The Next Generation Orthopedists: Two Years On

Two years ago we traveled through the residency match process with Matt Popa, then a fourth-year student at Case Western Reserve University School of Medicine in Cleveland, and Scott Tucker, then a fourth year student at Tulane University School of Medicine in New Orleans. Recommendation letters, interviews, lists of preferred programs, and what they would like to see done differently were all addressed. Now we’re checking in to see how their orthopedic education is progressing.

Scott Tucker, who got his first choice in the match—Tulane University—says that the first year was a bit like wandering through the woods without an Ortho GPS. “Frankly, the first week was rather frightening…and I felt pretty dumb. Suddenly being in a position to write orders, direct students, tell nurses what to do, and interact with patients…well, it was definitely unfamiliar territory. We were fortunate that the upper level residents were willing to let us lean on them.”

Dr. Scott TuckerIndeed, says Dr. Tucker, the issue of independence is one that takes some getting used to. “Learning how to be autonomous in making decisions and taking the initiative to act really takes the entire internship year. It is not until May that you are comfortable and feel that you can defend your decisions if need be. Now that I am finishing up my second year I say to those in the intern year, ‘How do you want to proceed?’ when it comes to cases. I hope that helps them focus their thoughts and gain some independence.”

Dr. Tucker raises an issue that some in the field are pushing for…more orthopedics in medical school. “I would have felt much more prepared for residency if I had encountered more musculoskeletal information in medical school. Orthopedic injuries are so prevalent that it would seem that institutions would want to add time to the musculoskeletal curriculum. This would be especially useful in the beginning of residency, particularly with general fracture management. For example, the curriculum should cover how to handle a sprain versus a displaced fracture. It would also help new residents to understand what are true orthopedic emergencies and what can wait. More orthopedic instruction in medical school would benefit budding general surgeons as well. If general surgeons were required to do a month of orthopedics as interns they would have a better idea of what we orthopedists are looking for. Many times, in a trauma case, for instance, the general surgeons are on the front lines and are calling us for assistance. It would help if they had some preliminary information.”

Describing the breakdown of year one, Dr. Tucker states,

During the intern year, we had three months of orthopedics, along with nine months of things like radiology, plastic surgery, ER, general surgery, trauma surgery etc. I think an anesthesia rotation would be interesting, and would give us a basic understanding of why certain types of anesthesia are given to which patients. We would be able to learn about local and regional blocks, the former of which is useful when we have to do fracture reductions in the ER. Plastic surgery is an area where we could have probably used a bit more information regarding wound care. The plastic surgeon at our institution did take pains to show us how to handle anything involving the lower extremities where there was a soft tissue defect. It was helpful to learn about the best ways to prepare a wound, and to find out what kind of flap should be applied.

“I wish I had spent more time in a true trauma ICU.” While most patients wouldn’t utter these words, some novice surgeons might. Dr. Tucker: “I could have used more exposure to a true ICU setting. We were in a general surgery stepdown ICU where the patients were recuperating after elective surgery. Being in a real ICU would have made it clear when someone really needs to be operated on immediately, or when the surgery can wait. The only exposure to true trauma ICU patients was during the on-call nights during my trauma surgery rotation (and they had ICU residents covering most of those patients). More exposure to resuscitative measures would have been helpful.”

The reality of his newly minted doctor status settling in, Scott Tucker entered the second year to find, well, more of everything. He notes, “Year two is harder, busier, and involves longer hours. The counterweight was that it was more interesting and I found myself caring more and feeling more wedded to the field. Starting Post Graduate Year 2 (PGY2) did involve more of a fear of the unknown, however, since I had become the first orthopedic responder and was responsible for things that I wasn’t in my intern year. Like most of my fellow residents, I became overly vigilant as I went about my day. I spent a lot of time trying to get comfortable with fracture reductions, made especially challenging because various fracture patterns behave differently. It was also a time that we learned how to physically manipulate people, something you don’t do in your first year.”

So much of orthopedic treatment is dependent on imaging these days so knowing how to interpret films is especially important. Dr. Tucker states, “I have worked hard to learn how to read the films correctly; I read them all myself and then look to the radiologists for input if I’m having a difficult time. On the history and physical front, we have not delved into that much. Most of my second year has been taking call and learning to take care of trauma patients.”

He concludes, “Despite my early hesitancy, I feel much more comfortable with nearly any orthopedic trauma situation when I’m on call, so I think I’ve achieved the goals intended for a second year orthopedic resident. That being said, I’m more than ready to hand off the primary call duties to the incoming residents! We orthopedic residents essentially get two intern years, so I’m looking forward to a little more sleep and more time to study. I’ve been lucky to have the opportunity to do a lot of surgeries this year, particularly in the trauma setting, which has laid the ideal groundwork for moving forward.”

Dr. Matt PopaDr. Matt Popa, now completing his second year of residency at Grand Rapids Medical Education and Research Center, reflects: “PGY1 involved three months dedicated to orthopedics, but an entire six months of orthopedic call. With all of this experience, I felt comfortable heading into my second year where I would have much less direct supervision in the ER. Having more responsibility meant that I was doing more procedures, which always looked easier than it actually was. Any skill took a few attempts before I got a feel for it (perhaps I wasn’t quite going in the right direction, etc.). Although the first year was very satisfying, it was full of trying times as well. It’s through mistakes that we often learn best and each day brought its own humbling educational moments.”

He adds, “I’m thankful that I no longer have to rotate on the surgical critical care unit. It was an excellent educational experience because I learned a great deal about the medical management of very ill patients as well as the signs that a patient is in serious trouble. At the same time, it was also rather depressing for the very same reasons…in addition to the occasional poor outcome.”

As they move forward, orthopedic residents gradually learn how to balance anticipation and trepidation. For Matt Popa, there was more of the former. “Although the second year brought more responsibility, I found it very exciting—especially when I was the only orthopedist on call in the ER. I began my PGY2 call schedule in the summer at our trauma center. I had taken a lot of calls in my first year, so I felt fairly well prepared. On the July 4th weekend we had the basic assortment of wrist, forearm, and tibia fractures. But we did have a dramatic case involving a 15-year-old kid who had stolen a car and sustained a traumatic below knee amputation with a complete fibulectomy when he crashed during the police chase.”

With so much knowledge to incorporate, says Dr. Popa, time is very valuable. His advice? “There has been a lot of talk about a reduction in resident duty hours. I would really like to encourage the American Academy of Orthopaedic Surgeons to maintain the 80 hour per week limit. Going to fewer hours per week would handicap us because there would be less time to experience the kind of education you can only obtain by being in the hospital.”

The conversation in the hallways is indeed intense regarding changes in the health care environment. Dr. Popa:

We talk a lot these days about the upcoming changes to resident education by the Accreditation Council for Graduate Medical Education/Institute of Medicine and the current health care reform legislation. I would prefer that the government have a much more limited role in health care and health care decision-making, as would most of the residents in my program.

On the patient communication front, Dr. Popa has learned one thing that is not quite what his previous instructors said it would be. “In medical school there was a strong emphasis on patient autonomy, certainly a fine ideal with regard to patient interaction. I am finding that, practically speaking, there are a number of patients that are comfortable deferring to the doctor’s opinion. Most importantly, honesty, humility, and a sense of humor form the foundation for a solid patient-doctor relationship.”

Then there are those patients, says Dr. Popa, who require extra care and attention. “Many of the patients referred to our resident clinic tend to be more difficult individuals. These patients end up in our clinic because of insurance or compliance issues or both. They can be trying and are often not the most rewarding. The bottom line is that it is hard to help people who won’t help themselves.”

“My knowledge and patient care have really developed these past two years, but I also understand more and more each day just how much there is to learn and to experience. As I’ve been told more than a few times, there’s a reason it’s a five-year program.”

And we will check in with Matt and Scott as they progress through their programs.