ortho attending AMA

[LoGo]

Nah, I think there is a bit of projection here. I make no assumptions about how hardworking someone is. I've been in this field long enough to know that no surgical specialty is truly a "lifestyle" specialty-- particularly during residency. When someone asks about lifestyle, I imagine someone who wants to work 9-5. Not that there is anything wrong with that, but I don't know any surgeon who does. Maybe some exist out there. So maybe I (and other surgeons) need a better explanation of what someone means when they ask about lifestyle.

As for why the derm sarcasm, I have a problem with dermatologists calling themselves "surgeons." Being a surgeon carries the implication that you underwent the grueling hours of a surgical residency. Sorry, but if you're barely going beyond dermis, it isn't surgery. But who knows, maybe I have my own biases. When I was a resident, starving and sleep-deprived after 30 hours of call, too dizzy from sleep deprivation to drive home safely, and trying instead to catch a few quiet minutes in the resident library, I was awoken by two giggling, dressed-to-the-nines derm residents, with fully done hair and makeup, loudly complaining about how 730am was too early to come in to work. (I had to be in by 430am, by comparison, and left at 9pm when they left at 3). So seeing these people call themselves "surgeons" when they weren't in the trenches pisses me off.

Sure derms aren't fixing skull base or unstable pelvis problems, but I think they are well trained for the type of surgical procedures they do. Analogous to MDs calling themselves researchers without going through a PhD - obviously they are still doing research, but not usually at the depth or breadth of a PhD and I think the same is true for derm vs surgery. Still surgery, but different breadth and depth (no pun intended) so of course training is not the same.

Changing topics, where do you see ortho in 15 years? My hunch has been that with tissue engineering advancements we will see more non-surgical approaches to ortho.

Also, can content interest alone get you through an ortho residency, or does there need to be an inherent love with the OR, regardless of content?

Thanks!

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[OrthoTraumaMD]

Is it possible to do shift work or work part time (~50 hours) in ortho?

You can do "locums" work, meaning you just take call at a hospital and do whatever comes in. It doesn't pay as well as a regular job, but it's the closest thing to "part time" that I can think of. Otherwise, we don't really do shift work.

 

[OrthoTraumaMD]

Sure derms aren't fixing skull base or unstable pelvis problems, but I think they are well trained for the type of surgical procedures they do. Analogous to MDs calling themselves researchers without going through a PhD - obviously they are still doing research, but not usually at the depth or breadth of a PhD and I think the same is true for derm vs surgery. Still surgery, but different breadth and depth (no pun intended) so of course training is not the same.

Changing topics, where do you see ortho in 15 years? My hunch has been that with tissue engineering advancements we will see more non-surgical approaches to ortho.

Also, can content interest alone get you through an ortho residency, or does there need to be an inherent love with the OR, regardless of content?

Thanks!

That's actually a perfect way to put it. I do research, but I wouldn't call myself a researcher the way a PhD would be. Derm may do surgery but they shouldn't (in my opinion) call themselves surgeons. Same for the ER doc who does procedures---they can open a chest but they are not surgeons.

As for your questions, re: Ortho in 15 years, I see some new innovations in terms of cartilage restoration and the ever-growing list of new implant options, but honestly the amount of operative Ortho will not change. First, it takes many years to adopt new technologies on a wide scale, and make them cheap enough and useful enough (evidence-based outcome data) to convince us to try them. Second, this is one of the few specialties where it's very difficult to remain minimally invasive or non-op, because it relies on the restoration of not only tissue but biomechanics. If you have end stage arthritis, unless you can grow a whole new knee in a vat, you're gonna need a TKA. And even if the new tissue is grown, it will likely need a surgeon to be implanted. Trauma is pretty safe too---much of what we do hasn't changed since the time of Hippocrates because the mechanisms of injury and human anatomy don't change, lol. This lies in stark contrast to vascular surgery, where many open procedures have been abandoned in favor of things like TEVAR that work just as well.

For your other question, if you don't love, or at least like being in the OR, you should not be a surgeon, in my opinion. Can you get through residency otherwise?....sure. But will be very hard, because it's the only "fun" part of residency when you're not doing scut work and consults, and if a surgeon hates being in the OR, the staff will likely get a sense of that and it will disrupt the team flow especially if the case doesn't go well. It's like the captain of the ship (an analogy often made in surgery) liking the sea but hating sailing. A love of any surgical content is sort of married to the OR inherently. Otherwise, you can do non-op Ortho (sports medicine). Same content, no surgery.

 

[halfwaycrooks]

I know the 'there is a fracture, I need to fix it' thing about ortho is way overblown but could you comment on how much knowledge from medical school you use on a day to day basis? Or do you feel like it is no longer relevant to your practice? I'm talking about things like pathology, pharmacology etc

 

[OrthoTraumaMD]

I know the 'there is a fracture, I need to fix it' thing about ortho is way overblown but could you comment on how much knowledge from medical school you use on a day to day basis? Or do you feel like it is no longer relevant to your practice? I'm talking about things like pathology, pharmacology etc

Not that much. But certain things that are relevant to my patients show up over and over again. So I'll separate it by field.
Neurology: distributions of nerves, which muscles are innervated. Important for not just spine rotation, but every day for postop patients
Vascular: limb vascularity/blood supply, and for me, pelvis in particular. Spine also needs that as well for their surgeries (artery of Adamkiewicz etc)
Anatomy: this is perhaps the most obvious. Not just of the limbs, but pelvis and abdomen as well-- when I fix an anterior ring injury, I need to understand the layers of the abdomen, the potential for hernias, etc.
Pharmacology: only relevant to the meds we use the most or those that are relevant to surgery/postop. Mechanism of action of anticoagulants, anti-inflammatories, pain medications, neuropathic pain meds (Neurontin)
Physiology: hard to answer... depends on the case.

Basically, ortho residency is so different that to me it felt like being in med school all over again - only this time, in addition to learning completely new material, I was also a resident with patient/call responsibilities. It was very stressful and that is why I push for more MSK education. Some recent data says as much as 40% of primary care visits are MSK related, yet PCPs have almost zero knowledge because med school doesn't devote much time to ortho (mine certainly did not).

I don't feel like any less of an MD because I am a subspecialist. That is the trend people are headed these days, and I don't have an issue with consulting medicine for diabetes management, because when they consult me for an ankle sprain, I'm happy to take it. My job is to know what they do not, and vice versa. I would not the be best person for a medical problem; I don't know the latest data on diabetes meds or blood sugar management (short of writing a sliding scale). So my managing it doesn't benefit the patient in any way, and in fact might hurt them. On the other hand, I can name twenty recent studies on femur fracture management and specific techniques and tricks to fix them, how to avoid a postop PE, what type of physical therapy someone should undergo, etc. So everyone does what they know how to do best.

 

[TheStallion16]

How many residency programs did you apply to? I've heard the norm is 40-50, but I've also heard that for competitive specialties many people apply to 80+. You mentioned you applied to some general surgery programs as a back up. Do you think it's wise to have a backup/apply to other specialities when trying for ortho because of its competitiveness? Thanks for doing this!

 

[Sam212]

Ortho resident here, currently in the trauma match. Where do you see the job market going in this field? I have heard of lots of level ii and level iii jobs, but pretty tight market at level Is. is that true? Also, do you even need a trauma fellowship for a level ii or iii job, given you had a pretty strong trauma program. I ask myself that question everyday. That and the fact that if orthopedics is becoming overspecialized. Would have loved to do general if there wasn't such trend of everyone doing fellowships.

 

[OrthoTraumaMD]

Ortho resident here, currently in the trauma match. Where do you see the job market going in this field? I have heard of lots of level ii and level iii jobs, but pretty tight market at level Is. is that true? Also, do you even need a trauma fellowship for a level ii or iii job, given you had a pretty strong trauma program. I ask myself that question everyday. That and the fact that if orthopedics is becoming overspecialized. Would have loved to do general if there wasn't such trend of everyone doing fellowships.

Excellent question. I will try to answer it without rambling too much because this is an interest of mine and is a constant topic of discussion at the OTA. It was also the topic of the first four articles/commentaries in the October issue of JOT, so if you haven't read them, I suggest you do. In terms of your question about level I jobs, yes it is true that they are pretty tight. I was an extremely strong Level I candidate coming out of residency/fellowship, and even for me, there were few options. The vast majority of available trauma jobs is at Level IIs, or Level IIIs that are trying to become level IIs. Now, you can argue about whether Level II hospitals nearby "stealing" cases from the Level I is good or not, but that is the reality. As a whole, trauma fellowships were always seen as a necessity in two things: complex periarticular and acetabular/pelvic fractures. If you feel that your residency program has given you that experience, then you don't need a trauma fellowship-- BUT you will not be hired by a Level I or II without one (Level III, maybe, but then you don't need a fellowship because you will never see the "real" trauma, it will bypass you... you'll be seeing a bunch of hip fractures for the most part, and be the equivalent of a community or private guy taking call).

New traumatologists as a whole are also doing less pelvis/tab cases because 1) cars are much safer than they used to be, so those injuries are rarer, and 2) the volume is "diluted" by the cases being siphoned off away from the Level I, so any individual surgeon's learning curve is extended because they're just not seeing those cases as frequently. Many trauma fellowships are also suffering from a lack of volume. Without revealing too much due to anonymity, I can say that the general OTA consensus among those in the know is that there are too many fellowships and too many trauma fellows, and not enough jobs. Those fellows are also not doing an adequate amount of cases. To make matters worse, "fellowships" are popping up all over the country, and are advertising themselves as "trauma fellowships" while not being accredited by the OTA. "Geriatric trauma fellowships" are the perfect example, and people coming out of them call themselves traumatologists without actually undergoing the vetting process that is standard for any OTA-accredited fellowship. The OTA is deciding on a response to these, and whether it should welcome them into the fold given the current climate, or push them away. This ties into your question about where I think the job market will go. I think there will still be the major Level I academic facilities, but the fastest growing market will be Level IIs with some academic component and an increased need to "keep" complex trauma due to the hospital's desire to make money. That is the situation that I, and many young trauma attendings, are in. The other side of that, though, is that traumatologists are much better trained to take care of the "bread and butter" trauma as well. We do plateaus, ankles, etc, better than a community surgeon taking trauma call. Our Xrays are more likely to be perfect, our approaches are more slick, and our outcomes are better--it is just the effect of specialization. And that, I think, is what we must not forget. Just because I am at a Level II and not seeing as many tabs/pelvises does NOT mean I'm not doing a highly specific service for those patients with less complex injuries. Doing a trauma fellowship makes me a specialist that is available to those patients at my Level II that would otherwise be fixed by some random person with no interest in trauma. And providing that service makes me happy, and I don't think I am any less of a trauma surgeon than my Level I colleagues.

 

[deleted823905]

Thank you in advance for answering these questions! It's awesome that you're doing this.

Anyways, I'm an undergrad interested in ortho - but I feel discouraged from ever trying to pursue it because of the stereotypes around orthopedic surgeons. I know you said not all orthopedic surgeons fit the stereotype, but I just feel like I'm the exact opposite of what you would expect from an orthopedic surgeon. For example, I'm a 5 foot tall, 99 lb Asian girl, I have no interest in sports (besides casual running), and I have a chronic baby face (I'm 20 but, I'm not exaggerating, most people think I'm 12 or 13 and I'm constantly mistaken for my younger brother's little sister). I'm also generally a quiet person and have a soft voice, so strangers tend to think I'm meek and mild even though I'm pretty competitive, stubborn, and confident.

I know I still have like 6-8 years before I even apply for residency, but I doubt my physical characteristics will change much as I am way done with puberty lol. Because of this, I wonder if people will disrespect me or not take me seriously (because I'm a small girl and look too young), which makes me shy away from ortho even though it seems really cool and something I want to learn more about. Am I wrong? Do you think any of this will significantly negatively affect me if I decide to pursue ortho one day? From what you've said, it seems as though first impressions and appearances matter a lot for women interested in ortho.

 

[OrthoTraumaMD]

Thank you in advance for answering these questions! It's awesome that you're doing this.

Anyways, I'm an undergrad interested in ortho - but I feel discouraged from ever trying to pursue it because of the stereotypes around orthopedic surgeons. I know you said not all orthopedic surgeons fit the stereotype, but I just feel like I'm the exact opposite of what you would expect from an orthopedic surgeon. For example, I'm a 5 foot tall, 99 lb Asian girl, I have no interest in sports (besides casual running), and I have a chronic baby face (I'm 20 but, I'm not exaggerating, most people think I'm 12 or 13 and I'm constantly mistaken for my younger brother's little sister). I'm also generally a quiet person and have a soft voice, so strangers tend to think I'm meek and mild even though I'm pretty competitive, stubborn, and confident.

I know I still have like 6-8 years before I even apply for residency, but I doubt my physical characteristics will change much as I am way done with puberty lol. Because of this, I wonder if people will disrespect me or not take me seriously (because I'm a small girl and look too young), which makes me shy away from ortho even though it seems really cool and something I want to learn more about. Am I wrong? Do you think any of this will significantly negatively affect me if I decide to pursue ortho one day? From what you've said, it seems as though first impressions and appearances matter a lot for women interested in ortho.

One of the toughest orthopods I ever knew was a tiny woman who didn't even clear 5 feet and had a limp. There's an achondroplastic dwarf (like Peter Dinklage in Game of Thrones) ortho surgeon out there too...look him up. If that's "not fitting the stereotype," I don't know what is. I share some of your characteristics, in the sense that I am also a thin woman who was a sci-fi geek/gamer type with no interest in sports or gym. I also looked young, and still do. You have two different phrases in your post that are somewhat contradictory: "...even though I'm pretty competitive, stubborn, and confident" and "I wonder if people will disrespect me or not take me seriously." There is a vast difference between appearing meek and actually being meek. People don't take me seriously even now, mostly because they mistake me for a nurse or a PA--- until I start talking. If you are truly confident and knowledgeable, and project it, people will quickly overlook your appearance. Yes, it will be harder for them to accept you as equally competent as someone who fits the stereotype, and your projection of confidence and skill might be in overdrive for a while, as mine was in the beginning---but after some time, you will get a reputation and become more comfortable in your own skin, and won't need to "prove yourself" anymore. Also, you can work the discrepancy to your advantage -- all the time I hear, "wow, you must be pretty tough." That stems directly from the fact that my appearance and my profession don't "match." This is actually in my favor-- you are seen as somehow "special" if you made it in ortho looking the way you do. (In reality, it's not true, and it is tough for everyone, huge guys and small women--- but people don't know that, and I've never corrected them because it messes with their cognitive dissonance.) As for what I said about first impressions and appearances, I was talking specifically about interviews and not looking too "wifey" (too made-up, etc), things you actually CAN control. Being small/Asian/baby-faced isn't in your power to change, but fortunately it won't hurt you except in initial, superficial encounters. As an aside, if you feel there is something you lack later on that you CAN control, and it will make you feel better about fitting in, then change it. For me it was physical strength-- I had, and have, zero interest in working out, but I do it because I have to maintain my endurance for my job (also, spraining my wrist while doing a cast was embarrassing and I resolved never to let that happen again).

 

[SurfingDoctor]

No one has mentioned this yet, but I want to write a post I think is important, because these are so easy to avoid and yet I see every single one perpetrated every year that I've been an attending:

Things that will kill your chances at an ortho program

During your rotation (away or home):
1. Being arrogant to the non-resident staff. Nurses, PAs, NPs, the janitor. Your job is to smile, be helpful, and do whatever they ask, even if it's "scut." You may think it's a no-brainer, but I've seen rotators tell our NPs, "I think you're mean" or "I think you could do better." Oh yes. Treat everyone like an attending, because you never know whose colleague/friend/cousin/wife/secret lover they may be. Shut your trap and keep your opinions to yourself (unless you see a patient being harmed).
2. Being the first to leave at the end of the day. Conversely, staying past the point of comfort and "hovering." To figure out when you can leave, meet with the chief resident on the service on the first day of your rotation and talk about your expectations-- ask "how can I best be of assistance, what are my responsibilities during rounds/conference/consults, and what are your expectations for me in terms of hours?" After that, play by ear-- if the junior resident is slammed, help them out and leave later.
3. Being on your smartphone during conference. It's such a temptation to quickly check your email OR even look stuff up--avoid it at all costs. If you hear a topic in conference, write it down for later, on paper.
4. Stealing cases from your co-rotators. We get it, most of us were gunners, but ortho is collaborative. Make sure the residents assign you somewhere and stick with it (if it's a free-for-all, make a schedule amongst yourselves). Don't fall all over yourself trying to scrub with the "most important," big name guy. It's really not as important as you think; plus, you never know what "little guy" has his ear and who would appreciate some student help in a difficult case.
5. Making fun of residents in front of other residents (this includes joining in when residents are making fun of their classmates)-- just don't say anything, 'smile and nod.'
6. Complaining about cases, length of the day, etc etc. Leave that for your spouse. There is no crying or whining in ortho (at least not at work-- I feel like I must have cried on a daily basis in PGY2, but always at home.)
7. Not preparing for cases. It's okay if you don't know the answer to a question, but no one will ask you super specific things--- basic anatomy suffices. Go over the cases for the next day with the residents and at least read the OrthoBullets section on the topic. Most residents will give you tips on what the attending might ask.
8. Flirting. You're there to work, so be professional. If you find yourself head over heels for someone in the program, leave that for when you're done with the rotation.
9. Lying. Just don't. Ever. Even if you messed up or forgot to do something, just admit to it so it can be fixed. If you didn't check a pulse, don't say that you did-- because if that patient has no pulse, it will make the resident think something happened.
10. A consequence of doing the above things: if you get a bad eval from the residents on any form during your rotation, your chances are almost nil. Most programs don't give residents the power to choose people for the match, but they do have the power of blacklisting-- no matter how good the letters/attending opinions/step scores may be, if the residents put you on their "do not take list," it's over.

During your interview:
1. Lying about anything on your application, including the extent of your involvement in a project.
2. Not knowing what your research involves or why you did it.
3. Saying, "Do I have to answer that question?" Unless they're asking an illegal question, just answer to the best of your ability. Anything else makes you sound shady.
4. Talking **** about your home program or any orthopaedic surgeon or resident (even if they don't come from that program). You would think this never happens, but I guarantee you there's at least one every interview season.
5. Getting drunk during the resident dinner. Bonus points for dancing on the table (yes, this happened too).

^ Goes for pretty much any rotation and interview in any specialty. Good advice.

 

[Goro]

Somebody actually said this during an interview????? What were they asked?

3. Saying, "Do I have to answer that question?" Unless they're asking an illegal question, just answer to the best of your ability. Anything else makes you sound shady.
4

 

[OrthoTraumaMD]

Somebody actually said this during an interview????? What were they asked?

They were asked what other programs they were interviewing at. Not an illegal question; but I could see it being uncomfortable, especially if you don't have that many interviews. But the hedging was a little freaky.

 

[akwho]

5. Getting drunk during the resident dinner. Bonus points for dancing on the table (yes, this happened too).

This story is ortho famous, and awesome.

 

[ridethecliche]

So that person that danced on the table was a shoo in right?

 

[OrthoTraumaMD]

So that person that danced on the table was a shoo in right?

Naturally.

 

[ridethecliche]

Naturally.

I have first hand experience of what happens after the conference is over for the day.

Y'all go ham at AAOS. I heard second and third hand stories about some of the attendings I worked with from the time the meeting was in Vegas and New Orleans. One of them was the chief of the trauma service, I'm sure you'd know who it was heh.

In any event, I have nothing to add.

Thank you for doing this. I've done a fair amount of research in ortho, but I don't think it's where I'll end up. These AMA's are always great to read though. I appreciate you taking the time to do this.

 

[OrthoTraumaMD]

I have first hand experience of what happens after the conference is over for the day.

Y'all go ham at AAOS. I heard second and third hand stories about some of the attendings I worked with from the time the meeting was in Vegas and New Orleans. One of them was the chief of the trauma service, I'm sure you'd know who it was heh.

In any event, I have nothing to add.

Thank you for doing this. I've done a fair amount of research in ortho, but I don't think it's where I'll end up. These AMA's are always great to read though. I appreciate you taking the time to do this.

I was at both of those meetings... I'm pretty sure I would know...or even have participated
Ortho conferences are always fun---mostly because of the reps, not the attendings! I miss being a resident, I think I was less boring then. Now I want to go to sleep at 930pm like an old lady. But god, sleep at a conference is the best--no one bothering you, no calls...heaven.
Anyway, you're welcome. I'm always curious to hear what students think and worry about. Sometimes it's not what I anticipate. Happy to answer any questions.

 

[YoungDoc25]

This has been awesome to read, so thank you very much for doing this! Two questions:

1) What made you choose ortho over gen surg? For either specialty, you obviously had to have a calling for the OR, but I just wanted to see if there was something that stood out to you that pushed you towards ortho/away from gen surg.
2) What's your relationship with general surgeons that have completed a trauma fellowship? I know the bones (couldn't resist, ha!) of the two fields are very different, but do you find yourself working next to them on cases very often?

 

[OrthoTraumaMD]

This has been awesome to read, so thank you very much for doing this! Two questions:

1) What made you choose ortho over gen surg? For either specialty, you obviously had to have a calling for the OR, but I just wanted to see if there was something that stood out to you that pushed you towards ortho/away from gen surg.

2) What's your relationship with general surgeons that have completed a trauma fellowship? I know the bones (couldn't resist, ha!) of the two fields are very different, but do you find yourself working next to them on cases very often?

1) I hate bowels. The GI tract makes me ill. Also, general surgeons work like dogs, particularly in trauma, and are not adequately compensated for it. GS trauma also have to stay in-house as an attending if they are on trauma call. None of that sounds appealing.

2) My relationship with gensurg trauma is love/hate, depending on the surgeon. The goal is to work together, but the goals of gensurg trauma and ortho trauma often don't align. I am concerned with restoring function, and they are concerned with preserving life. Ideally, attending-to-attending conversations and good, evidence-based trauma protocols solve/prevent most issues. Some personality clashes do happen, due to strong opinions/egos in both fields, but most of the time it is cooperative and cordial. As for frequency of working together, yes, it happens very frequently. At a trauma center that sees lots of polytrauma patients, the relationship between me and general surgery is probably the most important one outside of my relationship with my own partners, because most polytrauma patients are injured due to blunt trauma, causing both ortho and visceral injuries. I am very heavily reliant on literature and data, and make my decisions based on that, so I regularly review our protocols and make sure they are sound from an ortho perspective. A good example is the recent trend not to take a pelvis xray in the ER and just rely on the CT. The general trauma surgeon may not understand why that is insufficient from an ortho standpoint--to them, it is an unnecessary delay in a physiologically unstable trauma patient, but to me it provides vital information that determines everything from whether I come in that night to join the general surgeons in the OR to reviewing final xrays for healing/comparison. Usually I have found that once I explain things to them, they are very accepting. It's when you don't have the conversation and just stomp your way into their turf demanding stuff (the trauma patient is still primarily their patient!) that things get hairy.

 

[YoungDoc25]

1) I hate bowels. The GI tract makes me ill. Also, general surgeons work like dogs, particularly in trauma, and are not adequately compensated for it. GS trauma also have to stay in-house as an attending if they are on trauma call. None of that sounds appealing.

2) My relationship with gensurg trauma is love/hate, depending on the surgeon. The goal is to work together, but the goals of gensurg trauma and ortho trauma often don't align. I am concerned with restoring function, and they are concerned with preserving life. Ideally, attending-to-attending conversations and good, evidence-based trauma protocols solve/prevent most issues. Some personality clashes do happen, due to strong opinions/egos in both fields, but most of the time it is cooperative and cordial. As for frequency of working together, yes, it happens very frequently. At a trauma center that sees lots of polytrauma patients, the relationship between me and general surgery is probably the most important one outside of my relationship with my own partners, because most polytrauma patients are injured due to blunt trauma, causing both ortho and visceral injuries. I am very heavily reliant on literature and data, and make my decisions based on that, so I regularly review our protocols and make sure they are sound from an ortho perspective. A good example is the recent trend not to take a pelvis xray in the ER and just rely on the CT. The general trauma surgeon may not understand why that is insufficient from an ortho standpoint--to them, it is an unnecessary delay in a physiologically unstable trauma patient, but to me it provides vital information that determines everything from whether I come in that night to join the general surgeons in the OR to reviewing final xrays for healing/comparison. Usually I have found that once I explain things to them, they are very accepting. It's when you don't have the conversation and just stomp your way into their turf demanding stuff (the trauma patient is still primarily their patient!) that things get hairy.

Awesome insight! Thanks again!

 

[Psai]

No one has mentioned this yet, but I want to write a post I think is important, because these are so easy to avoid and yet I see every single one perpetrated every year that I've been an attending:

Things that will kill your chances at an ortho program

During your rotation (away or home):
1. Being arrogant to the non-resident staff. Nurses, PAs, NPs, the janitor. Your job is to smile, be helpful, and do whatever they ask, even if it's "scut." You may think it's a no-brainer, but I've seen rotators tell our NPs, "I think you're mean" or "I think you could do better." Oh yes. Treat everyone like an attending, because you never know whose colleague/friend/cousin/wife/secret lover they may be. Shut your trap and keep your opinions to yourself (unless you see a patient being harmed).
2. Being the first to leave at the end of the day. Conversely, staying past the point of comfort and "hovering." To figure out when you can leave, meet with the chief resident on the service on the first day of your rotation and talk about your expectations-- ask "how can I best be of assistance, what are my responsibilities during rounds/conference/consults, and what are your expectations for me in terms of hours?" After that, play by ear-- if the junior resident is slammed, help them out and leave later.
3. Being on your smartphone during conference. It's such a temptation to quickly check your email OR even look stuff up--avoid it at all costs. If you hear a topic in conference, write it down for later, on paper.
4. Stealing cases from your co-rotators. We get it, most of us were gunners, but ortho is collaborative. Make sure the residents assign you somewhere and stick with it (if it's a free-for-all, make a schedule amongst yourselves). Don't fall all over yourself trying to scrub with the "most important," big name guy. It's really not as important as you think; plus, you never know what "little guy" has his ear and who would appreciate some student help in a difficult case.
5. Making fun of residents in front of other residents (this includes joining in when residents are making fun of their classmates)-- just don't say anything, 'smile and nod.'
6. Complaining about cases, length of the day, etc etc. Leave that for your spouse. There is no crying or whining in ortho (at least not at work-- I feel like I must have cried on a daily basis in PGY2, but always at home.)
7. Not preparing for cases. It's okay if you don't know the answer to a question, but no one will ask you super specific things--- basic anatomy suffices. Go over the cases for the next day with the residents and at least read the OrthoBullets section on the topic. Most residents will give you tips on what the attending might ask.
8. Flirting. You're there to work, so be professional. If you find yourself head over heels for someone in the program, leave that for when you're done with the rotation.
9. Lying. Just don't. Ever. Even if you messed up or forgot to do something, just admit to it so it can be fixed. If you didn't check a pulse, don't say that you did-- because if that patient has no pulse, it will make the resident think something happened.
10. A consequence of doing the above things: if you get a bad eval from the residents on any form during your rotation, your chances are almost nil. Most programs don't give residents the power to choose people for the match, but they do have the power of blacklisting-- no matter how good the letters/attending opinions/step scores may be, if the residents put you on their "do not take list," it's over.

During your interview:
1. Lying about anything on your application, including the extent of your involvement in a project.
2. Not knowing what your research involves or why you did it.
3. Saying, "Do I have to answer that question?" Unless they're asking an illegal question, just answer to the best of your ability. Anything else makes you sound shady.
4. Talking **** about your home program or any orthopaedic surgeon or resident (even if they don't come from that program). You would think this never happens, but I guarantee you there's at least one every interview season.
5. Getting drunk during the resident dinner. Bonus points for dancing on the table (yes, this happened too).

Dancing on the table should be an autoaccept

 

[Ejm1]

Thank you for taking the time to answer our questions!

I am finishing up my undergrad this semester and I am starting to think about specialties. I am certainly interested in surgery, but I am by no means set on anything yet. I have one major worry about surgical specialties-- I do not have steady hands. I don't have any kind of tremor or anything but if I try to hold my hands still they shake ever so slightly. It was a minor issue when working in my lab performing certain technical procedures, but I was always able to overcome it. Do you think this would be an issue in surgery? I doubt it would it a specialty like ortho trauma, but what about something like general? I would hate for this to eliminate my chances of anything surgical.

Thanks in advance.

 

[basophilic]

Hi SDNers,

I have some free time and so am happy to answer any questions you may have about the myths and realities of orthopaedics, resident life, and general questions. Just avoid the "what are my chances with score X" questions-- so many better posts and options on this site for that. Orthogate is also a good site for their "ask the attending" section.

A bit about me: orthopaedic trauma attending, female, in my 30s, practicing in an academic setting in the US. Did my med school (allopathic/MD, if that matters), residency and fellowship training in the Northeast (though not all in the same place/state). My practice includes admin/research/education/mentorship responsibilities as well.

Ask away.

I'm a prospective MD/PhD premed interested in at least starting med school with goal of doing orthopedics (I'll still remain somewhat flexible, based on any new interests and med school performance). I absolutely love doing research in ortho, and already have a first-author in research pertaining to tendon biology and also have a promising second project on engineered cartilage where I have a good chance at publishing first-author. I'm also planning to present a poster at this year's ORS in March, and I hope to expand the breadth of my exposure to the field there (at least from the research side). And I have been looking at several regenerative and cell bio labs pertaining to the musculoskeletal system as potential targets for the MD/PhD. Also, I have only done a slight bit of shadowing of an ortho surgeon in which I got to look in the OR from a distance and understand the general work day and hoping to do a little more the next few months.
1. Apart from these what else can I do now to really gain more real-world exposure to the field? I too hope to go in the academic side of the field.
2. Apart from the regular (i.e. reading nonfiction relevant to the field, watching ortho surgical procedure videos directed for patients, reading online forums, and glancing at the ortho chapter in the schwartz surgery textbook), what else can I do to get a broad/informal view of the field?
3. If I don't get matched to ortho in med school, are there any alternative paths to the field? For example, I understand that plastic surgery can be done with either a super-competitive integrated residency or via the slightly longer route of general surgery followed by specialization in plastics.
4. Lastly, what are some things you like least about orthopedic surgery?

 

[OrthoTraumaMD]

I'm a prospective MD/PhD premed interested in at least starting med school with goal of doing orthopedics (I'll still remain somewhat flexible, based on any new interests and med school performance). I absolutely love doing research in ortho, and already have a first-author in research pertaining to tendon biology and also have a promising second project on engineered cartilage where I have a good chance at publishing first-author. I'm also planning to present a poster at this year's ORS in March, and I hope to expand the breadth of my exposure to the field there (at least from the research side). And I have been looking at several regenerative and cell bio labs pertaining to the musculoskeletal system as potential targets for the MD/PhD. Also, I have only done a slight bit of shadowing of an ortho surgeon in which I got to look in the OR from a distance and understand the general work day and hoping to do a little more the next few months.
1. Apart from these what else can I do now to really gain more real-world exposure to the field? I too hope to go in the academic side of the field.
2. Apart from the regular (i.e. reading nonfiction relevant to the field, watching ortho surgical procedure videos directed for patients, reading online forums, and glancing at the ortho chapter in the schwartz surgery textbook), what else can I do to get a broad/informal view of the field?
3. If I don't get matched to ortho in med school, are there any alternative paths to the field? For example, I understand that plastic surgery can be done with either a super-competitive integrated residency or via the slightly longer route of general surgery followed by specialization in plastics.
4. Lastly, what are some things you like least about orthopedic surgery?

First things first: relax. You're way ahead of the game in terms of ortho since you're only a premed. You sound very intense, and I am more worried about you developing tunnel vision in terms of not considering anything else. You need to become a well-rounded physician first--you will not get a chance after you do the deep dive into ortho. I regret not paying attention more on my medicine rotations.

Now, for your questions.

1) as a first or second year, try to do some shadowing in the OR with orthopods. The Ortho admin coordinator can hook you up. You will get plenty of chances during third and fourth year, though, so I wouldn't worry.

2) check out the OrthoBullets site. Lots of different topics with easy to understand explanations. Most Med schools have an Ortho surgery interest group, and they can get you more reading materials.

3) Hand surgery can be reached through plastics or general surgery. Spine can be done via neurosurgery, which is also competitive. Otherwise you get to perform some Ortho stuff like splinting and reductions in emergency medicine, but obviously won't be doing surgery there. There is also sports medicine which is nonoperative but has a lot of the same principles. PM&R incorporates lots of the rehab and functional aspects of Ortho. Podiatry can do basically anything an ortho foot and ankle guy can, but totally different training, and I've seen podiatrists totally butcher foot/ankle fractures. Otherwise it's pretty much Ortho or bust.

4) that's a tough question. What I like least is that we are often dependent on other services to allow us to do what we do (medicine, gensurg, anesthesia)--"clearances" and the like. Because musculoskeletal education is sorely lacking in the general med school curriculum, those other specialties often lack even the most basic understanding of ortho, and therefore don't really appreciate its intricacies and how important the restoration of function is--for example, the umpteenth time when the general surgeon waits til the next day to call with a consult for a fracture they know is there--giving me less time to plan and coordinate because they don't see it as "critical."

 

[DoctorCrush]

Thank you so much for your time! I apologize if this is a silly question, but did you say that you take home call at your level II facility? How exactly does that work? Do you have to be at the hospital within a certain time frame if an isolated ortho trauma is activated? Thanks!

 

[masaraksh]

Whats the best way to choose where to go for away rotations?

 

[OrthoTraumaMD]

Thank you so much for your time! I apologize if this is a silly question, but did you say that you take home call at your level II facility? How exactly does that work? Do you have to be at the hospital within a certain time frame if an isolated ortho trauma is activated? Thanks!

Yes. Depending on which hospital I am taking call at, I either have a PA (at the level 2) or resident (at the level 1) who is first call and sees the patient. Then if I need to come in urgently that night, I come in within 30 minutes.. but technically I just need to see the patient within 24 hours, so most things can be taken care of overnight by the PA or resident, and I just see them in the morning. Ortho attendings never need to take in-house call.

 

[OrthoTraumaMD]

Whats the best way to choose where to go for away rotations?

The main reasons people do specific aways are:
1) If you are looking at a very competitive program that heavily favors rotators (like Rush for example), and rotating there increases your chance of matching.
2) If there is a particular location of interest to you (a certain city for example).

There was just an article released on this in Jan 2017 JAAOS (aka the Yellow Journal). They looked at why ortho applicants actually do aways, and what they mean to students and residency program directors. The main takeaway from the article is that the primary reason for aways in the case of both students and program directors is to determine whether or not they are a good fit for the program, followed by (in the students' case) to increase their chances of matching at that program. People do equal amount of aways regardless of whether they think they are a competitive candidate (they stratified by the students' own appraisal of whether they were likely or unlikely to match).

So really, there is no good answer to this. Most programs automatically grant interviews to rotators, and from that article, about 1/3 of residents in a specific program either were in that program's med school or did an away there... so there is a heavy tilt in favor of rotators overall, because an away is basically a residency "audition." If you don't really care where you match, then choose your aways based on financial issues, program competitiveness, and location. If you really want to go to a specific program, I would recommend doing an away there.

 

[DoctorCrush]

Yes. Depending on which hospital I am taking call at, I either have a PA (at the level 2) or resident (at the level 1) who is first call and sees the patient. Then if I need to come in urgently that night, I come in within 30 minutes.. but technically I just need to see the patient within 24 hours, so most things can be taken care of overnight by the PA or resident, and I just see them in the morning. Ortho attendings never need to take in-house call.

I see, thank you!

I don't work in the hospital settings, so I don't know the formalities of things, but have you ever run into situation where an attending / provider was upset because they called an ortho traumatologist, only to be consulted by NP or PA? This is by no means of me trying to start a flame war about competent etc, I'm just curious because I've read so often about people being upset because they called for a consultation only to be addressed by the NP / PA etc. Obviously in your case, I'm assuming it works that way because your system is set up in that manner.

 

[OrthoTraumaMD]

I see, thank you!

I don't work in the hospital settings, so I don't know the formalities of things, but have you ever run into situation where an attending / provider was upset because they called an ortho traumatologist, only to be consulted by NP or PA? This is by no means of me trying to start a flame war about competent etc, I'm just curious because I've read so often about people being upset because they called for a consultation only to be addressed by the NP / PA etc. Obviously in your case, I'm assuming it works that way because your system is set up in that manner.

No. In most hospitals there is an ortho service, and it is implicitly understood that the "first call" person is not the attending (otherwise, what's the fun in being the attending?). It is also understood that the consult isn't "over" once the NP/PA/resident sees the patient-- they have to then talk to the attending and make a plan. Oftentimes, it's not even an ortho trauma issue, and then the resident will make the call as to which attending to contact. Certainly, I have gotten calls directly from other attendings before, but it happens rarely and usually with a very specific question ("not sure if this is really a consult / can you eyeball this for me / it's my mom or grandma or sister etc so please be extra careful with them"-that kind of stuff).

 

[FutureDoc1088]

For incoming ortho interns, do you have any recommendations for books to read prior to starting residency? I feel like many resources are in bullet point format (orthobullets, Millers), and was wondering if there was a good foundational book that would make these bulleted review resources more meaningful down the line. Thank you for your help!

 

[OrthoTraumaMD]

For incoming ortho interns, do you have any recommendations for books to read prior to starting residency? I feel like many resources are in bullet point format (orthobullets, Millers), and was wondering if there was a good foundational book that would make these bulleted review resources more meaningful down the line. Thank you for your help!

Two very thin books that will make a big difference down the line. If you read anything before residency, these two are it:
1) Hoppenfeld, "physical examination of the spine and extremities" (has a green cover)
2) Radin, "practical biomechanics for the Orthopaedic surgeon" second edition (out of print but you can get on used book sites or amazon)

Another good one, if you can track it down, is a tiny lifesaver called "the Orthopaedic intern pocket survival guide" by Derek Ochiai. That's more bulleted, but nice to have around in a pinch.

Otherwise, for the big textbooks, just start with hoppenfeld's surgical approaches, and also the first section of Rockwood and Green (or Skeletal Trauma, whatever your program uses) as that is the basis of many things including ER call. It includes functions of plates and screws, basic science etc before getting into the trauma stuff. I am partial to Rockwood, but I think Skeletal Trauma has the best sections on nonunion and malunion.

PS. Make sure you spend some time in intern year studying for and taking step 3. Take it in intern year--don't be tempted to push it off. The longer you wait, the more you forget the material--if you don't pass you can't graduate, and I've known chief residents who have had to take it several times before passing... Don't be the guy who causes your program director to bang his head against the wall.

 

[GonefromTX]

I'm an MS2 in Texas who's interested in ortho. I know you've already answered how to best pick aways but I'm interested to know what you did.

I was wondering how you chose your out-of-state away rotations. Were those places you picked for away rotations notoriously easier-to-match/easier hours for the residents/in a city you liked/trauma-intensive/were prestigious?

Also, did you apply to 80 residency programs by the same logic? Or did you just shotgun it and randomly applied everywhere? I would have no clue where to start (I probably wouldn't know of 5 hospitals outside of Texas lol).

Thanks in advance!

 

[OrthoTraumaMD]

I'm an MS2 in Texas who's interested in ortho. I know you've already answered how to best pick aways but I'm interested to know what you did.

I was wondering how you chose your out-of-state away rotations. Were those places you picked for away rotations notoriously easier-to-match/easier hours for the residents/in a city you liked/trauma-intensive/were prestigious?

Also, did you apply to 80 residency programs by the same logic? Or did you just shotgun it and randomly applied everywhere? I would have no clue where to start (I probably wouldn't know of 5 hospitals outside of Texas lol).

Thanks in advance!

I didn't do any out of state aways due to family constraints. I had wanted to stay in my home state so put all my eggs in that basket. If I had to do it again, I would have branched out a little more in my aways and would have gone to a "prestigious" school to rotate to improve my chances--but at the time, I was certain I was a poor candidate, so I didn't even want to try to "waste" an away on a school that wouldn't accept me anyway.

As far as applications, I basically drew a big circle around my home state and applied everywhere within it. No particular reason. But again, at the time my goal was quantity of programs to increase my interview chances. It wasn't selective, so don't go by what I did.

 

[OrthoTraumaMD]

This just came out in JBJS and I thought I'd share-- match data for ortho from the NRMP 2006-2014. The quality is a little grainy because I had to convert it to a JPEG. Note Step 1 scores, number of ranks, research "products" (article didn't define it well, as opposed to "research experiences," but basically it's anything you put on ERAS, including posters and other things). Like any article, you have to take the data and examine it critically - this relied on students' reporting accuracy.

 

[Chillbo Baggins]

This just came out in JBJS and I thought I'd share-- match data for ortho from the NRMP 2006-2014. The quality is a little grainy because I had to convert it to a JPEG. Note Step 1 scores, number of ranks, research "products" (article didn't define it well, as opposed to "research experiences," but basically it's anything you put on ERAS, including posters and other things). Like any article, you have to take the data and examine it critically - this relied on students' reporting accuracy.

Do you think that is the info that program directors will be using in the next year or so? Because those numbers are significantly lower than what's in the 2016 Charting Outcomes.

 

[OrthoTraumaMD]

Do you think that is the info that program directors will be using in the next year or so? Because those numbers are significantly lower than what's in the 2016 Charting Outcomes.


View attachment 213569

Not necessarily. This is an assessment of 2006-2014, and describes trends. But it's useful info, I think. Certainly the number of rankings definitely counted high when I was applying as well, so that trend stuck, as did the step 1 scores.

 

[Frogger27]

I am sorry if I am interpreting this wrong, but why are the step 1 scores and #of research significantly lower compared to the 2016 charting outcome? Increasing competitiveness over time?

 

[OrthoTraumaMD]

I am sorry if I am interpreting this wrong, but why are the step 1 scores and #of research significantly lower compared to the 2016 charting outcome? Increasing competitiveness over time?

Yes, I think so. It's increased every year.

 

[GonefromTX]

Why would mean number of research experience be lower than mean number of research products? Don't you need a research experience to (hopefully) publish a paper?

 

[OrthoTraumaMD]

Why would mean number of research experience be lower than mean number of research products? Don't you need a research experience to (hopefully) publish a paper?

I don't really understand that either. The article wasn't clear on the difference. I am thinking that each experience provides multiple products...or that the products (which includes presentations) are not all derived from actual "experiences."

 

[joker2400]

Why would mean number of research experience be lower than mean number of research products? Don't you need a research experience to (hopefully) publish a paper?

I think it really depends on you definition of a research experience. I have many "research products", but since they all come from working with the same attending and are all on the same general topic I consider that 1 experience.

 

[GonefromTX]

Speaking of research, can I please have your honest opinion if I have done adequate research?

So I have 4 publications: 1 case report on SCFE and 3 retrospective cohort studies on various topics on anesthesiology (analyzing NIS data). I had to work with the anesthesiology department because I wasn't able to find a project with ortho.

Is it bad that my research experience is not bench/clinical trial/ortho related? Do you think I should do more in third year or do you think I'm okay and should just focus on grades?

 

[OrthoTraumaMD]

Speaking of research, can I please have your honest opinion if I have done adequate research?

So I have 4 publications: 1 case report on SCFE and 3 retrospective cohort studies on various topics on anesthesiology (analyzing NIS data). I had to work with the anesthesiology department because I wasn't able to find a project with ortho.

Is it bad that my research experience is not bench/clinical trial/ortho related? Do you think I should do more in third year or do you think I'm okay and should just focus on grades?

It's hard to say. Going to try to answer these types of questions in a general rather than person-specific way because I want to keep this thread applicable to all. I will say that having SOME research is important, which you do, and that having it be in Ortho is helpful but not required. So no, it is not bad. When it comes to research, it's much more important to speak coherently about what you did, even if it's in another field. That said, if you have reasonable time to be involved in ortho projects without sacrificing grades, it's always worth it.

 

[Neuroplasticity]

Why would mean number of research experience be lower than mean number of research products? Don't you need a research experience to (hopefully) publish a paper?

I think this occurs when someone produces more than one product for each experience, ex. working in the same lab for 2 months and getting a publication + poster.

 

[Chillbo Baggins]

Why would mean number of research experience be lower than mean number of research products? Don't you need a research experience to (hopefully) publish a paper?

One specific research experience leading to an abstract, poster, conference presentation, and publication, for example.

 

[OrthoTraumaMD]

And we look at not just the number of research things, but what they are specifically. Especially if someone goes overboard and lists every class presentation they've ever done as "research."

 

[Optimus-Prime]

@OrthoTraumaMD really appreciate your time,

Was just wondering about your perspective on some southern programs, beginning to plan away rotations and figured the more opinions I hear the better

Any thoughts on Campbell Clinic, Louisville, UT Houston? Leaning towards more of a blue collar program, more than happy to give up the lifestyle to get my ass kicked and operate. Any particular programs you can think of in your neck of the woods?

 

[akuko2]

@OrthoTraumaMD, once again, thank you for your time! I heard an attending talking about some residencies possibly moving toward 6 years due to residency work hour restrictions/ lower number of cases per year. Apparently a program or two already has 6 year tracks. What is your take on this, do you think it will become common?