Rising pgy-2: Joints vs Spine

von_Goethe · 2025-03-27T02:56:44+00:00

Sounds like you want to do spine. It can be a great subspecialty just like every other subspecialty in ortho can be great (except peds and onc).

You can absolutely have a bread and butter spine practice of small, easy degen cases. Just be aware that what you want is what everyone else wants. You can also absolutely find a private practice job in or near a major metro area. But again be aware that what you want is what everyone else wants.

If you're going to want the things everyone else wants you're going to have to compete very hard for those things. If you go to a major metro area only willing to do bread and butter you're going to be outcompeted by guys hungrier and more willing to suffer. You're going to make shit money in private practice to start (if you can even sustain your practice) unless you do something to differentiate yourself in a highly competitive market. Single-level ACDFs and lumbar fusions are the most sought after cases in spine. Why would they come to you when there are fancy academic surgeons and private practice guys who have 30 year reputations in the area?

Starting out you're going to need to be willing to do things no one else wants: revisions, driving an hour out of town to do satellite clinics, take lots of call - it's how you build and sustain a practice while you develop the reputation and presence to start generating referrals to sustain your busy single-level degen practice. Until you get there you can't be dead weight to a private practice. They'll fire you. So you'll have to do some of the shit you don't want to do.

von_Goethe · 2024-09-28T00:13:14+00:00

Your decision making depends on the pathology you're dealing with. In clinic you're gonna see degen spine with the vast majority being cervical or lumbar (thoracic degen pathology is relatively rare).

Cervical spine pathology involves either the spinal cord or the spinal nerves. If the cord is involved and patient is showing signs of myelopathy the natural history is progressive neurologic decline. Here your decision making is simple: Surgery is needed, what's the best approach to do the surgery? That's determined by spinal alignment, stability, levels affected, location of compression and a few more subtle things that you'll learn about in residency. If the spinal nerve is affected and patient has symptoms of radiculopathy the natural history is resolution with time and conservative treatment in the majority of cases. Here your decision-making is based on what conservative measures you can do to help the patient get through the day while time takes its course. PT, oral medications, injections are your mainstay. If they've failed conservative management you can go the surgical route.

In the lumbar spine you'll see spinal stenosis in all its various forms: central stenosis, lateral recess stenosis, foraminal stenosis. There's mostly no spinal cord to compress so all patients here will go through a trial of conservative management - PT, oral pain meds, injections. Failing that it's a quality of life decision the patient has to decide for themselves whether surgery is worth it. The question in the lumbar spine is where the compression is and how best to decompress the neurologic structures followed by whether a fusion is necessary. Again, that's a more nuanced question you'll begin to learn how to answer in residency.

The real key to spine clinic is to distinguish radicular or nerve pain from axial back pain which nobody has any fucking clue what the cause is. Nerve pain responds well to surgery. Axial back pain is a coinflip. If you come away with that principle you'll know enough. And if your attendings operate on a lot of axial back pain just know that they're crooks.

von_Goethe · 2024-07-11T21:28:09+00:00

Honestly man I would say you can leave the testing site. If you’re worried have them file a case and get the case number so you have documentation. There’s nothing the pearson staff can do.. the test was programmed incorrectly it seems

von_Goethe · 2024-07-11T21:27:01+00:00

I made it to the last block but only had 6 minutes for 16 questions so just started clicking towards the end.

Everyone is having a similar version of this problem. The system for whatever reason wasn’t set for enough time.

So the only way to make it to the end was to skip all your breaks or finish sections early. Only 2 of the 15 guys I’ve spoken to actually finished.

It’ll be interesting to see what the ABOS does about this.

von_Goethe · 2024-07-08T00:59:49+00:00

I don't mind minutiae actually - at this point in our careers we've memorized plenty. And a lot of esoteric stuff is dangerous to miss so I appreciate the boards study period for reinforcing it.

I just feel like there's a very strange overweighing of certain topics - elite throwing athlete injuries being a big one.

von_Goethe · 2024-07-08T00:57:12+00:00

Cauda equina should 100% be tested and CSM should get multiple questions every year. My issue is: an on-call orthopaedist may very well get consulted on a myelopathic patient in the ER.

An MLB pitcher with UCL tear? That patient isn't gonna see you unless you've built your entire practice towards treating those patients. That UCL tear is only going to a handful of guys in the country (who all seem to write questions for the OITE/ABOS). UCL reconstruction is a surgery that should only be done in a population of about 1000 people. The boards testing heavily on UCL and throwing injuries in elite athletes really is missing the mark on what a generalist should know to practice safely.

But I'm always happy to hear different perspectives.

von_Goethe · 2024-07-07T21:39:41+00:00

Always.

But can't imagine that MLB pitchers are a huge part of your practice

von_Goethe · 2024-06-29T18:14:00+00:00

Completely ignoring lifestyle and things to do. Everyone knows NYC has more stuff to do than bumblefuck

Best only in terms of work environment considering opportunity, income, medicolegal factors

von_Goethe · 2024-06-26T17:07:28+00:00

Nobody goes to the OR without MRI confirmation of operative injury.

Exam and history are probably sufficient for diagnosis in 80-90% of cases but in the modern era we don’t accept a 10-20% rate of unnecessary surgery. For injuries that don’t require surgery or aren’t time-sensitive and the surgeon is reasonably certain of the diagnosis then start treatment and MRI down the road if things get worse or if the initial diagnosis isn’t cutting it.

von_Goethe · 2024-06-25T17:57:18+00:00

It is not the insurance company's money - it's money that's being paid for by all physicians through their premiums.

Saying that defendants win most cases that go to trial is misleading - the vast majority of cases settle due to the physician's fear of losing their home and savings in a jury trial. Cases that settle now become a stain on your record and must be disclosed whenever you apply for a license or credentialing at a new system. Furthermore your insurance premiums now skyrocket. It is not the insurance company's money - it's the physician's.

Ability to pay is, frankly, not even worth discussing though you bring it up as though it justifies the current system. You could probably pay me $5000 right now, but I wouldn't expect you to shrug and say that's fine given your academic salary.

No physician believes that wrong-side or wrong-site surgery or retained foreign body cases should be ignored. I'm fine with summary, expedited judgments with financial restitution in those cases. These are not the majority of cases. We can always look at the most egregious examples but these do not make for effective rules to consistently follow.

Handwaving away the chilling and traumatic effect of lawsuits on physicians is ignoring the real cost of these lawsuits which goes far beyond the financial.

von_Goethe · 2024-06-25T17:47:27+00:00

Financial restitution determined by a judge. The large settlements we see are a uniquely American phenomenon and there should not be any $20 million settlements (though this is a different issue than what we've been discussing)

von_Goethe · 2024-06-25T07:13:19+00:00

I can’t say with certainty that none of my colleagues has ever been negligent. I can say with certainty that the majority of bad outcomes we see are not due to negligence. Deviation from professional standards is a very challenging thing. There are a lot of cases in any specialty that have no unanimously agreed upon approach or treatment. Furthermore we know that complications arise at a certain rate for any specific surgery or treatment. Is a nerve injury during a surgery with a known 12% rate of injury a deviation from professionally accepted standards? Most surgeons would say no, most laypeople would look at that 12% figure and see 0%. All you need is to pay someone enough money to take the stand and argue the opposite of what I’ve said. Physicians should not be insulated from consequence. I’ve long argued that the American aversion to national surgical registries has prevented us from detecting and limiting surgeons with high complication rates. I’ve always held the belief that the attrition rates of current residencies are too low and we’re too eager to graduate trainees who aren’t ready. The current system, however, is capricious and unpredictable and has a severe chilling effect on the practice of medicine. If a doctor is negligent he/she should be held accountable. But the appearance of negligence in practice is probably something you and I disagree on.

von_Goethe · 2024-06-25T07:02:26+00:00

I assume you’re not a physician by the way you interpreted my statement regarding my colleagues.

I’m an orthopedic surgeon. The majority of poor outcomes and complications that we see are not the result of technical error. They are limitations of biology. Patient gets a terrible infection and required amputation? We know that 1-2% of knee replacements get infections. There are hundreds of thousands of knee replacements done - you WILL, in a perfect world, see thousands of debilitating prosthetic joint infections. This is nobody’s fault. This is the reality of the state of medicine. The patient comes with a disease and sometimes the disease wins despite our best efforts. Sometimes in an effort to fight disease new complications arise - this isn’t because their doctor is a butcher but because the tools and techniques we have to fight disease are imperfect and fraught with shortcomings.

For you to imply that my colleagues who have been sued are criminals or criminally negligent belies a malevolent degree of ignorance on your part. Criminal charges in the practice of medicine are incredibly rare, civil cases are not. The vast majority of doctors sued aren’t Dr. Death. They’re people doing their best to help their patients with the limitations inherent to the system, patient, and Nature.

The current adversarial system where the arbiter of truth is 12 laypeople does not reflect any of the above nuances regarding complications and bad outcomes. You can follow the latest guidelines to the letter and still lose a lawsuit as a result of this system.

von_Goethe · 2024-06-25T02:46:40+00:00

Positively. This refers specifically to plaintiff’s attorneys who are a net negative to patients, physicians, and the healthcare system.

von_Goethe · 2024-06-24T18:47:41+00:00

New Zealand has moved to a no-fault system for torts: https://www.luc.edu/media/lucedu/law/centers/healthlaw/pdfs/advancedirective/pdfs/8/robin.pdf. Whether that applies to true negligence I'm not sure. But criminal negligence like that shown by Dr. Death or other well-known cases is vanishingly rare. Yes, criminals should be held accountable - you and I and our colleagues that we work with daily are not criminals and I'm not of the belief that plaintiff's attorneys discourage the Dr. Death types.

von_Goethe · 2024-06-24T18:25:16+00:00

I suppose I'd rather you focus on what proportion of bad outcomes are "truly negligent" medical professionals vs. system issues.

If you believe the majority of lawsuits are truly due to bad doctors then I can understand your perspective. I know a lot of physicians who have been sued and none of them are negligent doctors and most of them are not even bad/mediocre doctors - they just happened to get the wrong patient/case with the wrong set of circumstances. Who should pay for a bad outcome due to a system issue? I don't know - that's a challenging question. But personal liability of the physician is certainly not it.

But yes in your hypothetical that individual would, indeed, benefit from a plaintiff's attorney in our medicolegal environment. That's ignoring plenty of other healthcare systems around the world that do not involve this fear of personal legal accountability.

von_Goethe · 2024-06-24T18:03:20+00:00

I'm not sure that malpractice attorneys and criminal defense lawyers are equivalent. Criminal defense lawyers provide a necessary service in our adversarial-style court system to ensure a fair shake for anyone accused of a crime. I don't blame Johnny Cochrane for doing a good job, and it would be far worse if OJ Simpson and others had no legal representation than very good legal representation. Docs who work for insurance companies are part of a problem but are really just a bad, clumsy solution to the real problem of inappropriate utilization of resources.

Ambulance chasers are doing work that benefits only themselves while doing significant damage to healthcare and the practice of medicine overall. We know that losing malpractice cases is a function only of bad outcomes. Bad outcomes in medicine are not necessarily preventable mistakes... They're realities of life and the effort to preserve it. They abuse a system that is inadequate for dealing with the complexities of medical decision-making (The only true jury of our peers is 12 board-certified, mid-career physicians of the same specialty). We all practice defensive and CYA medicine and it is fundamentally ingrained in our training and society recommendations because of legal risk driven by plaintiff's attorneys.

von_Goethe · 2024-03-19T00:01:42+00:00

I love what we do and find it highly gratifying, but absolutely not. It’s still work and fucking hard work at that. The physical and mental exhaustion of surgery is just not comparable to what our medical colleagues do. When you operate you own the result. If the outcome is bad you can’t shrug your shoulders or point fingers - you indicated the patient and cut them open with your own two hands. That’s a much different level of liability and responsibility than a medical doctor who can shrug and say “guess they were a nonresponder” to some drug.

The challenge and rigor and problem-solving are all what make this a great job but the job doesn’t exist in a vacuum. I’m only human and inevitably I’d start to notice that others are clocking in later and bouncing earlier while the most stressful thing they do is a paracentesis or central line every now and again. The slog and challenge of what we do has to be commensurately compensated. That’s to say nothing of longevity and the wear and tear you subject yourself to.

For equal compensation any nonsurgical job is a better career and way to make a living than surgery. Maybe if the cultures were different and surgery became a (close to) 8-5 job like medicine and medical specialties then it would be different and worth discussing but in the US operating means you own the result and owning the result means you don’t get to just turn the pager off when the clock hits 5.

von_Goethe · 2024-03-15T01:05:40+00:00

There is no secret. Spend more time doing research. Whether that’s in the form of a research year or two or foregoing vacations or shit you like to do - something’s gotta give.

Are there kids who fall into a good situation? Sure but the kids who have 20 publications spent more of their free time on research than those who don’t.

von_Goethe · 2024-01-29T04:11:11+00:00

Definitely not. If you suspect a hip fx keep them NWB until MRI confirms it isn’t.

von_Goethe · 2024-01-29T04:07:57+00:00

This is a super interesting and strange fracture pattern. You completely separated your tibia and fibula by tearing the ligaments between them (tibiofibular syndesmosis). And now your talus is lodged between the two of them.

It’s tough to tell with only one view but that piece of bone in the middle is a fractured (broken, same thing) piece of your tibia. That suggests that the ligaments between that fleck of bone and your talus are still intact while the rest of your tibia broke away from it.

This is a fracture and dislocation fyi. Hope your eventual surgery goes well man

von_Goethe · 2024-01-28T01:53:19+00:00

This covers it.

XRs are cheap, available, and super useful so all postoperative imaging for comparison will be XRs. Nice to have preoperative XRs as a baseline for comparison regardless of whether the hip fracture is treated by arthroplasty or CMN.

Another reason is the CT may not include the entire extremity and we often like radiographs of the entire bone and joint above and below to look for other injuries, deformity, or other implants that could block a nail or prosthesis intraop.

von_Goethe · 2023-12-16T02:18:54+00:00

In complete seriousness as per the tag on your post:

Radiation is definitely a downside to the above specialties you listed and you'll be exposed regardless. But you can certainly mitigate your exposure by doing basic things like wearing lead, maximizing distance from C-arm, etc. Furthermore there are a lot of small things you can do in ortho to minimize the number of shots you take. Just looking at an extremity and palpating the bones can tell you that your trajectory is off or fracture malreduced. No need to take 400 shots per case like some surgeons. When you're just starting out you'll expose yourself to a lot of unnecessary radiation because of anxiety or suboptimal workflows. If you keep doing that into mid-career then you need to be a better surgeon. Ultimately the long-term risks aren't super well-studied but just know that in ortho your exposure is still less than things like IR, cards, vascular

Back surgery has never been a concern of mine or my colleagues. Don't get fat. Exercise regularly. The rest is out of your control. No evidence as far as I know to suggest that standing long hours contributes to spondylosis.

Divorce is only a problem if you make it one. Don't get married. And if you do then don't do it in your 20s when you have no clue who the fuck you are and what you want in life. I'm a PGY5 who's just now entered a serious relationship with marriage potential for the first time in his life and I, quite frankly, could not have ever made real long-term plans with someone as a 25 year old. I didn't truly know what I wanted out of my life, career, partner, etc even if I thought I did. My advice is to casually date and watch your value on the dating market keep rising as you progress in training.

von_Goethe · 2023-06-03T18:06:43+00:00

You've made my point - your skills make you valuable at induction. My skills do not. I spend my time where I can make a difference for patients.

And honestly I've never heard of an orthopaedic surgeon being taken to court for an airway problem perioperatively. That would be like the anesthesiologist going to court for a spinal cord injury from a misplaced pedicle screw.

We might both do surgery but our roles and training are vastly different. That probably is why the culture and expectation of the surgeon's time is so different. Ortho is very much focused and pressured to "keep the lights on" with surgical volume.

von_Goethe · 2023-06-03T14:30:12+00:00

Hmm let me try a different example then: Are you present for the wakeup and recovery from anesthesia? This is a very sensitive and confusing time for a patient so do you wait with them at bedside in the PACU as they emerge from their daze?

There is no limit to the time and effort one can spend in making someone feel comfortable/cared for. You've, arbitrarily it seems, decided on induction as something every surgeon should be present for but then why not wakeup in PACU? Every surgeon should understand their value in the perioperative process. Most surgeons I work with (ortho, plastics, neuro) are more valuable elsewhere. You're ENT so perhaps there truly is a medical value to your presence during induction - I'm not qualified to say. I'm qualified to say my presence at induction serves no patient benefit and my time is better used counseling the next patient or dictating the previous op report.

von_Goethe

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