Dem Bones: Orthopedics Elective

     I'm already starting week 3 of my eighth rotation, but it's taken me until now to finally finish writing about my sixth rotation: my elective in orthopedics. I will admit that when I initially ranked orthopedics as a high preference for my elective rotation, I did it primarily because the rotation site was only 3 miles from my apartment, and I'll also admit that it was so very nice to have such a short commute, especially after months of commutes that usually lasted an hour (if not two) each way. However, in my life I have often found that some of the things I've done for purely practical (or at least not lofty) motives, have sometimes turned out to be some of the best things I've done. I think this was the case with my orthopedics rotation, which quickly became one of my favorites. 

     The biggest factor in my enjoyment of this rotation came from the people there. The practice was made up of both PAs and MDs, plus the radiologists, scrub techs, and administrative staff, and it often felt like a big family. My very first day I noticed the picture at right and felt put at ease by the obvious sense of humor that seemed to pervade the office. Soon I noticed more and more signs: a My Little Pony sticker on the hand sanitizer, evil eyebrows and mustache on a baby photo, even fart jokes on a calendar. I learned that practical jokes happened fairly often, and that, once everyone was comfortable with you, sarcastic and snarky quips would be headed your way. It was great. It frequently felt like I was back at the coffee shop with my wonderful coworkers there but, instead of catering to customers, I was caring for patients. It was truly the people who made this rotation so enjoyable, and after emergency medicine, where I'd had a different preceptor almost every shift (which made it difficult to know and become comfortable with any of them), it was a relief to feel relaxed and like I belonged. As I'm now looking at applying for jobs and beginning my life as a PA-C, this rotation was an excellent reminder that the people you work with can make or break a position. Before this rotation I had not been particularly interested in orthopedics, but I began to think that it was maybe something I should look into, if only so that I could work in such an environment with such people. 

Hoppenfeld's, the classic text on orthopedic
examination, has some great illustrations

     It wasn't just the sense of humor and friendliness of the office that was so appealing; everyone was eager to teach. Again, compared to some of my previous rotations, this was a dream come true. Rather than feeling like a nuisance or that my presence only slowed things down, the doctors and PAs took time to train me, going over the way they performed exams or presented patients or did procedures. I think it worked out pretty well for everyone, because by the end of the rotation I began to function similarly to one of the PAs employed by the practice. I would see patients, presenting them to my supervisor with my assessment and plan, and would move on to see the next patient while they checked out my first. Then, by the time they finished, I was prepared with the next patient and could keep things moving smoothly. Obviously I was still learning and I wasn't correct 100% of the time, but it certainly boosts your confidence to have the MD or PA come out of the room and say, "I agree with what your assessment. Go give them a shot/PT referral/prescription/etc." If I was off, they always made sure to explain why they thought differently and went over any exam findings I missed or extra tests I could have done to get a better differential. It was excellent. 

This doctor looks way too pleased to be
palpating some glutes.

     Another things my preceptors did wonderfully? They made their patients active participants in their care and made sure their voices were heard. One thing you definitely notice in medicine is that patients can often fall into one of two extremes: either they have little to no trust for any clinicians (sometimes reasonable, and sometimes not), or they put all their trust in their clinicians and prefer not to make any decisions themselves. There are frustrations to dealing with both kinds of patients, but whether the patient assumes that a provider is only suggesting a treatment because they're greedy and want money, or the patient is prepared to let the provider make any and all decisions, it's important to hear from the patient and get a sense of what was most important to them when it came to their issues and treatment. This was often obvious in orthopedics. If a patient came in with horrible arthritis of their knees, we could be fairly certain that NSAIDs and cortisone injections might help to keep the pain under control, but they wouldn't cure the problem, and that a knee replacement would probably be needed in the future. The question was most often when, not if. However, the timing of such an operation was not really a question we could answer. We needed to know if the patient could take time off from work, could get help while they recovered, and if the surgery would allow them to continue to participate in the activities they enjoyed. The question tended to come down to "how does this pain affect the life of the patient, and when do the cons of the surgery become less than the cons of life without it?" Only the patient could answer that. We could provide information (e.g. how long the recovery time was, what the chances of improvement were, how long the alternative therapies might work, what activities will be limited after a replacement) and advice, but, though some patients asked, we could not make that choice for them. I really appreciated how the MDs and PAs were willing to have these conversations, often multiple times, so that the patients had a chance to ask all their questions, voice all their concerns, and express their values. It might have required more time and effort, but I think it was best for everyone in the long run, especially the patients. 

This is not normal. Just FYI.

     One last kernel of wisdom I learned during my time in orthopedics, which is relevant to both patients and clinicians, is that you "treat the patient, not the imaging." Many times we had patients who came in and thought if they just had an x-ray or a CT or an MRI, their problem would be obvious, and they sometimes became upset that we insisted on taking a history and doing a physical exam. The truth that we had to explain to them was that imaging gives us just that: an image, a picture of their anatomy. It doesn't come with a diagnosis written at the top, and even when radiologists provide a report, they are rarely 100% certain of the diagnosis. Often a read comes back that says something like, "abnormalities consistent with a or b, but c, d, or e cannot be excluded at this time. Please correlate with clinical exam." Certainly there are times when the imaging seems obvious, but even then the history and exam are important. Time after time we'd see an x-ray that showed horrible arthritis or bunions, only to discover that it was the other foot or knee, or even something entirely different, that actually bothered the patient. Sometimes we had the opposite problem: someone's x-ray seemed normal, but they were in horrible pain or had lost function of a joint. Those were often harder discussions. We'd have to explain that all imaging is limited, each imaging modality is better for different things (e.g. x-rays are great for bones but not soft tissues), some abnormalities in anatomy don't even show up in imaging right away, and that, all too often, getting the imaging doesn't change how we treat the problem. These hard discussions seemed to come up most frequently with spine patients. Those patients often had very painful problems, but the treatments we have for back issues are still rather limited or take a good deal of time, so it was understandable that they were eager to have any and every imaging if it meant finding a solution for their pain. Sadly, imaging for spine problems isn't always helpful or justified, or at least not right away, so frequently we had to give the hard and disappointing answer. Whether you're a PA, MD, NP, nurse, etc., most of us went into medicine to help and to heal, which makes it so much harder when our options to do just that are limited, or when the timeline is longer than we'd like. This is the situation we clinicians live in, however, and until someone figures out how to cure every ailment in the world, we have to acknowledge these difficult issues, be honest with our patients when they arise, explain all the options, and then work with our patients to do whatever we can to aid healing and alleviate pain. It's not always easy to do, but it can be done, as my time in orthopedics showed me over and over again. 

Lent 2016 (27/30)

     This Wednesday I will leave Oregon after a lovely Christmas break and wonderful rotation in family medicine, and return to snowy Boston. I will also be celebrating Ash Wednesday, the beginning of Lent. I grew up in "low" churches that did not celebrate the seasons of the church year, so as an adult who now tries to incorporate some of these traditions into my life, Lent can feel like a fresh and interesting way to connect more deeply with God, as well as with the Christian community as a whole. However, I know people who've grown up in churches where traditions are followed, but only after these traditions have been stripped of all meaning, joy, and purpose, and I can understand why people who have experienced this might be reluctant to participate in Lent, or anything that resembles empty traditionalism or legalism. All good things have the potential to be corrupted and twisted, and the traditions of the church are no exception. To those people though, I'd like to recommend that they give it another chance. Look into the history of Lent, its origins and original intent. See as a time of preparation, self-reflection, and joining not just in the sufferings of Christ, but in the shared experience of Christians throughout the world and throughout the ages. I'd also give the same advice to those who have never celebrated Lent before, though I'd add that perhaps it might be best to start slow and to seek guidance from those who have done this already.
     Whether you're new to Lent or have been observing it your whole life, I have a few suggestions of ways you can celebrate it this year. As I'm in the middle of clinical rotations right now and my life is pretty packed, I don't have the time to write a post quite as large as the one I did last year. Instead, I plan to update and reemphasize some things for this year, and I'd suggest that anyone looking for further ideas or guidance go to my post from last year: 40 Ideas for Lent (just be aware that some of my comments are a year old and a few cultural references I make are no longer valid) or to some of the links I include at the end of this post. I'll admit that some of my ideas for this year are colored by the fact that, for Americans at least, 2016 is an election year. To me, that makes the idea of a time of self-reflection and confession even more important than it usually is. And now, without further ado, my top recommendations for Lent this year: 

• If you give something up, make it count -This means not only deciding to fast from something that will actually be a sacrifice for you (e.g. giving up asparagus is not a sacrifice if you hate all vegetables anyway), but finding ways to take the time, energy, and money that would have gone toward your chosen sacrifice and redirect it toward something good. In the past, when people fasted from meat on Fridays (or all through Lent), they could take the money that would have been used to purchase meat and instead give it away as alms. Blood: Water Mission (who have also created a prayer book for Lent) is encouraging people to give up all beverages except water for Lent, and then to donate their saved money toward building a well in a community in Africa. If this is something that interests you, you can set up an account with them and track your donation. Other people can choose to support you and add to your donation, or, if you have a competitive spirit and prefer to make life a game, you can join with others to create a team and compete to see who can raise the most. Alternatively, the book A Place at the Table gives ideas of how to live in solidarity with the poor for 40 days, and then donate the money you save to charities and organizations who help these same people. 
• Try a spiritual discipline -The 12 spiritual disciplines suggested by Richard Foster are prayer, meditation, fasting, studying, submission, solitude, simplicity, service, confession, guidance, celebration, and worship. Dallas Willard's list is similar, but slightly different. His highlighted disciplines are solitude, silence, fasting, frugality, chastity, secrecy, sacrifice, study, worship, celebration, service, prayer, fellowship, confession, and submission. Other disciplines, like hospitality and observing the Sabbath, are also common suggestions. I wouldn't try tackling a set of twelve, or all the ones suggested here, during Lent, since there's not enough time to do them all justice and you'll just get stressed out, but perhaps you could pick just one or two to focus on. For suggestions and guidance, you could read one of the linked books by Foster or Willard, or Jana Riess' account of trying to do 12 disciplines in one year. You could also try reading just a book or two that focuses on the discipline you choose. I don't have a good list of suggestions for that yet, but I'm practicing one spiritual discipline each month this year, and with that I'm trying to read at least one book for each discipline during the month I focus on it, so hopefully by next Lent I'll have some good recommendations.  
• Read a Gospel (or four) -N.T. Wright has done three great devotionals for Lent, each based on one of the synoptic gospels, so any of the three could be an excellent choice to guide you this season. You can also choose one gospel to read on your own, or perhaps read all four. As you go through the gospels, I'd challenge you to come up with some questions to ask yourself and focus your studies. Some suggestions could be: What did Jesus focus on? Which topics did He talk about the most? With whom did He become angry? With whom was He most gentle? What practices did He follow that you wish to emulate? What aspects of your life should you change to be more like Him? As we are in an election year, perhaps you could ask yourself some questions like the following: How did Jesus interact with the government of His time? In what ways was His death driven by political motives? What would He consider to be the most pressing issue of His time, or of our time? If I heard Jesus make some of the statements made by some of this year's candidates, would that seem fitting or disturbing?* 

• Try to see another side -Lent is traditionally a time of self-reflection, and I think a large part of this can be to challenge yourself with differing views. Humans are prone to many biases, including selection bias (purposely selecting only the data with which you agree) and confirmation bias (only interpreting data in a way that fit your preconceptions), and both biases can make self-reflection and personal growth difficult (after all, why change if everyone around me agrees with me and says I'm doing everything correctly?). As a countermeasure, perhaps this Lent you could set out to purposely hear from others who might disagree with you. I'm not saying you'll necessarily change your mind, but trying to understand why someone holds a differing viewpoint will guard against the assumptions that everyone thinks as you do, or that everyone who doesn't agree with you is a fool. Whether or not your position changes, truly wrestling with the other side of an issue will likely make you more empathetic, reveal some strengths of the other view, and make you reevaluate just how valid your own position is. This seems particularly important this year. I think we'd all like a lot more respectful debates and a lot less mud slinging and name-calling out of our politicians, no matter which party you below to. So how do you do this (for my examples, I'm mostly referring to discussions of different issues within Christianity, though the principles can apply to issues in other realms as well)? One way is to pick a specific issue (e.g. non-violence, women in leadership, homosexuality, etc.) and find a book or blog written by someone whose stance differs from yours (I have suggestions for particular topics for anyone who is interested). You can also change the time period of the authors you usually read. If, for example, you normally gravitate toward Lewis or Bonhoeffer, perhaps try reading works from the first centuries of the church. If you love reading works by the Puritans, try reading some Progressive authors. You could also stick to the same time period but switch the authors, like reading the Desert Mothers rather than the Desert Fathers. 
• Visit another church -This is sort of along the lines of the previous suggestion, though the purpose would be less to change your stance on a particular issue, and more experience the varied expressions of the Christian faith and to understand that just because your church has "always done it this way" does not mean it's the only way. Many churches collaborate during Lent (like the Catholic and Episcopalian churches of my hometown that share a Stations of the Cross), so it might not even be difficult to find an opportunity to do this. I especially suggest this if you're from a "low" church and have never experienced a "high" church celebration of Lent and Easter. Not everyone likes the "smells and bells" approach, but I still think there's something significant and beautiful to Catholics performing baptisms as part of the celebration of Christ's resurrection, or the Greek Orthodox standing in darkness on the night of Holy Saturday, waiting for midnight to strike and the Light (in the form of candles held by the priests) to reenter the world on Easter morning. Experiencing different traditions might just develop within you a new appreciation for your brothers and sisters, and/or deepen your own worship.

     Sarah Bessey gives a beautiful explanation of why Lent is important to her, and provides some great resources for people looking to celebrate it, in her blog post "Why Lent is Matters to Me." For a discussion of human biases and ideas on how to see "the Other Side," I recommend this podcast episode from Don't Feed the Trolls. For reading suggestions, this post, and the comments on it, include some excellent suggestions: Lent: Book Recommendations. This website also has some suggestions specific to Lent 2010, but it's a pretty great overview of Lent and includes some excellent, and simple, suggestions: Lent 2010. Finally, here are some more book suggestions, though, with the exception of The Grand Paradox, I suggest these based on the recommendations of others, and not my own experience. 

• Bread and Wine: Readings for Lent and Easter
• God For Us: Rediscovering the Meaning of Lent and Easter
• A World Worth Saving: Lenten Spiritual Practices for Action
• Forgiveness: A Lenten Study
• Hidden in Christ: Living As God's Beloved
• The Grand Paradox: The Messiness of Life, the Mystery of God, and the Necessity of Faith
• The Kingdom and the Cross
• The Ignation Workout for Lent: 40 Days of Prayer, Reflection, and Action
• Small Surrenders: A Lenten Journey
• The Way of the Heart: The Spirituality of the Desert Fathers and Mothers
• Fasting: Spiritual Freedom Beyond Our Appetites
• Journey to Easter: Spiritual Reflections on the Lenten Season

*For anyone wondering just what that would look like, Jimmy Kimmel has done his own take, and I think by watching the video you can guess my opinion on whether or not these politicians' statements are fitting or disturbing.