Essential Tremor: Potential Obstacle?

[CPSCCRSB1]

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I see this topic has been discussed before on this message board, but I've reviewed some of the past threads on this topic, and it seems there are mixed feelings.

I'm a Pre-med student, and I wish to be an orthopaedic or cardiothoracic surgeon. I've been diagnosed with an essential tremor. My physician says everyone has a tremor, and that I shouldn't worry. I don't really know how to gauge the seriousness of the tremor, but I feel as if it would affect my ability to do fine motor work.

What I'm really looking for is advice from an MD in the field of Orthopaedics or cardiothoracics. How much is this going to affect me, especially given that essential tremors are progressive? How bad does the tremor have to be before I need to start thinking about choosing a different line of work?

Additionally, I am aware that certain medications (propranolol, beta blockers) can smooth out a tremor. How effective are these?

I realize this is ought not to be my primary concern at this point, but it is. Any input would be helpful.

Thanks in advance.
NR

 

[Dimoak]

Part of your post is very close to "asking for medical advice", even though that may not have been your intention. But either way, you should focus on getting into medical school if that is your goal, and at that point, you can further evaluate your propensity for various specializations and gauge whether your situation could affect your decision.

 

[basupran]

Chill out for now and focus on getting into medical school. Once there, you will find out if you really want to be a cts or orthopod.

I also have a mild tremor. When I started medical school, I thought I couldn't become a surgeon because of this tremor. After some time in the OR, I learned to control the tremor by balancing my instruments and limiting my caffeine intake. Either way, don't worry about it just yet.

And yes, propanolol does help with tremors-my friend took it during his surgery core so he wouldn't shake as much when tying.

on a sidenote: ortho is for the most part more of a tremor friendly surgical subspecialty

 

[Winged Scapula]

1. Agreed...don't worry about it now. You may not even like surgery when you do it in medical school.

2. Everyone has a tremor but there are ways to control it with positioning and medication. As one of my ped surgery attendings used to say, "everyone has a tremor, I just don't want to know about it"

3. Not all surgery requires fine motor skills. CT is MUCH more reliant on fine suturing skills than general Orthopaedics.

4. I've known several surgeons with ET which was controlled one way or another. So it is possible.

 

[CPSCCRSB1]

Thanks guys. Exactly the type of reply I was hoping for.

 

[ESU_MD]

Tremors are only a big deal when you are not the attending and someone else is watching you. It is human nature to be self-conscious

I have seen congenital heart surgeons with tremors and they do just fine.

If you can perform this surgery with a tremor, you can do anything with a tremor.

 

[GeraldMonroe]

How much does tremor/hand quality affect how good a surgeon one becomes?

Now that I'm in medical school, I feel safe saying I'd like to see if I could be a surgeon. I know it's extremely tough, and I have the impression that a big chunk of the medical students who want to be surgeons on day 1 of medical school change their mind.

In any case, if I were a surgeon, I'd want to be the best I could be. So, I wonder how much innate factors like small amounts of tremble and overall coordination affect how good a surgeon one ends up being. My hands appear to be pretty steady, and I can use tools well, but I'm not a violin playing prodigy with hands like a robot.

In the long run, would it be my hands holding me back from ever being "top tier"? (I guess aspiring to be 'the best' is unrealistic, but surely there is a 'top tier' of world class, expert surgeons. And I'm not saying I could ever be 'top tier', but I'm curious as to whether factors I have no control over would put a brick wall in the way of ever reaching that level. I mean, I can't be a professional athlete, not ever. I never had the genes for it, and I'm too old now to learn how to play golf or football, ect to a pro level. For all practical purposes, there is a brick wall preventing me from ever playing in the same golf tournament as Tiger Woods, even if that were my one and only goal in life)

 

[filter07]

A top tier surgeon is one that does research and gets published, not one who operates well.

Skills in the OR only translate to local success. Sort of being the best minor league player ever. To be recognized in the big leagues you have to be a research guy that publishes important papers or writes books. (Just the way it is...)

So whether or not you have essential tremor is pretty irrelevant to becoming a top tier surgeon. I have personally seen a giant in the field, whose books are widely read, who also happened to have one of the worst tremors I've ever seen. He was able to place his sutures perfectly though.

I have also seen some extremely deft surgeons who will dissipate into obscurity in private practice. He might have a reputation with the anesthesiologists or scrub techs, but not many others will really know. Rare are the ones that remain in academia and can still run circles around most in the OR. I have seen those too.

Anyway, essential tremors can be overcome, I think.

 

[SLUser11]

A top tier surgeon is one that does research and gets published, not one who operates well.

Okay.


I guess it depends on how you define "top tier." The best clinician? The best teacher? The most famous (obviously your choice)? The best technician?

 

[filter07]

You're probably right about it depending on the definition. "World class" would imply some sort of recognition by your peers though, which as I mentioned, would be unlikely based solely on skill in the OR or even at the bedside. Even someone who is a wizard in the OR would need to publish his/her results to make it known to others. Like I said, most time the only audience in the OR is the anesthesiologist/CRNA, scrub tech, and circulator.

Another way of saying it is that there's more to being a surgeon than cutting, tying, and suturing better than everyone else. The general public tends to overemphasize the "gifted hands" aspect of surgery. As SLUser11 alluded, there are multiple aspects that contribute to being a "top tier" surgeon. He is also right to point out that those mired in academia overemphasize research.

 

[GeraldMonroe]

To me, publishing one's ideas in dead tree format doesn't really sound like the kind of thing that would make someone a "top tier" surgeon. It doesn't really say much about how likely a patient is to survive a surgeon's care.

Here's an article by "Malcolm Gladwell" where he talks about what I would consider a "top tier" surgeon. http://www.newyorker.com/archive/1999/08/02/1999_08_02_057_TNY_LIBRY_000018760

Charlie Wilson is described as having "distinctive fluidity and grace", and how he can finish operations "ordinary neurosurgeons" would take "hours" to complete in twenty-five minutes. The article says he performs his "two thousand nine hundred and eighty-seventh transsphenoidal resection of a pituitary tumor", and is practicing at age 69 in the article. While there's some debate over this, it kind of looks like if one needed brain surgery, it looks like going to a man like this one would maximize one's odds of survival.

So I'm curious how ones becomes that good, and what kind of things (like tremors) put a brick wall in the way of someone reaching that level.

 

[SLUser11]

You're probably right about it depending on the definition. "World class" would imply some sort of recognition by your peers though, which as I mentioned, would be unlikely based solely on skill in the OR or even at the bedside. Even someone who is a wizard in the OR would need to publish his/her results to make it known to others. Like I said, most time the only audience in the OR is the anesthesiologist/CRNA, scrub tech, and circulator.

Another way of saying it is that there's more to being a surgeon than cutting, tying, and suturing better than everyone else. The general public tends to overemphasize the "gifted hands" aspect of surgery. As SLUser11 alluded, there are multiple aspects that contribute to being a "top tier" surgeon. He is also right to point out that those mired in academia overemphasize research.

Absolutely. Gifted hands will only get you so far.....and you're right....they're not going to get any buildings named after you.

My practice goals and current learning environment are very different than yours, so obviously our priorities are different. When I think "top tier," I think of someone that combines all of the positive surgeon traits, and is a true Man-of-all-seasons....which is admittedly my most over-used cliche. If I had to pick one of those traits that I admire the most, it's probably being the best teacher.

 

[SocialistMD]

While there's some debate over this, it kind of looks like if one needed brain surgery, it looks like going to a man like this one would maximize one's odds of survival.
So I'm curious how ones becomes that good, and what kind of things (like tremors) put a brick wall in the way of someone reaching that level.

As stated before, there really isn't any way to know who is the best technical surgeon unless an article like the one you cited (which, by the way, are incredibly rare and this particular one has enough persuasive prose to make you feel in awe of the guy, deserved [probably] or not) exists, you can't know. Non-surgeons who refer you to a surgeon don't know operative skill, they know how well they get along with the surgeon, how much their mutual patients like their bedside manner and how thorough their correspondence notes are. Yes, if you (as a surgeon) kill 2-3 of a referring physician's patients you may not get the referral in the future, but the referral tends to be based more on practice partnerships than anything (eg: at a community hospital where I work, non-surgeons always say "call Dr. X or whoever is on call from his/her group for the surgical consult") else.
Even worse are these "rate my doctor" websites popping up all over. I invite any resident to google him or herself and I can almost guarantee that the first three sites will be from vitals, healthgrades, linkedin or ucomparehealthcare (those are my top four). Most of these are based not on anything other than reviews written by patients. What patients take the time to write reviews like this? Angry ones. Most reviews on these sites are not flattering.

To get to your question about how to be a good technical surgeon, most of it (that you can control; there are some people who are just smoother than others) has to do with economy of motion. Those who look slick in the OR do so because their hands only move where they need to and there isn't a lot of excess. This can be done with or without a tremor. However, one of the most overlooked traits of a great surgeon is the judgment of knowing who needs an operation and when. As stated before, there is more to being a surgeon than simply being a technician. The operation accounts for less than half of the hospital stay in outpatient procedures; for inpatient procedures it is much less. To me, mastering the ability to take care of your patient for the rest of their hospitalization, that time spent outside of the operating room, is what truly defines a great surgeon.

 

[GeraldMonroe]

I've heard that phrase several times, almost verbatim. The dean of my medical school said the exact same thing when I asked him this question.

I don't really understand what it means. A friend told me about an attending vascular surgeon who did an operation involving a patient's aorta. When wheeling the patient out, the patient's pulse began rising and the bp falling. The surgeon cut the patient's staples, and thrust his gloved hand into the patient's chest to grab the aorta and cover the hole. He straddled the patient on the stretcher while they wheeled it back into the O.R.

That's skill. Of course, maybe an even better surgeon wouldn't get in this situation in the first place. But, in any case, I'm not really asking about how someone becomes the 'heavy hitter' surgeon, I'm asking about how you get to the level that you can save someone's life half on instinct like in this story. Or improvise a modification to an operation on the fly because the textbook method isn't going to work. Or remove a brain tumor without so much as nicking the surrounding brain tissues.

Being able to decide not to do an operation when appropriate doesn't really seem like the same thing. If I take my car to the shop, the best mechanic is the one that can get it running again for the longest remaining time. Not the one that says the best he can do is to tell me to drive the car gently because he can't fix it. A surgeon's job sounds like that of a mechanic, except that spare parts are almost completely unavailable, so most surgeries jury-rig surviving body systems to carry the load.

I mean, sure, a surgeon has eons more education in a vastly more complicated 'car', but it kind of sounds like the same job in the end.

The mechanic that publishes a shelf full of manuals, or has his name on the sign outside is by no means the best by any stretch of the imagination.

 

[SocialistMD]

I'm asking about how you get to the level that you can save someone's life half on instinct

How about this phrase? "That's the reason it is a five-year residency." I had a chief and a fourth-year resident both make similar saves during my intern year. It is simply experience.

...maybe an even better surgeon wouldn't get in this situation in the first place...

Everyone has complications, even the most technically gifted.

Being able to decide not to do an operation when appropriate doesn't really seem like the same thing. If I take my car to the shop, the best mechanic is the one that can get it running again for the longest remaining time. Not the one that says the best he can do is to tell me to drive the car gently because he can't fix it. A surgeon's job sounds like that of a mechanic, except that spare parts are almost completely unavailable, so most surgeries jury-rig surviving body systems to carry the load.

That's why you don't get it. Being a surgeon isn't like being a mechanic. The closest correct analogy would be a mechanic recognizing he couldn't fix it, giving you an oil change to prevent further wear and a new muffler to cut down on the sound versus a mechanic who tries to fix the same car only to have it explode in the process. Some people don't need to run any longer, especially when the only running they do is riding a vent in the ICU for months on end until everyone finally realizes the futility. Recognizing that end prior to surgery can allow for preserved patient dignity, decreased emotional pain for the family and decreased medical costs (for the social utilitarians out there).

The mechanic that publishes a shelf full of manuals, or has his name on the sign outside is by no means the best by any stretch of the imagination.

Right, but everyone knows Bob Vila and thinks he is the master carpenter because that's the only name they know.

 

[GeraldMonroe]

I understand better now. I read about how doctors in Europe will send patients home and tell them to have a beer and enjoy the remnant of life they have remaining. That the government will even pay for terminal patients to enjoy one last vacation at a spa or somewhere nice. Ironically, paying for a luxury vacation for a patient instead of futile medical care would save the taxpayers vast sums of money. (the vacation helps the patients feel better about the fact that they aren't receiving $500,000 in painful treatments, I suppose)

Trying to help patients go peacefully and in pleasant surroundings sounds vastly better than a round of painful, pointless treatments followed by a slow lingering death in a shoddy skilled nursing facility run by medicare. I've seen those places when I was an EMT, they're unbelievably awful and depressing.

 

[Winged Scapula]

Trying to help patients go peacefully and in pleasant surroundings sounds vastly better than a round of painful, pointless treatments followed by a slow lingering death in a shoddy skilled nursing facility run by medicare. I've seen those places when I was an EMT, they're unbelievably awful and depressing.

Sure it does.

But you have not experienced the frustration of dealing with families who want you to spend every last resource on futile care for their demented granny. America is full of people who want "only the best", who don't care what it costs or whether or not it will realistically work. These are also the families who typically will not pay the bill when granny doesn't survive.

Americans are used to having the best and have not learned that there is a point at which further treatment is not adviseable and just because you can doesn't mean you should.

/rant off

 

[filter07]

Americans only want the best because they have been conditioned to think that they don't have to pay for it. From the uneducated gunshot victim all the way up to the President of the United States, Americans for some stupid reason believe that someone else will bear the cost.

I would like the families of futile ICU patients to start having to pay the bills after a reasonable amount of effort is made. We'll soon see if they really want "all the best" or "everything possible".

 

[Winged Scapula]

I would like the families of futile ICU patients to start having to pay the bills after a reasonable amount of effort is made. We'll soon see if they really want "all the best" or "everything possible".

Dr: "Before we can start beloved granny on CVVHD, we'll need a deposit of $35,000".

Family: "Uh never mind. Just let her go comfortably."

 

[maxheadroom]

Everyone has complications, even the most technically gifted.

Very, very true. In my experience, the "most technically gifted" sometimes even have worse complications when they start to buy into the notion that they so great. My worst complications have been with an attending who is a fantastic surgeon, but tends to push procedures beyond their expected benefits. He doesn't believe in saying, "I'm sorry, but I don't think I can help you."

 

[smq123]

Dr: "Before we can start beloved granny on CVVHD, we'll need a deposit of $35,000".

Family: "Uh never mind. Just let her go comfortably."

I wonder if that would work.

I saw an 80 year old man who was bullied (by his daughter) into letting the vascular surgeon fix his rapidly expanding AAA - the patient himself said that he just wanted to die peacefully and with dignity. And, of course, they specifically said to "do everything."

The man ended up needing 32 units PRBCs and, I think, 24 units FFP. This was right before he died anyway.

I wondered if it would really be that unprofessional to ask that the family, who had demanded his AAA repair in the first place, be required to donate a unit of blood on a regular basis for the next 5 years. Hey, they cleaned out the blood bank, they should have to help replenish it.

 

[JackADeli]

I am just going to bring the discussion back around to the original topic of your tremor and ability to become a surgeon.

1. I agree with everyon, worry about getting into med school first.
2. Your personal MD that actually knows you and your tremor told you don't worry cause in his/her opinion not a major issue.... take comfort in that. We can't diagnose it on-line.
3. I know numerous CT surgeons that have significant tremors... some even just direct it oposite the direction the heart is fibrillating😉
4. As mentioned, you will likely be able to brace yourself/position yourself to counter/control it.
5. New technologies help too.... The Intuitive DaVinci robot actually senses tremor and counters it. This makes the instruments move smoother at the end of the robot then in the hands of the best surgeon.
6. It is counterintuitive but there are some senior surgeons out there that had worsening tremors and thought their career was over.... they then streamlined and specialized in robotic surgery.... so I guess you can teach an old dog new tricks.
7. like already said, your PCP thinks your tremor is fine and you need to just focus on getting into medical school.... don't find reasons for fairlure this early.

JD

 

[mpp]

Medications can work for essential tremor and when they fail, deep brain stimulation or thalamotomy works wonders. We do it all the time in people of all ages with excellent results and confirmed in multiple blinded RCTs.

 

[santai]

I am just going to bring the discussion back around to the original topic of your tremor and ability to become a surgeon.

1. I agree with everyon, worry about getting into med school first.
2. Your personal MD that actually knows you and your tremor told you don't worry cause in his/her opinion not a major issue.... take comfort in that. We can't diagnose it on-line.
3. I know numerous CT surgeons that have significant tremors... some even just direct it oposite the direction the heart is fibrillating😉
4. As mentioned, you will likely be able to brace yourself/position yourself to counter/control it.
5. New technologies help too.... The Intuitive DaVinci robot actually senses tremor and counters it. This makes the instruments move smoother at the end of the robot then in the hands of the best surgeon.
6. It is counterintuitive but there are some senior surgeons out there that had worsening tremors and thought their career was over.... they then streamlined and specialized in robotic surgery.... so I guess you can teach an old dog new tricks.
7. like already said, your PCP thinks your tremor is fine and you need to just focus on getting into medical school.... don't find reasons for fairlure this early.

JD

LOL funny mental imagery.