Casting: the junior Ortho Pod

I had the amazing opportunity to sit down with a generational icon of Orthopaedics, Dr. Jon "JP" Warner. Dr. Warner is the chief of the MGH (Boston) Shoulder Service, a professor at Harvard Medical School, and a top researcher, innovator, and investor (eg: he helped create VuMedi - the most popular platform for virtual surgical education). He founded the Codman Shoulder Society (http://codmansociety.org/), an open forum for discussion of upper-extremity cases, business-x-medicine articles, and global collaboration. 

This enlightening conversation covers an incredible range of topics, which I will attempt to detail below. See website for full show notes & sponsor links. Personally, I found that reading Porter's "Redefining Healthcare" and reading blog posts featuring articles by Ioannidis and Krummel, are a great start. Enjoy!

MD Consultants: mdconsultants.ca code ORTHOPOD15

MCAT Prep 101: prep101.com/casting code 350CASTINGPOD

Timestamps:

2:30-4:40: Building a "brand" - how to make yourself externally desirable (eg: titles, affiliations..).

4:45-9:15: His journey to becoming a shoulder surgeon. His framework for making decision relies on analytics and intution, detailed in Simon Sinek's "Start with Why".

9:30-11:30: Critiques of the state of Orthopaedic Surgery research: relying on fragile data and Level 4 evidence to answer uninteresting questions.

11:30-12:30: Cites Paul Grammont as an example of true innovation, "thinking outside the box" requires taking what exists and building something unique, rather than simply regurgitating.

12:30-15:15: Discussing the Stanford Biodesign Innovation program, his biggest regret (prioritizing resume building over innovation).

15:15-18:30: Issues in American healthcare: rising costs are a symptom of misaligned value. "Kaiserization of American Healthcare", where doctors are commoditized and made into pawns (UPMC is a classic case study).

18:30-20:30: Wonderful tour of the greatest Orthopaedic innovators and a common theme: they all exist outside the mainstream institutions. 

20:30-22:00: Major Canadian innovations include the Tenet Spider-Arm, Dr. Danny Goel's PrecisionOS.

22:00-23:45: AI will revolutionize Orthopaedics by doing what we can do better and faster.

24:45-27:15: Defining value in healthcare: Codman found that measuring costs, treatments, outcomes, “true costs” was the key.

27:15-31:30: The crucible of medicine: Surgeons get paid to operate, and they do not get paid if they do not operate.

31:30-36:15: Case study: Martini Prostate Cancer group in Germany.

36:15-37:30: Having transparency of outcomes is the most important thing. Key outcomes for patients include reoperation and infection rates.

37:30-39:45: Most US Orthopaedic Programs don’t measure or post PROMs. Hypothesizes that it is due to not wanting to expose themselves.

39:45-40:45: Limitations of Registry data.

40:45-43:15: Canadian fellows and their penchance for innovation.

43:15-45:15: Number one piece of advice to trainees: find a mentor, someone who will help you succeed.

45:15-52:00: Legacy building, what is a worthy legacy, creating the Codman Shoulder Society

Links:

(https://hbr.org/2013/10/the-strategy-that-will-fix-health-care)

(https://journaloei.scholasticahq.com/article/17086-how-can-patients-determine-reliable-orthopedic-care)

(https://journals.lww.com/jbjsjournal/Fulltext/2007/02000/The_Reverse_Total_Shoulder_Prosthesis__The_New_Kid.1.aspx)

(https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020124)

I wanted to share some words of advice I received from Dr. James Andrews. Dr. Andrews is the father of Orthopaedic Sports Medicine, and has operated on the Hall of Fame athletes for generations. He is an inspiration to Orthopaedic trainees, and his advice is thoughtful and widely applicable. In his letter, he discusses the importance of staying disciplines, setting goals, and loving what you do.

Timestamps

:10 - Upcoming Episode

:15 to 1:20 - Introduction to Dr. James Andrews  (Podcast here: https://www.andrewssportsmedicine.com/victory-over-injury-podcast/dr-james-andrews)

1:20 to 2:15 - Backstory to the letter (Awesome article: https://www.entrepreneur.com/article/314465)

2:15 to 4:30 - The Letter (Goal Setting, Staying on the Straight & Narrow, Doing What you Love)

4:30 to 6:10 - Epilogue, How I Set Goals

I sat down with Cam Elgie (PGY-1, NOSM) for a fantastic conversation that covers:

- The immense shift in responsibility upon starting residency in the OR and ward (MS4: help out, R1: take ownership)

- The importance of humanizing patients when providing care 

- Key advice for staying well during call shifts (DRINK WATER!)

If you're going to listen to any episode, this is the one. High yield, high energy, and clearly listed responsibilities make this a must-listen for incoming R1s.

Timestamps:

0:00 to 3:00 - Unique highlights of NOSM (small program, excellent nature, early responsibility)

3:00 to 5:15 - Learning how to be a doctor (being responsible for patient safety, taking ownership of patients)

5:15 to 6:15 - Ward management (Pain, Medications, Disposition, Followup)

6:15 to 8:00 - Daily responsibilities (Rounding, Prioritizing, Organizing Dispo/FU, Preventing Complications), Keep the service moving

8:00 to 8:30 - Preoperative optimization (ABx, pRBCs, NPO, Meds), Follow patients postop

8:30 to 9:30 - Clinic (Injections, Autonomy, Documentation)

9:30 to 10:30 - Pre-OR Checklists (NPO, Meds, ABx, ACO, Cardiac risk, pRBC), Growth from Assisting to Ownership

10:30 to 12:15 - OR Mentality (Planning, Equipment, Table, Positioning, Tourniquet, Meds, TXA, Ancef, Allergies, Incision, Approach), Specifics (Incision, Retraction, Layers), Postop (Splint, Followup, Recovery)

12:15 to 14:25 - Time Management (Juggling pages, consults, cases, imaging on OR days), Teeing things up (Prioritize, Call Ahead)

14:25 to 15:00 - Having the confidence to attempt procedures, reductions, injections (Safely!)

15:00 to 16:30 - The difference between a poor resident and a great resident, treating patients like humans

16:30 to 17:45 - OR Advice: Mindful watching (Position, Body, Needle, Bite Size), Volume & Repetition

17:45 to 20:00 - Overcoming setbacks: feeling amateurish, difficulty seeing planes, having to "know everything", being handed the knife

20:00 to 21:15 - Cam's Golden Rule for Staying Well On Call!

I sat down with Dr. Tanis Worthy (PGY-1, McMaster) to discuss key topics including:

- The key to a smooth residency transition

- Changing responsibilities and perspectives

- Maintaining mental toughness - and self-compassion

Our excellent conversation details the rise of one of Orthopaedic Surgery's future stars

Timestamps:

1:00-2:45 High-yield CaRMS interview prep

2:45-5:15 How to impress residents & faculty

5:15-7:45 Relationship building early in residency

7:45-10:00 Problem solving as your new job

10:00-12:00 Projecting confidence in yourself

12:00-14:00 Staying balanced in residency

14:00-16:00 The toughest thing about residency

16:00-17:10 Final message to medical students

I sat down with Taylor Woolnough (PGY-1, Ottawa) to discuss key topics including:

- The best way to ensure that you impress residents & staff at CaRMS interviews

- The most important skill to develop early in residency

- How to project confidence to command respect in the OR

- The importance of vulnerability and resiliency in the PGY-1 year

Our fascinating conversation gives a glimpse into the thought process of a highly successful resident carving out his place in an Orthopaedic Surgery program.

Timestamps:

:30-5:00 The best way to make an unforgettable impression at CaRMS interviews

5:00-6:00 Preparation strategies for interviews

6:00-9:30 Selecting a residency program

9:30-10:30 Identifying a good residency program culture

10:30-13:30 The most important skill he learned in PGY-1: saying no

13:30-15:00 Debunking common myths: how skills and learning trump knowledge

15:00-16:00 The most important thing he'd want to hear from an applicant

16:00-19:30 The traits he has picked up from his senior residents

19:30-22:30 Cheat code for hitting the ground running in residency

23:00-26:00 Dealing with unexpected setbacks

Summary: I am joined by Jeff Kay (PGY-4) to discuss paediatric supracondylar fractures. Learning objectives include (1) identify a supracondylar fracture based on radiographic signs, (2) describe the Gartland classification of supracondylar fractures, (3) summarize emergency assessment of associated neurovascular injuries, (4) discuss closed reduction maneuvers, casting position and CRPP pin configuration.

Timestamps:

1:15 - Background & Epidemiology

2:15 - Extension vs Flexion-type

2:30 - Anatomy

3:25 - Radiographic signs

6:35 - Initial Assessment

9:30 - Upper Extremity Neuro Assessment

11:00 - Gartland Classification

12:30 - Nonoperative Treatment (Casting)

14:15 - Deciding on Operative Management

15:30 - Closed Reduction Maneuvers

17:10 - Emergency Management

18:35 - CRPP Pin Configuration

19:30 - 3-Lateral vs Cross-pins (see images in Resources)

20:10 - CRPP Pin Configuration (cont - see JAAOS paper in Resources)

20:50 - Medial Pin 

21:40 - Ulnar n. Protection

22:20 - Clinical Scenario

Resources:

Lateral Pins: https://www.orthopaedicsone.com/download/thumbnails/33687548/fig+9.jpg?version=1&modificationDate=1332443777000 vs Cross pins: https://www.cjhr.org/articles/2017/4/1/images/CHRISMEDJHealthRes_2017_4_1_43_196066_u9.jpg of Type 3 fractures 

Management of Supracondylar Humerus Fractures (JAAOS, 2012): https://journals.lww.com/jaaos/Abstract/2012/02000/Management_of_Supracondylar_Humerus_Fractures_in.2.aspx

Gartland Classification: https://radiopaedia.org/articles/gartland-classification-of-supracondylar-humeral-fractures

OrthoBullets: https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--pediatri

Summary: I'm joined by Mo Sarraj (PGY-2) to discuss hip fractures. Learning objectives are (1) accurately classify fractures of the proximal femur, (2) describe treatment options for each fracture type, (3) understand landmark RCTs in hip fracture management, (4) learn high-yield pearls for managing hip fracture patients in residency.

Timestamps:

1:15 - Background (Hip Fractures)

1:30 - Assessment

2:45 - Anatomy

4:05 - Diagnosis

5:45 - Femoral Neck Fracture (FNF) Classifications

6:20 - Pauwel's Classification

7:05 - Garden Classification

7:40 - FNF Treatment

8:30 - Stable FNF Treatment Options

10:15 - Assessing Intraoperative Reduction

11:00 - Cancellous Screw ORIF

14:45 - Sliding Hip Screws

15:00 - FAITH trial

16:05 - Unstable FNF Treatment Options

17:30 - Hemiarthroplasty vs THA

18:20 - HEALTH trial

18:50 - Intertrochanteric Fractures (ITF)

19:30 - ITF Classification

21:35 - ITF Treatments

23:10 - Subtrochanteric Fractures

24:00 - Clinical Scenario & Practical Tips

30:10 - Summary

Resources:

Hip Fracture Management Summary Paper (NEJM, 2017): https://www.nejm.org/doi/10.1056/NEJMcp1611090

HIP ATTACK (Lancet, 2020): https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30058-1/fulltext

FAITH (Lancet, 2017: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30066-1/fulltext

HEALTH (NEJM, 2019): https://www.nejm.org/doi/full/10.1056/NEJMoa1906190 

Intertrochanteric Fracture Treatment Biomechanics (IJO, 2015): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443419/ 

OrthoBullets: https://www.orthobullets.com/trauma/1037/femoral-neck-fractures & https://www.orthobullets.com/trauma/1038/intertrochanteric-fractures

Welcome to Casting: The Orthopaedics Podcast for Medical Students. This episode is an overview of the learning objectives and reasons behind starting this podcast. 

Multimedia medical education (MME) has become increasingly important in the context of the COVID-19 pandemic, representing a trend towards asynchronous and customized free online learning in medical education. Medical students are generally lower down on the totem pole in teaching hospitals; senior Orthopaedic Surgery rotations are more useful for networking, assessing program fit, and understanding the rigors of a surgical training program. 

This podcast is designed to help senior medical students make the jump to residency. We focus on the high-yield learning points for common Orthopaedic Surgery presentations. Each episode features interviews with residents to tackle educational objectives and clinical scenarios. Without further ado, here is episode 0 of Casting!