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.