So, today we have Doctor Michelle who is a pediatric orthopedic surgeon. Tell me about what your practice is. Oh I do pediatric orthopedics and that means that I take care of children, with orthopedic injuries and orthopedic problems in both a clinical setting, as well as in the operating room. And I also get to interact with learners who are orthopedic surgery residents and pediatric orthopedic fellows who are learning about pediatric orthopedics. >> Cool. How do you know when they're ready to be entrusted. That, I think that, that is really based on familiarity. >> Mm-hm. >> And that comes to, I kind of, I gather that information in different ways. A lot of it comes through interactions in the clinic setting where we see many, many patients together and the residents will first, take a history and do physical exam. And then, really come up with a diagnosis and a treatment plan on their own. And then we discuss it together. And in that setting, I can see, I can really test out, is my physical exam match up with theirs? Does my does my diagnosis match theirs? Is our plan the same? Are they thinking or worried about the same things that I am? And so that setting helps me to understand what they are thinking and how progressive they are learning it. And also in the emergency department we take care of children which have been injured and, and they are, always important things to be remember or think about that can go with certain injuries and are they really beginning to understand and think about those things. So that helps me to understand where they are with their learning. >> Okay, let's say you have a resident or a fellow you feel like is pretty good and you want to let them have some degree of autonomy. What does that look like or how, how do you think about that? >> So I think this becomes most challenging and most important, in the operating room setting. And so we have a routine where especially for operative cases that are scheduled where we a resident is assigned a surgical case to do with me. And beforehand we have a lot of preparation. And that, I think that's where it starts. So, we talk about the procedure itself. We talk about the patient and, and what the diagnosis is, and why that procedure is indicated for the diagnosis. We talk about and look up any literature a, associated with that. >> Mm-hm. >> And we also talk about relevent anatomy and, and, and how will we do the procedure. >> Mm-hm. >> How will we arrange the room, how will we position the patient, and what could we expect? >> So, so do you do that through questioning, or do you, are you kind of doing open-ended and see what comes out, and lets you know kind of their expertise? >> it, I, tailor, I think it's pretty individual, for each learner. For the younger learners. Who are in their second, or maybe third year of their five year total orthopedic residency. For the younger learners I will maybe direct that a little bit more. lead, point to an article that they should read for this particular case. Remind them a book with the anatomy that they should review. As the learners progress through. wh, I expect them to do more of that on their own and have more resources on their be able to, to come to those resources on their own. And so, but, but there would be some questioning then, so, what have you read for this, and, and what do we need to think about? What are you're plans? >> Yeah, and it seems like it's very much surgical, but when you think about it, when you're practicing in any field that happens, so for pediatrics or emergency medicine. >> Yes. >> You're getting a sense of what do they know and not know, because that gives you a sense of how much you can trust them to do what they're going to do. >> Right, that's exactly right, yeah. And but then there are some things that I think are specific to the operating room. So how do I, turn over the reins? Or how do I let the resident really gain the experience that they need to to, over, over that five year period to then go out and, and practice orthopedic surgery? I, we do this, the discussion, that sort of planning session. Sometimes the day before. Sometimes we can do it, the same day as the surgery. And then, and then in the operation itself, I sort of evaluate how well are they executing what we talked about. How well are they positioning the patient, is it matching what we planned? and, and then in the operation itself, I try to let the residents do the safe portions of the surgery. >> Mm-hm. >> And have me, have my hands as little involved as, as needed. >> Mm-hm. >> while, while at the same time have them understand that I'm absolutely there to, to help and to, to guide. The ways I can do that are, I can hold the limb in a certain position. What that allows me to do is make sure that the resident can see what they need to see. And, and allow me to see what I need to see. It also allows me feedback, so I can use instruments, surgical instruments or my hand on the, on say a, an ankle itself. And I can fee, I can get haptic feedback. >> Mm hmm. >> I can feel are they in the right place, is the tissue moving in the place that it should. So I try to use everything I can to really, sense what they're doing and, and make sure that it's safe >> So in many ways, there, it's your eyes but their hands, so it's you really kind of doing the work but you're making sure that it's being done, safely. >> Yes, and, I'm very particular about the way we set things up in the operating room, so that everyone can see and m, most specifically I can see what the resident is doing. And that can be through a surgical exposure, but also through our use of the interoperative fluoroscopy and interoperative X-ray, so that we are sure to set things up so that we can, I can make sure that, that every step is going smoothly. >> And you, and you're, you're very careful in monitoring along the way that everything is safe and it's being done appropriately, and then you take back over, or you get more involved when things are, not the way that you would think that they should be going. >> Yeah. >> Essentially. >> And that's, a, a lot of that comes through dialogue, too. So, the, you know, I think the last piece of familiarity with a resident is, does this person really. Understand what they know and what they don't know. And can they communicate that. So as an example, a, a, a, in a case that a junior resident might perform. We describe the approach together. But he was very candid and said, I understand step 1,2, and 3. >> Mm hm >> But I don't really understand the fourth step. Can you show that to me? And so that exchange allowed me to let him do step 1,2,and 3 more comfortably. And I could very easily step in and demonstrate what we were saying about the fourth step, and then he could take over and do that. >> Yeah, and it's really reassuring that you've got a learner when they say, I feel comfortable with this and this, but I don't with that, because then you know that they're not over confident and just trying to do things that they may not really be able to do. >> Yeah, that's exactly right. The other thing that I really appreciate and try to encourage the residents is to marry what they're doing in the surgery as if they're on a cooking show. [LAUGH]. So this is where I add a dash of salt or something like that. >> Yeah. >> But, so if we are doing a surgery on the ankle. >> Mm-hm. >> Again, they right say to me, I am, here I'm looking for these three tendons and this, but I'm most concerned about the artery which I know runs between them. >> Mm-hm. >> And I'm going to very carefully dissect with, whatever tool they're using and the, that and I'm dissecting in the direction of the vessels, but not across the direction of the vessels and that, if they can explain what they're doing and what they're worried about then I can say, oh those are the same things that I am worried about and they are approaching it well. And I can let them do more. >> Mm-mm. >> If they can't really explain to me what they're doing, or where they are, or what their, what, what their goal is, or what they're worried about. Then I don't feel as comfortable letting them, explore that learning on their own, and I might do more in that case. >> That makes good sense, so that it's, it's the awareness, because when you think about it, operatively, it's the, it's the things that might get you into trouble that you really worry about. >> [LAUGH] That's exactly right. >> And it's true medicine as well, right, so for us it's what is the red flags for any medical problem, or what are the things that are going to kill somebody, and if, and if, if a resident has a pretty good awareness of it, then I feel like I can give them more reign, right? I can give them more autonomy. But if they're really not even aware of the things that they might bumble into, then that's when we have to kind of re-approach and be a little bit more careful with it. >> Mm-hm, yeah. >> So it's a, it's similar to, to other fields. That's, that's really interesting, thank you. >> Yeah, yeah. The one ,I guess the one last thing that I try to do is I, it's. I am a surgeon. >> Mm-hm. >> And I love to operate, and I love to teach that. >> Mm-hm. >> But I'd really love to just operate. [LAUGH] And so it's, I have to consciously do something different with my hands on the surgical field, so that I can allow the resident to explore their learning and to, and to really gain these skills. And so, things like holding the limb or positioning the limb gives me the chance to. To participate, to monitor, both by looking and that feedback that I get on the feeling of it, are they drilling in the right place and things like that. And, it keeps my hands busy so that the resident can be doing the procedure as well. As, as they're progressing. >> Yeah. >> And that's they're doing better, better, better, they can do more. >> Yeah. It's always tempting to like jump in and do it. Right? [LAUGH]. >> Exactly. So I actively try to keep myself participating but tied up with a different portion of helping with the procedure, so I'm not doing all of that, and so that they can experience their learning. >> Yeah, and I think we have to, because in July, July 1, they're on their own. And if we've never given them on their own, then how could they possibly practice, you know, on their own that day? >> Yes, that's exactly right. >> Great, well thank you so much, I appreciate your insight. >> Thank you.
