to antegrade three k wires into the distal pole of the scaphoid. And then I was able to manipulate the carpus, which you know, include the lunate, which helped manipulate the proximal pole of the scaphoid, given the scapholunate ligament, back into position. And I think it was a combination of manual manipulation, use of a hohmann retractor around the
proximal pole. And I was able to obtain an anatomical reduction, I drove all three pins across the proximal pole. And I use one of those to place a micro screw, a headless screw, and then I created a window to insert our vascularized bone flap, and I was really could not have been happier, I left the OR, thinking that I don't think I've been happier with a case in as long
as I can remember. And certainly part of that is attributed to the frustration that I experienced, and the nearly coming to the decision that I could not obtain what I hoped to obtain preoperatively.
That's what makes surgery so exciting. And you know, I think, you know, the fact that you still get excited about cases is great, you know, I hope that you know, when I'm, you know, 87 years old, like you, I'm still able to get into cases and you know, telling, regaling these these cases, and sharing the stories. But that's
fantastic. So it sounds like you reduced the proximal, you reduce the carpus to the distal fragments, and then fired your wires, as opposed to bringing the distal fragment to the proximal pole.
I think that's right. It was a combination of all that. Yeah, it was a really unusual reduction maneuver. Again, you don't usually have to do much reduction with the proximal pole. But you know-
What size, what size k wires were they?
I had two, four-fives, let me Yeah, that should probably finish that. To obtain the reduction, I use two, four-fives and one three-five. And the three five was really used to drive the screw, I left both of the four-five k wires in place in addition to the screw, and I added a third k wire, as taught by Joe Slade at the distal scaphoid into the capitate.
To block the SC joint.
Yes, exactly. To decrease those forces on the proximal scaphoid and the non union site.
Yeah. So I mean for you know you, for those of you that are earlier on or perhaps aren't surgeons, you want to stop the scaphoid from trying to flex and try to deform across your fracture site. And for those of you that are trainees, I mean, I think this is a great example of when you're doing a case, you're doing a fracture case being judicious and strategic about where and what type of k wires you place and
where you place them. Because if he had not put in that three-five wire, he would have had to put, you know, a whole new path for a micro screw or it just would not have been as smooth. So that's something that you should always keep in the back of your mind, you know, when you're using those k wires, just just don't just put them anywhere, you know.
Yeah, the other teaching point I think I processed after, I tend to make an assumption that trainees will prepare for surgery, they'll ask for help if they need to and finding the right articles. And I think you and I've talked about this, but but what I don't insist on is a written preoperative plan. In this case, it probably would have been helpful to go through reduction steps, just the complexity of this case was different, I
think, than many that I do. And so a written preoperative plan about how to attempt reduction, how to place wires versus screws versus etc, etc. might have been useful. And I did not do that. I have great trainees, it's not about their quality or their interest or their preparation. It's just about another way to think about training.
Yeah, I mean, I'll be very blunt, you know, I don't make our fellows template fracture cases, I make our residents template fracture cases when they're with me, because it's not like it's a ton of cases and I want to see how they're thinking about strategy, planning, all the things that they need to own as they, you know, become independent surgeons. So, I templated every fracture case, as a resident on the trauma service, I know that they don't do that, you know, for every case here on the
trauma service. But I think that it's something where, you know, I ask them to draw up a template, we look at the template together, we look at the template afterwards, I ask them what they thought went well and how it deviated from the template and I try to tell them how my decision making may have differed from theirs and why and not necessarily that I'm right and they're wrong. It's just there are different ways to do it.
Yeah it's the preparation, which is the key. It's not even the actual template, you know, it is just the preparation, which is so important.
Absolutely.
Any good reviews to share.
Yeah, so we've had a fantastic email that was sent in by Dr. Frank Walter. Frank, thank you for listening. He's tells us that he's an upper extremity surgeon in Wisconsin. Sorry about my Bucks beating your Packers buddy. I became a listener this year after seeing a recommendation on the listserv, shout out to the listserv folks, it's been time well spent. I especially love the non dogmatic approach that you both use to talk about these
common problems. That is to say that you were teaching me new and often better, more efficient ways to treat patients without making me feel, quote, dumb, smiley emoji because we know you're not dumb, Frank, come on, I appreciate that you have created a great thing. And I certainly hope that you can keep it going. I have my therapist and assistants listening as well. And they have picked up lots of pearls. So Frank, we appreciate the email. We love the fact that you're getting
people listening. And if you ever have anything you want to share with us about how we can do better please, please let us know.
Absolutely. Thank you. Thank you, Frank. Very, again, very nice words. And this is our fuel comments and questions and interactions are what make this fun for Chris and I.
I will say if anybody leaves us a five star review on iTunes and puts any sort of question in there, we will literally answer it on the air. So that is your automatic way to get your question asked on the air. If you leave us a five star review on iTunes. So please feel free to do that, or email us at handpodcast@gmail.com.
Perfect. We were discussing a couple of not specifically clinical topics. And today, Chris, and I believe it'll be an interesting conversation to talk a little about practice development, and how our practices have developed and a little about marketing. And the hope is that we can get a marketing expert and the plan is to get a marketing expert to join us, either directly after this podcast or in the near term.
I think that'll be a good topic. I mean, so back in the stone ages. At the turn of the century, when a young strapping Chuck Goldfarb was coming out of his fellowship. How did, how were you set up for your practice? What did your practice look like? And what were you told about what your practice would be?
So it's pretty obvious that I have an academic practice. And that was always my plan. And I had a significant interest in pediatric and congenital care. And other than that, I like several of my mentors thought a more general adult practice would make sense.
And I guess my my personal principles, which I believe others would echo, include the need to stay broad in one's practice as long as possible, I just think it makes sense, the sooner we narrow our practice parameters, if our practice location changes, or something about practice dynamic changes, I think it's hard to then broaden your patient population later. And so staying broad was a goal. I'll keep going for a minute and say that, as we've also said, on this podcast, that
opportunities arise. And those opportunities can be unexpected and can be dramatic. And so the opportunity that arise that arose, for me, was the opportunity to care, participate in the care of the St. Louis Rams football team. And I became an assistant team physician, I traveled with the team. And I realized that A) I like that, I no longer travel, haven't for many years, and B) the opportunity to take care of sports, at every level, really appealed to me. And that became
a huge part of my practice. Now part of that was because my partners weren't necessarily interested in that. And again, that's an opportunity. But I built on that so that my date, my practice today is pediatric and congenital, sports, I've limited and I've recently limited the age of my patients. And so for a patient who just randomly calls in it's 45 years and younger. But it's been a it's been a very slow process that has, you know, taken 20 years to get there.
So you mentioned earlier about the benefits of staying broad as long as you can. And you've listed a few reasons, dive deeper into that, you know, so because I think we have a lot of current fellows, and perhaps residents that are listening and that are interested in, you know, different practice environments. You know, did you know what was your thought process in doing so or was that were you told you had to do that?
I believe that one can choose to step into a practice that's very focused in only a limited number of practice settings in the United States, and it may be different elsewhere. But for anyone to come in and say I'm just going to do brachial plexus, unless you're at a very, again, a very limited number of centers, that's not possible. And so I think it has to be a process of developing your name, developing
connections. And so while you are perhaps building your preferred practice, staying broad brings many benefits it establish, it in of itself establishes your relationships, gets your name out in the community, gives you chances to if you're in academics to write and just keeps your skill set A) as broad as possible, and two allows you to fully develop that skill set, because no one is fully developed as a surgeon after fellowship. And so that repetition in different areas is
absolutely beneficial. And if one chooses to narrow his or her practice later, well, that's fine. But I just think that it needs to be broad for as long as possible.
What do you think the slope on that learning curve starts to flatten out? You know, you've been in the game for 20 years now? Do you feel like you are still kind of in that climbing phase? Or do you feel like you're not plateaued, but you know, a space, a flatter slope.
I think the first 10 years are key, I think by five years, you know, the learning curve has definitely flattened by the time you get into your 40s. And this is 100%. just my opinion, there's no science behind this, I think into your 40s, you still absolutely learn and I still learn today, but that the curve
becomes much flatter. I think what I've learned a little bit during the pandemic, and having to operate in places that I may not operate, is that part of the reason I believe I stay sharp and I am stimulated is the fact that I have residents and fellows. They don't there's no, there's no escaping accountability in our current practice situation. But the learning curve is very different now, for me.
Do you think it's your surgical skill? Or do you think it's maturing as a doctor or as a person or all of them?
It's everything, it's family, requirements outside of work. It's the fact that most cases now my surgical skills are probably as good as there ever will be. Right? There's been there has been science around when do you peak as a surgeon, and, you know, at my age it is probably is 50. In between, I don't know was at 40 and 60. Or, you know, today may be different than it was 20 years ago, but, but I think surgical skills are pretty good. At my age, decision making is pretty good at my age.
And so those things become easier. But everything's swirling around, it's just more difficult.
Well, now, now you're, you know, a leader in our department. And you were chief co chief of the hand service for quite some time. So you've seen Junior surgeons come in the hand service, peds service, and just our department in general, have you noticed any shifts over time, as you know, in terms of how starting surgeons approach their practice?
I don't know that I've noticed shifts over time. But it's clear, like your practice is a great example. And you have a very focused interest. And that is nerve any shape, any size, any location. And you you're wise enough to realize that's going to take time to build, there's a lot of dynamics around that. But yet you built a thriving practice in hand surgery. And I don't know what your goals are, I'd be interested to hear is one day your practice 90% or 100% nerve,
or is that never a goal. But you know, there are different things that I think have have grabbed you as well. And certainly the WALANT type surgery seems to be an area now whether that's purely the local market forces that is driving your interest in WALANT, or whether you really like that and will continue to make that a part of your
practice. I think you're a good example of someone who has an interest and is either taking the time to get to a, you know, a dominant nerve practice, or maybe decides that not only will you practice nerve, how do you think about it for yourself? And then we can talk about others?
Yeah, I mean, I think that I actually was having this discussion with one of our fellows Shobhit this week, and I don't know if I want to have an only nerve practice, because I do like hand surgery a lot. You know, there are some things that I like more than others. You know, I don't know if I want to limit sort of myself based on conditions. But you know, it's more fun when you have trainees
and they bring new ideas. And you know, I love fixing fractures, I love, you know, running the gamut of the hand surgery stuff. And I think I'm still in the skill accumulation phase of my career, as you mentioned earlier, so the more
skills I pick up the better. Who knows when a dissection technique that I use in a thumb, CMC, arthroplasty may be useful when I'm, you know, exploring a nerve, it's, it's, I think, for me, I recognize that I'm still getting better at what I do, and why not expose myself to as much as I can, and maybe down the line, you know, I'll try to narrow myself to only nerve I was thinking about that after we
interviewed Amy. And you know, I think when she started her practice in Columbus after moving from from washu, she only wanted nerve. So I think that there are definitely ups and downs to it. And I'm honestly not sure yet. But I do like what I do right now, obviously I love the practice I have because it's busy in the hand surgery perspective, and it's busy and growing in from a nerve perspective.
I think that's that's well said. And this is in contradistinction to one of our partners, Ryan Calfee, who has kept a broad practice and really, you know, he has always enjoyed trauma from the elbow distally but he has a very broad practice, one could say it's a bread and butter hand practice. He's extraordinarily busy because he's good and he's affable. But it's just a different approach and I don't think Ryan has any interest in ever tapering his practice.
Yeah, and I mean, I actually was reading a, I'm still reading a book, my wife is reminding me that it's taking me months to get through this book. It's a book called range. And it's you know, why generalists thrive in a specialist world. And, you know, I honestly think there's a lot of value in, you know, in what you can learn by doing cases of different sorts.
And honestly, I, you know, doing trauma call has been very good for me, because it's allowed me to, you know, keep some skills up that I learned in residency. And there are many times where I wish I had paid more attention to some rotations in my residency, so that I could have picked up skills that would have been useful now, like, for example, like, I explore the brachial plexus with some frequency, and, you know, a year for an acdf, you're literally
inches away. And I wish I had paid more attention during those acdf approaches, because maybe I would have picked up a few more tricks in terms of exposing nerve roots, I feel good about what I do now. But you know, there, there are things where I wish I had paid a little more attention as a resident to because I think it's, it's really important to have a broad range of skills.
I think that's well said. And I think one of the one of the, you know, given my advanced age, as you so commonly and delightfully note is, you know, staying on
Donald Trump is not president anymore, you, you're still you're oriented times four.
The you know, it is about, you know, staying young is about doing different things. And I think that's part of my life. And we talked about learning Spanish and the like. But moving over and doing more true pediatric orthopedic surgery five years ago has been great, you know, it's reinvigorated my interest in that field. And I think doing new things is good. And so that's another danger, you taper your practice too much. And it becomes routine, it becomes mundane, no matter how
specialized. And, you know, that kind of stuff, just over time, I think it's old.
Well, and I think, a good example of, you know, seeing how mixing things up in your practice can be helpful. It was one of our partners, Marty Boyer, starting to do flaps, you know, I think as recently as five years ago, and seeing not only a clinical need, but then also, you know, recognizing that this was a way for him to stay fresh, and to learn new skills and to apply recent skills. So I think that's a good example. I had one question I wanted to ask
you. Because I think there are probably a lot of people in the who are listening who are thinking about private practice jobs, did you ever look at private practice as an option for yourself? Or even, perhaps they weren't around as much, you know, way back in the day, but you know, hospital employed jobs other than the university setting?
Yeah, I think, you know, private private practices today run the gamut as far as the size of the practice. But the supergroup practices have certainly become much more commonplace than they were 20 years ago. And that's for a number of reasons. And we can talk about that. That's a super interesting topic to me as well, based on payers and, and negotiations and the like, I never did think about private practice. I certainly in in private practice, unless you are
in a very large group. I think by definition, you have to be broader based in how you approach things. There are certainly exceptions to that. But I think in general, that is the rule. And again, no problem with that. It's just a different way of thinking about it.
Yeah, I think that I think this is one area where we'll probably need to bring somebody on to talk about private practice. Because, you know, I came in knowing that I wanted to do academics, I think largely because my dad was in private practice, as a general surgeon, and I saw the toll that took I saw how hard that was.
And he, you know, admittedly, he was in solo practice, which made it very challenging, you know, taking all of your own calls, you know, sometimes having to find somebody to, you know, to cover yourself, because to cover your patients, if you wanted to go out of town, vacation, etc, all the financial burden, you know, seeing when referring physicians would retire and not, you know, renewing that crop of referrals, that that looked hard. It was more than I wanted
to deal with. And then also, you know, I had academic inclinations in terms of research, so I kind of went in this direction.
Yeah, you know, it's been, it's been fun to watch. One of the many zoom benefits for conference during the pandemic has been that we have included some private practice hand surgeons, and honestly, we'd welcome that to anyone in our conferences on Monday mornings early and several of our previous residents and fellows join us. And that's a win, I think they enjoy it, we enjoy having a
different perspective. So just because one is in private practice doesn't need make it a necessity that that person feel isolated and, and not in the spirit of what we do. Obviously, we're not saying that. So, when we think about practice, development, marketing becomes, you know, is is by necessity, a part of that discussion, when you join a big practice, like Washington University orthopedics. Or a major private practice, a large private practice, you have some some
benefits built in. That is the practice is a referral source. And people get sent to Washington University orthopedics or Washington University hand surgery, and then they may come to you or I, and that that is unbelievably important.
Yeah, I think that is super important. But you know, I think that, you know, when you come in as a new attending, you know, in our practice, and I can only say, based on our practice, you, you want to be busy, and you want to feel like you're doing something other than
relying on the machine. And I remember, you know, when I started having to, you know, not having to but, you know, being asked, and then saying yes, to go out to, you know, to different primary primary care offices and, you know, essentially shake hands and say, Hello, and maybe give a talk at lunch, you know, do you see value in that now, now that you're the other, you're the number two in our department.
I absolutely think there's value there it is non quantifiable value. But one has to figure out a way to make connections in the community, especially with some different trends that we've all noted. So what there are two things that always strike me as interesting comparing our practice of medicine today versus 20-30 years ago. The first is the doctor's lounge. I don't remember if we've talked about that on this podcast before, but the doctors lounge used to be
vital. That's where you saw other doctors in every specialty. Maybe you ate lunch with them, maybe ate breakfast with them. And you became friends with them. And that drove referrals. Well, the doctor's lounge looks very different today. And I don't think that built in network is there. And then the second issue is, ER. So ER, coverage is still important to many in the community. But in previous generations, it was the way to build a practice, because that's
where you got patients. That's where you showed patients, you were very good and, and a great person to be seen. And that's where you could depend on word of mouth to spread that the new doctor was good. And, and that's less prominent these days. Any comment on those two issues?
Yeah, well, you know, as as we record this, I'm sitting in doctors lounge with Dr. Alexander Aleem your, your other podcast co host. I won't say you're cheating on me with Alexander. But he says he has a better podcast, but he probably he probably puts more effort into the editing process than I do. No, he says you are, but yeah, no, I think you're right.
You know, the the absence of the doctor's lounge, I think, you know, I saw that with my dad, you know, I would actually go make rounds with my dad on the weekend. And he would just be chatting people up. And, you know, he would say that guy sends me patients. I get that. I probably I think, you know, it's it's a function of a number of things. Some of it, I think, is generational changes in terms of how a younger generation approaches social interactions.
And perhaps, you know, some could argue that the doctors lounge has shifted to online forums, and different different ways of doing it. And then in terms of ER coverage, I totally get that I'm sure that a lot of our listeners who are in private practice, still rely on the ER, and the relationships with the ER doctors. You know not only to, you know, for existing patients, but for future
patients. So yeah, I mean, I, I personally did not find the going to different primary care practices to be of tremendous immediate, quantifiable benefit, but maybe they it had a difference that I did not appreciate. But one thing I did find really helpful and still find really helpful and really enjoy doing is actually going and talking to physical therapy, OT and hand therapy groups. I enjoy that, especially as I've developed, you know, as you mentioned, the subspecialty
practice. Did you do that a lot? Or do you still do that?
I have done that many times over the years. And I agree, if you wanted to quantify time invested versus return on that time, talking to therapists and trainers and different groups like that, seemingly would pay much greater dividends versus talking to physicians, and those relationships I would state as being vital. So for me, dealing with local universities and dealing with local high schools, having the athletic trainer relationship has been huge. And I call people after every clinic
visit. So if if a trainer sends me a patient, again, no matter what the level is, I try to make verbal communication with that trainer and let him or her know what I thought and what the plan is not only sending them the note, but also talking to them. Those relationships for someone interested in sports are incredibly important.
Yeah, and I think that you know, putting a face and or a voice to a name of somebody who's seen your patients afterwards and potentially sending you back that patient or sending you new patients. That is incredibly helpful. So I found that to be very good.
useful in terms of, you know, building my general hand surgery practice as well as the the nerve niche, because I have had patients who have been sent over, you know, at the recommendation of the therapist that they're seeing, because, you know, some of the nerve issues they were having, perhaps, were not being addressed in the way that the therapist thought, most useful.
Yeah, and therapists, especially in hand surgery are a wealth of knowledge, they are a good judge of quality. And, you know, I'm always flattered when an occupational therapist, a hand therapist sends patients our way, because I believe that is the ultimate compliment.
Yah I mean if you're looking for a hand surgeon in your community ask the hand therapist who to send people to, because I think they have a good sense of what's going on and whose patients do well. And you know, they can see basically the whole gamut of it.
So the face to face discussions and giving talks in the community and region may be helpful, may be not the best use of our time, but certainly are helpful. And when you're younger, you have more time because your clinical practice is not hugely busy. Then we get to online marketing, which, you know, we've always struggled with return on investment. So how do you judge ROI for online marketing? And what does that even mean? I do think there are a variety of different things a practice can
do, and an individual can do. So what are the some of the things that you think about, for either social media or just online presence?
Well, I'm pretty sure that, you know, social media wise, you know, the stuff we do for the podcast, and, you know, my personal Twitter and Instagram stuff, that's not bringing me patients, you know, and then that's not the purpose of it, right? Like, the podcast, honestly, we, we did it because it's fun. It gets our voices out there, it gets our teaching
styles out there. And then the Twitter and Instagram stuff that for me is academic networking, essentially, it's the new version of going to a meeting almost, and networking with people at a meeting. So I don't do that to generate patients. And honestly, because I'm in academics, you know, I come to work, and I work hard, and I do my best to get my name out
there. But I'm not relying on online marketing, to drive patients to my practice, I do encourage patients to leave reviews online, because we all know that that's useful. Because when patients find out who they're going to see, the first thing they do is Google you. And we talked before a little bit, at least in our grand rounds we did about the importance of those reviews, and perhaps how you can shape them, as well as the pitfalls of them. How do you
approach it? You've obviously seen the rise of the Internet during your career.
Yeah, I think you're right on the money. So the things I do online are not meant to drive business. But it's always nice when it does. So the podcasts, as you said that that's not its goal, and it rarely produces patients, you know, coming to our office, Twitter and Instagram the same. The interesting one for me is my blog, which I've been doing for, I want to say six or seven years. And there is a huge amount of information there. And I started for the purpose of
educating families. And that remains its purpose it's not about attracting business. However, certainly people have chosen to travel to St. Louis, because of that information and context that I've made. So again, the time invested, versus the patient yield, makes it absolutely not the right strategy to build a practice. But that was never my goal. And any patients that I am lucky enough to treat through that process. Well, that's great.
It's interesting watching what our practice does online, there are targeted ads that are done. There's search engine optimization, which can be done. Our practice does some things. But I don't know.
Yeah, man, I think that, you know, this is a constant push and pull for think Surgeons of different generations. And you want to be savvy, you want to be you know, at the forefront of things you don't want to be left behind. But especially with social media, I think you don't want to be viewed as a self promoter. And I think that is a struggle that many people have and why some people don't do social media is because they don't want to to look like they're trying to put themselves to the
forefront too much. And I definitely, you know, can I understand the merits of that argument. And I think there's a right way and a wrong way to do things. I mean, if you make it about your content and about the message and not about you, and you back it up with great clinical care and great academic work in our setting. I mean, I think that you have every reason to be out there and you know,
showcase the whole thing. You know, I don't know how, how do you view it because you seem to be of your generation of surgeons. And I don't mean that in any way for any of your generation of surgeons, you're out there more than others.
I I don't want this to come off wrong. But I think in academics especially. Our brand is under our control. So how I am seen by the academic orthopedic enhanced surgeon community is based on what I share with that community. And I can choose to only share the manuscripts that I write. And that would tell a story. I can choose to share how I speak at annual meetings and various meetings. And that will tell a story. But I can also add to that story with social media.
And that's how I think about it because it is my brand. And it is my brand is certainly caught up in the Washington University, orthopedics brand. But I like to think that I can control and share with people who I am, how I think about problems, how I think about patient care, through these online social media opportunities.
You know, I think that that's one thing where, you know, we'll we'll see where it goes, I I like doing this in terms of social media stuff. I don't put in as much effort, I think, as others do. Some people bank a lot on social media presence, and put a lot of effort into it, because it does take time to do it well. And it's you know, it's just as we've said before, it's just another thing. I actually wanted to pivot a little bit and mention that, you know, when I And nothing to add with your
story. I think that's hilarious. was when Shobhit, our fellow and I were closing a case recently, he kind of asked me how I ended up doing what I do in terms of nerve, you know, and I think that's probably there's probably a little bit you know, you can people can learn something from that. You know, and you may remember this story differently. I'm sure I'm certain Marty remembers this story differently. But Shobhit asked me how I became the nerve guy in
our practice. And I remember I was a fellow and it was the end of August and I was just coming back from the microsurgery trip to India. And we, I had just touched down in Newark, turned on my phone, was checking my email, and I see an email from Marty to David Chuang worldfamous microsurgeon at Chang Gung Memorial Hospital. were two of our former fellows a couple years before me, Danos and Duretti Fufa had done some additional training and emails says, you know, it's from Marty
to David. I'm copied on it. It says, David, I hope you're doing well. You know, I wanted to introduce you to my current fellow and soon to be junior partner, he is going to be our peripheral nerve expert. And I'd like him to come spend six months with you in Chang Gung. And I was first off, I was like, kind of like, a little pissed. I was like, you know, I didn't nobody told me I was gonna be the peripheral nerve person. Nobody told me that I was gonna have to spend six months in
Taiwan. What if I don't like nerve? What if, my wife's gonna kill me if I go to Taiwan for six months. That being said, I ended up loving nerve it fits my personality perfectly. It brings, I think, a lot to the fellowship to have that. And then I ended up whittling down the time in Taiwan to approximately three weeks, which I got a lot out of, and was able to, you know, say that I trained in Taiwan and Chang Gung and have the connections there, but
not get divorced. So that worked out pretty well, the long story, but that's the I will say that as much as I think that keeping your practice broad at the beginning, having a niche, and not something you only do but having a focus is incredibly helpful as a career accelerant. Particularly if you're in academics, I can't say that would apply in private practice, because there are so many considerations if you try to
close yourself off. But if you're in academics, having something that you're interested in, or you're told that you're interested in, is incredibly helpful in terms of building your career. Is that how you remember it?
May- not exactly I don't know. I don't, yah I mean it'd be interesting, good to hear Marty's side of that story. But I agree with the career accelerant phrase for picking a niche. You have to be careful though. Once you are defined as X surgeon, nerve surgeon, congenital surgeon, it's hard to break that mold. And what you'll find is when you are invited to speak often it is only on those topics. And that can be really career limiting. So you have to be careful and make sure your passion is real.
I would expect that many are influenced by mentors. Even selected cases or rotations can really have an outsized impact on what we think we like. exposure is everything. And that's why prospective fellows should keep their worldview as wide as possible, because you don't know what you're going to fall in love with. And so having different types of faculty mentors, and different exposures to different areas of hand surgery are really important.
Yeah, you You may remember this story. You may not, I hope you don't. When I was interviewing for the faculty position, I you know, one of my mentors in New York was Aaron Daluiski, who now does a decent amount of congenital hand surgery and has pivoted his career he and Samir are jumpstarting that at HSS. But he was really interested in congenital and we had written a couple of review articles together and I remember sitting across from you in the old
offices. And you were like so I see that you've written a couple articles on congenital, do you, do you want to be a congenital hand surgeon? And I was just like a deer in headlights I mean like? I just want a job.
I wonder if I was threatened by that or encouraging of that. At that point. When did you join our practice? What year?
That interview was literally Lindley's first or second month on the practice, in the practice.
So I was probably being protective of Lindley.
Yeah, I don't know. It was, it was an awkward interaction. And I'm hoping you'd forgotten about it.
I had for sure, for sure.
Good, and I'm glad I reminded you. But yeah, no, I agree with what you're saying. You don't want to get pigeonholed too much, especially if you do enjoy the broader, you know, practice parts of it. And you want to be known for the other things, I think, you know, one strategy I've tried to take is that if I'm asked to give a talk, and you, for example, I want to talk about nerves, they ask me to talk about something else, I'll say, Sure, happy to do it. Can I also talk about
nerve? And then conversely, if I want to stay known for you know, not necessarily this, like, for example, distal radius fractures. If somebody asked me to give a talk on nerve, I'll say, Well, can I also give this talk I have on distal radius fractures or social media, or, you know, work life balance, you know, I've done that before. Because I think that that's an important talk to give that not everybody sees during their
training. So there are ways to try to keep yourself broad, even if you if external forces are trying to pigeonhole you.
I think that's really good advice. And we probably need to wind down, I would say that one thing, one factor I think about is being true to yourself, when it's not easy, and so practice selection, you know, you need to be honest, we all need to be honest with ourselves about what we want, in our practice, in our lives, balance, time. And likewise, with with time, we how we hone down our practice, and it's very
easy to not not do that. And you and I have talked about that making goals and, and and being true. And I think that's incredibly important for all of this. And the same thing goes for marketing, you know, I you know, there was not marketing 30 years ago, in medicine, it just didn't exist, it was considered bad form. And so you can call it marketing, you can call it advertising that didn't exist. And now it's all over, billboards, radio, newspaper,
magazines it's everywhere. And so we our approach is just to try to take the high road, it's never about denigrating anyone else. It's about promoting what we offer. But being true to yourself in all aspects of life, I think are incredibly important.
Well, I think to bring it to a close, I mean, you know, you and I have had a mutual mentor in Richard Gelberman. And you know, what I loved about, you know, at least from what I knew about his hiring philosophy is that he would bring people here because he wanted the best people here. And he would have an idea of what he wanted them to do clinically. But if it didn't work out with what they envisioned for themselves or, it
didn't make them happy. I think he was totally fine with people pivoting and doing something else. And I don't think I was the first person hired by the hand service to do nerve. I ended up being the one that said, Yes.
I think that's exactly right. And that's probably a really good way to close. So again, our goal is to bring in someone with marketing chops, and educate us both and those who listen about opportunities and what the state of the art is in the marketing world. Hopefully, we'll do that real soon.
Absolutely. Well Enjoy the rest of your day.
Thank you.
Alright, take care.
Hey, Chris. That was fun. Let's do it again, real soon.
Sounds good. We'll be sure to check us out on Twitter @handpodcast. Hey, Chuck, what's your Twitter handle?
Mine is @congenitalhand. What about you?
Mine is @ChrisDyMD spelled d y. And if you'd like to email us, you can reach us at handpodcast@gmail.com.
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