Residency Insight -- A PRESENT Podiatry eZine

Robert Frykberg,
DPM, MPH
PRESENT Editor,
Diabetic Limb Salvage

Experience

It’s funny how ostensibly minor things or events at the time can have such a long lasting effect on us as we go through life. Like a bad experience or outcome in your residency that can haunt you for years to come. Remember that first operative disaster or postoperative infection? Did the patient require subsequent hospitalization and did you have to eat crow and tell him/her that? Worse yet, what if the patient lost a toe after such an event? You indeed do lose sleep over such things, because you only want to do right for your patients – and when things go bad, you feel bad. How about the simple hammertoe surgery that went awry? Instead of being straight, it is now deviated laterally, because you failed to put that K-wire in the second toe PIP joint – you thought you could get away without it because you might have been in a hurry or really didn’t think it mattered. We’ve all been there and had to live with the patient’s perpetually swollen toe and questions about “How come that toe is crooked now, Doctor?” Have you ever (yet) had to continually follow up on such patients each time they come into clinic and your heart sinks when you see their name on the schedule? Before entering the room, you take a deep breath, put on a smile, and wonder what can I say to the patient this time? “How can I help him with this problem?” These are indeed “teachable moments” that we all experience and learn from (hopefully).

Did you ever wonder why your attending always cautions you to think about what you are doing or what operation you are planning for those patients? Residents seem to want to do the latest and greatest operation (i.e. triple arthrodesis, pan talar arthrodesis, ankle fusion, external ring fixation, etc.) for focused rearfoot problems or even for the relatively straightforward problem. Your attending, however, is basing his approach on years of experience and complications – recognizing that complex procedures can have complex complications. Hence the recommendation for a subtalar fusion alone at the time for that isolated subtalar arthritis might be more appropriate than fusing all 3 joints in the absence of attendant symptoms. Or, more commonly, Residents like to do more complex bunionectomy procedures because of their natural desire to acquire diversity in procedural skills. But what of that 70 year old woman with a large bunion and hallux valgus deformity? Surely an intermetatarsal angle of 17 degrees mandates a Lapidus fusion or at the very least, a base wedge osteotomy, does it not? What if her complaint is just a painful bunion? Does that complaint warrant a more involved operation with concomitant non-weight bearing and a cast for four to six weeks? Have you considered the recuperative period, relative immobility, difficulty with non-weight bearing, and the potential for a VTE in such a patient?

As has often been said, we treat patients, not just x-rays. There are many ways to approach a given condition (hence the reason why there are so many types of bunionectomy procedures). So the “art” of medicine and surgery is the ability to merge the ideal with the practical for the patient at hand – especially when there are no absolutes in terms of procedure selection. Although not “textbook” perfect, I would choose not to do the procedure that our professors might have instructed us to do for this patient at one time. I would choose what is best for the patient – I would perform a procedure or combination of procedures that would still do the job, but allow the patient to remain relatively mobile during the postoperative period. Dare I say it? A Keller arthroplasty with a distal metaphyseal osteotomy would serve this geriatric patient quite well. She could be walking somewhat right from the get-go, and would likely avoid a number of potential problems while wearing only a postoperative shoe. Granted, many would argue with me about such a procedure selection, but my experience (good and bad) tells me that this is an excellent combination of procedures for such a patient. Again, it is the synthesis of experience with the knowledge of the ideal that guides our decisions (although we have little data to support what the “ideal” procedures are for any given combinations of pathology).

Let us also consider the alternative, because simple is not always the best way to go. There is a downside to a simple approach to a complex problem – failure. In my example above, a simplified approach did not equate with a “simple” operation , consisting essentially of two osteotomies with internal fixation. An easier recovery with the aforementioned procedures would be the goal, while still correcting the underlying deformity. In contrast, a simple bunionectomy (i.e. Silver) would most certainly lead to a dismal failure and the necessity to repeat the operation in the future. Those of us who have been there and done that are quick to point out the shortcomings of oversimplification in this regard.

Indeed, experience is the fine tuning that makes us all better doctors. In your training, you must constantly read, study, and expand your knowledge, not just of foot and ankle surgery, but of medicine and biomechanics as well. Prepare for your specialty boards. Upon graduation from your two or three year Residency, you’ll think you pretty much know it all – until you are on your own and have to deal with your own disasters. Take comfort – with each major problem behind you, a little bit more is learned, and experience is gained. Anything that you can learn from the mistakes of others is a considerable bonus. These are the valuable lessons learned from practicing your specialty. You never get it totally right – that’s why they call it a Practice!

Best regards,