Patient Conversations: What to say and not say

Chuck and Chris build on a hand society symposium led by Don Lalonde- What to Say and What not to Say to patients.  Chuck and Chris discussion tips to build the patient relationship and challenges in doing so.  We look forward to your thoughts and your tips.  We also discuss the medical school tradition of the white coat ceremony!

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Transcript

Charles Goldfarb: 0:03

Welcome to the upper hand podcast where Chuck and Chris talk Hand Surgery.

Chris Dy: 0:07

We are two hand surgeons at Washington University in St. Louis here to talk about all things hand surgery related from technical to personal. Please

Charles Goldfarb: 0:15

subscribe, wherever you get your podcasts. And

Chris Dy: 0:19

thank you in advance for leaving a review and leaving a rating wherever you get your podcasts. Oh,

Charles Goldfarb: 0:24

hey, Chris.

Chris Dy: 0:25

Thanks, Chuck. How are you?

Charles Goldfarb: 0:27

Great. I am great. How are you?

Chris Dy: 0:29

I'm wonderful. So funny story tell you. My kids, for some reason, I think they were very much like, we don't like YouTube for kids. But they've seen enough stuff, where they actually want to record videos of themselves doing stuff. And they want me to record videos of them. And at the end, they're like, please check on our channel. And like, Whoa, this is kind of weird. And then my daughter, my I was home with my daughter, and she was having dinner. And she's like, take a video of me. She's like, how do you? How do you get on the TV? And I'm like, well, she's like, Have you been on the TV? I was like, Well, yeah, she was on the TV. Like, you know, they did like a new segment about a a patient that I had a few years ago that had a bad perineal nerve injury. And we did a reconstruction and end up doing great. So there's a segment on the local news. And I was on there. And I was like, You remember when I was on TV? And she's like, No, I was like, okay, so I was like, actually, I'm on TV every couple of weeks. And so then I pulled up our, our upper hand on YouTube, and she was super impressed. So for those of you that listen to us, you can actually watch us if you want to, on YouTube and in our rapidly expanding YouTube presence.

Charles Goldfarb: 1:38

I what an easy way to impress your kids. My kids are not so easily impressed anymore. But that's great. That is that's great. I it would freak me out if my young children were I mean, even since my kids were young things have changed so much. My goodness.

Chris Dy: 1:56

Yeah, we're, we're pretty protective of, you know, posting images that we don't post images of them on any social media kind of things. And we try to be very careful about what they're allowed to view. But my parents are not as careful when they're watching the children about what I what they allowed the kids to view. So some of that stuff does leak through. And you know, that algorithm is pretty scary, to be honest with you. For

Charles Goldfarb: 2:22

sure. I am two things about for those on YouTube. I'm wearing a St. Louis City. S see. So in St. Louis. It's St. Louis City soccer club, not FC, not football club. So. But by the time this drops, I hope things have gone well, for our soccer team. It was an amazing regular season, and we hope their success continues into the playoffs. I've also gotten geared up with some nice headphones and microphone. You and I seem to alternate never do this at the same time. But hopefully our audio quality or at least mine will be better this time. All right.

Chris Dy: 2:57

Well, I think we do the recording off of your computer. So honestly, you always have the home court advantage on the on the audio. And today because I'm rounding I have I didn't bring the whole setup. But I do try to use the whole setup when I'm recording from home. Yeah,

Charles Goldfarb: 3:14

so I did. So I had a really special event a couple of weeks ago, which is I went to my son's white coat ceremony. And for those of you I think everyone can imagine what that is, honestly, I'd never been to a white coat ceremony. We didn't have white coat ceremonies back in the day. And I you know, I'm not really into pomp and circumstance. And I was kind of like, okay, you know, I'll definitely be there. I wasn't sure what to expect. It was fantastic.

Chris Dy: 3:46

Well, I mean, that's great. You should include the important detail that your son is a first year medical student that ceremony supposed to be about and why it was so fantastic.

Charles Goldfarb: 3:55

Yeah. So Jake is here at Wash U and started med school, I guess right after Labor Day has had a few tests. It is pass fail. But as my wife and I continue to impress upon him, no one wants to pass fail doctor, so don't just study to pass. And yeah, he's, you know, he's loving it. It's, it's just so interesting. It's a very different medical school environment. Today, and I think the vast majority, if not all of that is fantastic. In the white coat ceremony, they were basically there was a lot of speakers, which are the Dean spoke and the Associate Dean for education spoke that great. They were fantastic. There was a guest speaker it was fantastic. I think two things a couple of things struck me three things maybe. The first is

Chris Dy: 4:45

that the university done three things. I know.

Charles Goldfarb: 4:48

My brain can't handle more than two. The first thing is they received their white coats after all the speakers from their coach. So There are coaching groups within the medical school. And I think they looked like there was maybe 10 or 12 kids for each group. And so their coach was up there and, you know, gave them their, and put their white coat on which, you know, coaching for students, I think it's probably the right approach. People smarter than me, I put a lot of thought into this. But if you if you kind of start early with the wellness and the kind of cerebral aspects of medicine, it can only be a benefit.

Chris Dy: 5:28

Right? Absolutely. Yeah, it's a it's a long career, medical school itself. The days feel very long, but the years tend to fly by. It's kinda like residency in that regard.

Charles Goldfarb: 5:38

And child and child rearing? Yes. As I'm

Chris Dy: 5:42

fully aware, it's funny. I do see like, it's getting bigger before my eyes. And then like, if you're in the you're in the weeds on this stuff, and you're like, oh, man, it's gonna be it's gonna fly by.

Charles Goldfarb: 5:51

Yeah, it's totally his favorite statement is the days are long, especially with young kids. But the years are short. Right,

Chris Dy: 5:58

right. Well, did you so you got to see the ceremony. Yeah. Tell me your other things. Yeah.

Charles Goldfarb: 6:03

Yeah. So I got to see the ceremony. I didn't get to say what Talia because they we were only allotted two tickets. And so Talia got one and the girlfriend, Ali flew in from New York. And so that was great. And so I had to sneak in playing the doctor card. And so that worked out, thankfully. So I was able to get in the room. The room was packed. And so the two of the things that were fascinating to me, number one, the diversity of the class is astounding. Like, obviously, I knew it was going to be a diverse class blew my mind in every way. And it wasn't just ethnic or racial. It was geographic. It was everything. So there certainly were obviously a lot of us. You know, kids, there were people from across the world. There were Russians, there were Chinese. I just in this geopolitical error. I wasn't even sure that was possible. But it definitely is. And so that was that was just fascinating to me, and wonderful. And the second thing was, when I was a medical student, here we go, because it's like, oh, God, here we go. You know, it was keep your head down, speak when spoken to. And the lower the profile, the better. And that was medicine, you know, for many, many years, and it's medicines clearly evolving. And I think that is the right word. But it was it was kind of a joyous occasion. So you'd walk up to get your white coat, you sort of wave at the crowd, maybe take a selfie with your coach, and you know, there'll be some cat calls from the cat calls, right? Especially, there'll be some hooting and hollering from the crowd. It was it was it was just a very, there wasn't such a serious vibe, even though the messaging from the speakers was serious. So it was it was a fantastic event.

Chris Dy: 7:55

generational differences. So they say, yes. Did they have to do the Hippocratic Oath?

Charles Goldfarb: 8:02

They did you know, I think most men I don't know what yours was like. I'm certain that you had a white coat ceremony. The you know, I think it's an updated they wrote their own Hippocratic Oath, not their own Hippocratic Oath, they wrote their own oath and they stood and they read it it was fairly long, certainly comprehensive and really good. Really, really good.

Chris Dy: 8:24

That's great. Yeah, no, I um, yes, I did have a white coat ceremony. I still remember it in the sweltering heat of a Miami August in the research quadrangle at the Medical Campus, getting our coats which, you know, was a was a nice thing. It wasn't I don't think my parents came down because it wasn't a mountain. It wasn't a huge deal. And I didn't realize it was a huge deal. But I remember that ceremony also remember, my last white coat Sarah was actually during my residency. And this is a they no longer do this at HSS because it used to be that you didn't get your long white coat until you were a chief resident. So there was actual white coat ceremony during the residency graduation so as the chiefs were graduating, they would put long coats on the PGY fours who are still men wearing short coats which is super interesting cuz I actually wore a long coat in med school and had to switch your your short coat during during residency, internship and residency. And the person that that put on my coat was none other than Dr. Marshall Burks who was our guest about a month ago on the podcast. It is now a very dear friend. So that was that was my last white coat ceremony experience but as I learned recently at the at the HSS alumni meeting the HSS residents Now all we're long coats, so I think it's probably the only residency orthopedic residency in country where that was still a vestige of the past.

Charles Goldfarb: 9:50

Yeah, the white coats are really an interesting phenomenon. First of all, I don't wear a white coat almost ever like I almost never wear one for a lot of reasons and you The pediatric population, there's always been this sort of built in excuse that, you know, want to scare the kids. And there's some truth that I just not a white coat guy. But there used to be, you could clearly tell the ranks and at Wash U in general surgery, which was hardcore. You were, you know, as an intern, and as a resident, you always had a short white coat and you weren't 24/7 Unless you were in the O R, and you hung it on the hook outside the door to improve it immediately on. But the other interesting thing about back in the day was you never wore scrubs outside the operating room. Now we say don't wear scrubs outside the hospital. But back in the day, it was white coat and your your tie and you know shirt and tie. And again, mostly male, so shirt and tie was appropriate. Things have changed.

Chris Dy: 10:47

Yeah, one last thing about your dress before we move on, I remember as a rotating medical student that what was then the hospital for joint diseases and is now the I think the NYU Langone orthopedic hospital. But I was there rotating as a student and they were very strict. It was if you are not like you're saying in the or you had to have a white coat on top of your scrubs. And if you left the floor where the or was you had to change. So so if you for example, if you were gonna go see a patient between cases, you had to change back into your professional attire, and then go see the patient and come back and change back when they were strict. That was the culture it set the tone professionally. I don't know if they still do it that way. But maybe a listener can tell us if you're at what was formerly joint diseases, but it was it's definitely a culture center. And I think there has been a lot of change in terms of you know, what people expect their physicians to look like. I know there have been surveys about what looks more. You know, Dr. Lee, for example. And it's interesting, I've had part we had this conversation with partners where like, sometimes like you're wearing scrubs, and you're like, Oh, my goodness, did you just take some time out of surgery to come see me? Are you on your way to surgery? Thank you. Or it's like, Why do you look like a slob? Today? You're wearing your pajamas?

Charles Goldfarb: 12:00

I know, I think I've said here, you know, COVID changed everything for me because I began putting on Scrubs every day when I came to the hospital and then not wearing those scrubs home. And I continue to do that. So I must look like a slob to some and thankfully, most patients seemed fine with it. I have had a couple of patients typically older comment that I went a little casual and clinic and I just laugh. You know, the same people use a comment about my beard, you know?

Chris Dy: 12:30

I use I used to wear a tie with all the time the tie was a COVID. Casually I still wear a white coat and clinic and you know it's Yeah, I don't know if I'll change that. But you know, I think maybe, maybe one day as I develop some grades I'll change.

Charles Goldfarb: 12:47

Yeah, I don't to be very clear, because I know there's some younger listeners, I do think appearance, and the persona of being a patient's physician matters. And if we dumb it down, so to speak, or bring it down to the lowest common denominator, I think we lose something. And I am acutely aware of that, and I try to make up for my scrubbed attire. But I still take even though my practice is not it, I still think it matters. And I you know, we can complain about that. And I'm gonna get on a soapbox for a second, but we can complain about doctors place in society. But we have to own some of that. And it's just it's really as interesting.

Chris Dy: 13:36

Well, I mean, to be honest with you as the reason why I wore white coat and a shirt and tie and clinic is because especially starting practice, I looked a lot younger. And you know, that is the kind of the credibility aspect. At least you don't want somebody to question your credibility even more if you're not wearing a white coat or you're not looking like you're you're supposed to. And again, that's some of that's assumptions on our end and in trying to make sure that we're withholding kind of that place in society. But it is less common for people to ask me how old I am now although I do love it when people ask me and I take a very because I used to get pretty defensive about it. And I think I've shared this somewhere attorneys I used to get kind of like oh, you know, I get worked up about it. And I joke about my student loans and suddenly it was a fine and then now and they tell me I look young. I'm like thank you. I have been trying to sleep more jokingly say you know, these, these nighttime serums are working whatever it is so I appreciate it now.

Charles Goldfarb: 14:29

It's true. One more last thing I love that one, no one asked me because they think they think they're gonna insult me by like saying you're old. Are you young enough to be doing this?

Chris Dy: 14:41

We should thank our sponsors at practice link so the forehand is sponsored by practice link.com Those widely used physician job search and career advancement resource. Becoming

Charles Goldfarb: 14:50

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Chris Dy: 15:00

Is that backslash or a forward slash? I can. That's

Charles Goldfarb: 15:03

a backslash. I

Chris Dy: 15:04

think, I don't know, as I don't know why I haven't thought of that. All right, they're tired. The people are tired. They want to get to the meat potatoes. Chuck, what are we talking about today? We,

Charles Goldfarb: 15:15

one theme from the hand Society meeting, which seemed to be really, really well received was around tips for success. And we were fortunate to hear from our partner Marty Boyer, who was the founders lecture for President Jennifer Wolf, and shared his what he calls his 10 rules, which I wasn't a fellow under Dr. Boyer. But so I have a vague remembrance of some of those rules. But it was a very well received talk. And I was fortunate to participate in a symposium on Saturday, which was excellent. was not particularly well attended, because it was Saturday afternoon. But I thought we were going to talk about some of I'd like to talk about some of those points. Yeah,

Chris Dy: 16:03

that'd be great. Yeah, one of the one of the boiler rules of surgery in life is a try to take the early flight home, and I think that might have affected your attendance. So once everybody heard that lecture,

Charles Goldfarb: 16:15

yes, it probably did, it probably did. So to lay the groundwork for the panel, DONILON organized it and I was kosun was the speaker, Jim Chang was a speaker, and Tamara Rosenthal was a speaker as well. So that

Chris Dy: 16:36

is a high power group. So you've got two former hand society presidents one, one person who is in the presidential line for the

Charles Goldfarb: 16:43

society and then the

Chris Dy: 16:46

society. So that is a high power group. And then like The Godfather of Alana moderating the panels. So this is some this is, this should have been the most attended session in the whole darn course.

Charles Goldfarb: 16:56

It's interesting when you plan well, you're kind but you when you plan these meetings, you always wrestle with well, if I put something in, I hope this was the thought. If I put something really good later will people stay. And if you put everything good early and put the less potentially popular symposia and ICOs later, you know, does that mean people don't stay, it doesn't matter, like people just don't stay, they're gonna leave when they're gonna leave. Listen,

Chris Dy: 17:23

you know, I didn't go to the main meeting this year. But I remember last year, I got the coveted 6am, Saturday morning time slot for a research methodology ICL. I hear you in terms of, even though you think it's amazing content, and this may not have been the biggest job, but you know, people are gonna die, they're gonna be there, they're not. So you know, that's, you know, as much as your content was probably amazing. I hopefully, well, I guess there wasn't a recording this year, so at least you can distill it for us. Now,

Charles Goldfarb: 17:49

I'm going to do just that. I'm gonna start with a quote, which to me resonated, and I believe it's important. This is by Albert Schweitzer, who was sort of a renaissance man back in the day and won a Nobel Prize. But he said, Success is not the key to happiness. Happiness is the key to success. If you love what you are doing, you will be successful. And I know that resonates with you. And it resonated with me. And I'll say one more thing, and then love your thoughts. You know, when I am not happy is typically because I've had a challenging patient interaction, or outcome. And I tend to really separate that patients who may not have done as well as I hoped or thought or patients that were unhappy whether or not I felt like I did everything I could have been should have done for them. I learned from those, but those affect my happiness. And so I think if you do the right stuff, prioritize your patients, success is going to find you at least that's what I hope and expect. But I would love your thoughts on this general concept.

Chris Dy: 18:59

You know, I don't Yeah, I agree. And I don't think there's a whole lot to elaborate on that. But I think that if, you know, success is how you define it. Right. And I think that a lot of us, especially in the pursuit of getting to where you are in terms of medical training. For many of us, it is lots of external measures of success and validation. But then all of a sudden, you get into practice, and it is, yes, there are external measures of success, the metrics of some of which would include productivity measures, compensation, those kinds of things. But it seems to be that if you were in the inevitable, relentless pursuit of the RVU, you're not gonna be happy. And I think the wonderful thing is much you're talking about, you know, the lowly robot physician, sometimes now holding society. But when we think that our work is intrinsically joyous in many ways, especially I think, for those of us that have chosen to be you know, surgeons, we tend to we have a personality that tends to like to see these kinds of outcomes happen pretty quickly. Now obviously not the case for nerve but for The vast majority of what we do you help people on a tangible and substantial and meaningful and measurable way.

Charles Goldfarb: 20:08

While said, in our therapy colleagues who may be listening, they get a little something more than we do, at least I think they have, in many ways develop a closer relationship with the patient, because of time invested at therapy sessions, and can really, you know, see more of that progress, you and I get intermittent glimpses at progress, and patient success stories, but that's what matters. And again, I really do feel like that if you quote unquote, do the right thing. It really does tend to work out. And that sounds easy. It's not always easy. Time and pressures, and various things get in the way. And I, you know, I do think about what you said, I've never been one to write down five year 10 year plans. But if we're talking about career success, that is a really important starting point.

Chris Dy: 21:00

Yeah, and just to touch on your point about the, you know, the things that our therapy colleagues get out of the relationships, you know, that is, for lack of a better term, that it's quite an intimate relationship that you have, like, with all the physical touch that's typically involved with, you know, somebody who's helping a patient through through recovery, and then like the constant contact and frequency of that contact, which explains why all of our therapists get way more gifts from patients than we do, which is so funny come holidays, even the therapists in our group will come in and it's like, well, I got all these cookies, and I don't know what to do. Like, I didn't get any. I kid I kid.

Charles Goldfarb: 21:39

All right. So the assignment for this symposium was to, you know, what to say or not say to patients, and I really liked that I actually wanted to start with what to do. And some of this will sound, you know, like, you've heard it 1000 times. But in a room with a patient, I'm sure you're gonna have stuff to add, but I wanted to keep it simple. I always sit down. I and I say this carefully, because it's really important. I'm better at it today than I was 10 years ago. I listened. And sounds cheesy sounds obvious. But there's a difference between sort of listening or being distracted, or, and really empathetically listening to patients, it shows, I am way better at that today. And honestly, it's a win for me as well, because I do, I do think I connect better.

Chris Dy: 22:30

Yeah, I'm not been a good listener for a long time. And I think that the more you, because usually how our minds work, and I think our therapy colleagues will think the same way too. But at least the surgeons, as soon as somebody starts talking, your job is to hone in on a diagnosis and come up with a plan. And oftentimes it is those first few sentences that give it away. And then the temptation is, you know, in the studies only show the physician interrupts somebody within the first 30 seconds or whatever. Because I kind of know what's going on pretty quickly. For the most part, I kind of want to move on to my exam and stuff. And it's like, really taking the time, even if it is an extra 20 seconds, just making people listening first and foremost, but then also making people feel heard and listened to. That's a total art. And I think the tricky part about our patient clinic encounters is that there's such a high bar that we need to meet in such a relatively short amount of time. And honestly, as hand surgeons, we don't need that much time. So yes, we're scheduled because honestly, you don't need a ton of time with most patients, at least that that initial part. And then it is trying to get that personal touch of understanding their goals, setting expectations, coming up with a mutually agreeable plan. Although typically, for most surgeons, were kind of steering that conversation. All

Charles Goldfarb: 23:48

really well said I. The one other point, which I know you will agree with is that you don't you know, at some point, sometimes you have to stand up and bring things to a close. And that doesn't have honestly happened very often. But for whatever reason. And I really tried to ask patients at the end of each visit, and I brought this up with my son who had a had a, you know, medical school encounter that a plant patient encounter and the feedback he got was, you did great. The only thing you didn't do is ask me if I had any questions. And I said to him, I don't ever say it that way. I don't ever say with my hand on the doorknob. I don't I always say seated. What questions do you have? Not? Do you have any questions and that's subtle difference. But it's a very different statement. That patient here patient, I

Chris Dy: 24:34

guess I learned I guess I learned it from you because I kind of do the same thing. I say What else can I What can I answer for you? You know, because if you ask, Do you have any questions? It's just it's a binary kind of closed question. closed ended, you know, answer. But if you leave it open, I think it helps a little bit. And again, you can't do it on the way out. Although sometimes I really want to be

Charles Goldfarb: 24:56

honest with you. It's true. It's true. All right, what does Say so

Chris Dy: 25:01

hold on before we move on to that. Why don't we thank our sponsors at checkpoint and I will let you read the first part so you don't have to pronounce the thing and the second part you know

Charles Goldfarb: 25:10

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Chris Dy: 25:33

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Charles Goldfarb: 26:00

Thank you, you saved me, I would have made a complete asset myself. That

Chris Dy: 26:04

was gonna laugh when she

Charles Goldfarb: 26:07

Alright, so what to say. And then I have a what to not say section. And this is this is interesting, because I think I like to emphasize to patients and perhaps us more to certain patients in the recovery, whether it's post operative or whatever. I like to remind people when they are doing well. Now, if they're not doing well, I don't tell them you're doing well. But I often just say the simple line, I'm glad you're doing so well. And patients, you know, I think they have intrinsic expectations? Of course they do. We have the benefit of seeing lots of patients with a particular, you know, injury or malady or whatever. And so I think I can honestly say that, and sometimes it's important for patients to hear do you do that?

Chris Dy: 26:52

Yeah, I think so. I mean, especially with the, you know, usually for fractures, it's pretty consistent where people should be after afterwards, you know, oftentimes our therapy colleagues will give us a sense of where people are. So I think it's good to get a sense of that, if you can, from notes or from, you know, updates from the therapist. For nerve, it's trickier. And patients have no idea what they're supposed to be where they're supposed to be. So having something grounding them saying you're doing okay, or don't worry, it's way too early to expect to see anything, I'm doing these exams mainly, so I can just check but I wouldn't expect to see anything for another so and so months, in reminding them like, that's actually whatever's going on right now is good. Like if they're having a change in their, you know, pain, or they're having cramping their muscles just in the nerve kind of space, like these are good things. So don't be alarmed. And actually, you're able to turn that turn that around and message that in a way that is encouraging. But yeah, absolutely. I think it's helpful to provide updates the patient's on kind of where they're supposed to be, because they have no idea in terms of, you know, what, what to expect, unless they've had, for example, like a contralateral surgery, like they've already had one cubital tunnel surgery, so they know what to expect for the other side. Yeah.

Charles Goldfarb: 27:58

And the classic one for me is just a radius thing. You know, the destroyers can be solidly healed, they still have owner side of wrist pain, so we have to remind them of what that means. The challenge with bilateral stage surgeries is that

Chris Dy: 28:11

I tell I tell people that like when I say even holding like, Look, you kind of know what to expect here. I will tell you, no to No, no patient has ever had the same experience on both sides.

Charles Goldfarb: 28:21

Yeah, and I always add, I hope that this has a little easier than the last but it might not be. All right, the next one. And I know that you and I agree on this, I feel really strongly the longer I do this job, the more strongly I feel, is essentially say something like my job is to outline your treatment options. It's not to tell you what to do. Of course, we as physicians can say things how we want but I think that's important. I don't unless a patient says doc, what would you do? What would you do if that was in your family? What would you do if this was your kid? I will answer those questions. But I just tried to give patients options. Yeah,

Chris Dy: 28:59

I remember. I remember, Dan was saying when he was still on faculty here at Wash U. I remember seeing patients with him, and he was still relatively early in practice. And he was like, Well, why did you say this was like, Look, I give him the options. You give him the menu. And I think that some patients, most patients like that. But there are still some patients say, Doc, what would what would you do? You're the doctor, I'll do whatever you want. How do you approach that? Do you truly think about it from what you would want or from what you think is best? Are you still paternalistic in terms of what you think this patient would want from your likely very limited interaction with them? Yeah,

Charles Goldfarb: 29:34

I think in many situations, that's not hard, and I do have an opinion. But if I don't, if I either don't know enough, then I'll ask questions or if I just don't know that there is a right or wrong choice. I'll say that. I don't mind giving my opinion. I certainly will give my opinion. But if I don't have an opinion that I tried, I just am honest about that. I might say I might not do option three or four, but one and two or, you know, whether it's a kubaton, decompression or transposition, the you know, there's pros and cons, and here's what they are. And I think ultimately, you have to choose what makes sense for you.

Chris Dy: 30:11

I think it's so tricky to try to put yourself in the patient's shoes, I think that's where the listening part comes in. And, you know, in terms of at least it for fractures and stuff, that tends to be a little more straightforward in terms of how they hurt themselves, and what their eventual goals are, and the timeline for those goals. You know, if somebody hurts themselves playing pickleball, and they want to get back to playing pickleball right away, even if they're a little bit older, I may really consider fixing their distal radius fracture, because that's an active person who wants to get back to doing active things. And that makes me think, like, alright, this is somebody who probably would benefit from surgery more than somebody else. But then you look at some of the more elective type, you know, things like you're saying, cubital tunnel surgery, I think everybody's appetite for risk is different. And trying to understand somebody's somebody's risk calculus is very, very challenging, and to limit interactions we have

Charles Goldfarb: 31:01

that's challenging and understanding or predicting pain is challenging. And I'm upfront about both of those. Right? I don't I don't try to predict pain. I explain that to patients. But that's that's exactly right. I see it the same way.

Chris Dy: 31:14

Like, you know, just I guess one more thing, like along those lines, like one example is that like for a stable all learner, but somebody who has cubital, tunnel symptoms that has had, you know, has tried non operative measures, and still has persistent symptoms, you know, your risk of having a second surgery after an insight to cubital tunnel decompression is probably somewhere between seven to 20%. And, but it's much quicker recovery. And so it's like, Well, do you just want one surgery to be done forever, but have a longer recovery versus there's a chance you're gonna need a second surgery, even though patients who have a second surgery may not do as well. So it's a little bit more nuanced? I mean, that's the kind of quick decision that we have to make in clinic when somebody asks us, what would you do if it was you? Or what would you do for me? Yeah,

Charles Goldfarb: 31:57

going totally on the wrong direction on this, the more I do transpositions, especially subcutaneous with the fascia cutaneous flap, the more I think the recovery is not bad. And patient patients tend to fly through another episode. My last what to say is, I say something along the lines of Look, I can't look you in the eye and promise that this surgery that we've discussed, will cure you. I just don't know that. But what I do know is that I wouldn't offer this as an option for you unless I thought it had a reasonable chance to be to be helpful.

Chris Dy: 32:30

Yeah, totally. I totally agree with that, you know, and again, we're gonna get in trouble for agreeing with each other too much here. But I think it is kind of a personality thing, in terms of how we approach these interactions, but you know, I wouldn't offer them something that I don't think would help that. So I think that, you know, you do kind of make these quick decisions, as you quickly get to know somebody. And if it doesn't make sense for them to have surgery, even though their x ray and their textbook and the indications are textbook, say, Look, I don't I don't really think you should have this done. And I think it is very, very powerful. Or at least it should be when a surgeon tells you that you should not have surgery. You know, I don't know if it's true in the reverse. But if somebody tells you who makes a living doing something, tells you you shouldn't have surgery that I think is very influential. And

Charles Goldfarb: 33:17

I say it, I'm sure you do, too. I say that say, Look, I'm a surgeon, I make my living doing surgery, I don't think you benefit from having surgery, I hope you understand that. I'm just giving you my honest opinion. And for some patients, they need to hear that for some patients, it's still not enough. Right?

Chris Dy: 33:33

I think there are a lot of different ways to approach it. I think one of our other partners is very much you know, more paternalistic, the longer that they practice in terms of, you know, kind of saying, Look, this is what I think you should do, and you're, you know, you're wrong, you're not going to do what I want. And I get that too. Because oftentimes, patients don't know what they don't know. And we do have so much a bigger wealth of knowledge and in so many other people, in terms of, you know, what we understand and how we predict what how somebody is going to do so I can totally see how if that is not the right approach for for some of our listeners, too.

Charles Goldfarb: 34:07

Yeah, exactly. There's two words I don't like to say. And the first is maybe stimulated by my wife, I don't like the word find, actually looked it up and find can if you look it up in the dictionary, it can mean really good, extraordinary even. But I don't think that's the modern day connotation. I think fine means okay. So I often catch myself after surgery, I'll go talk to the patient in the family. I'll say your surgery went fine. And then I'll actually stop and I'll correct myself and say, Look, I don't like that word. Your surgery went as well as we could have expected or went perfectly. But fine to me is a level below so I don't use that word anymore.

Chris Dy: 34:50

As as one of my mentors in residency would say and he was John Healy always had these kind of seemingly off the cuff but incredibly profound sayings because probably because we were in Clinica like 11pm, but it was Words have meanings meanings, have words, use them both appropriately. And that just stuck with me. And I think it definitely matters, the language that you use. And I think that the precision in which we use that language is super important. Yeah,

Charles Goldfarb: 35:18

and the other one is fix. Now, I'm from Alabama. So sometimes I might have said,

Chris Dy: 35:25

this podcast, and I, but

Charles Goldfarb: 35:27

that's not what I mean. But again, my wife, she hates fixing she hates my shirt, like good. I know, I've said that. But no, I don't like it when and I usually don't say it, but patients will say back to me. And so I was in a conversation last week. And I said, you know, we're going to, you know, repair your distal radius fracture. And they said, Well, when you fix my destroys fracture, and I said, I don't love that word. Here's why I don't love that word. Because it implies like closing a door, you know, you're gonna fix it, it's done move on, everyone's happy lives happily ever after. It's just too final for me. So I don't use the word fix. Yeah,

Chris Dy: 36:04

I think along those lines, what I one word, I will not say or I will correct patients, if they bring it up is perfect. Or same, because it's never perfect or the same after an injury or after a surgery. And I think that is somewhere if you especially for again, getting to my space of nerves, if you message things correctly, from the beginning about how this will not be the same as it was before, it will not be perfect. That won't be the same as the other side. That is such a critical part of the messaging and messaging to get done at the beginning. And you have to do it delicately. Because you don't want to deflate hope. So it's all about how you say these things, and how you how you put together the sentences in the encounter, and then repeat, you know, repeating that messaging over time, because oftentimes, they stop listening to you. Because you've told them some other thing that's, you know, kind of devastating. Yeah,

Charles Goldfarb: 36:55

that's exactly right. My last one, and you're not gonna have this conversation forever. And maybe we should do a follow up episode at some point. But when patients ask, you know, for me, there's so many athletes in my clinic. And it's always when can I get back to play. And it's just another thing you cannot promise, you can give your estimate. And I you know, parents hear what they want to hear, especially with the adolescent elite athlete. Trainers hear what they want to hear, and agents hear what they want to hear. So I think we have to be very specific. And always err a little bit on the long side, because you look good. When you get them back faster. You don't look good, if it takes them longer. So everyone's different, the recovery will look different. There's things we can anticipate. So I am purposefully a little vague, but not intentionally prolonging things, but just a little vague.

Chris Dy: 37:39

Yeah, no, I agree with that. I think that he'll getting back to your point about, you know, patients don't quite have the compass that we have. And enough, you know, the reverse of what you're saying is that patients oftentimes will, will not use their extremity as much as they probably can or should, because for fear of hurting themselves or hurting, hurting what we what we help them accomplish with surgery. And I think that the close I think one of the things that I picked up from Hardy was the saying, you won't hurt it, it might hurt you in terms of recovery. And for something as simple and not simple. Simple is also another word I don't like to use, straightforward as you know, carpal tunnel or trigger relief. Oh,

Charles Goldfarb: 38:19

well said and I agree with both those simple is not appropriate. In fact, for I call syndactyly. Either cutaneous or complex, simply we use the term simple for syndactyly. There's nothing simple about syndactyly. So that's a great point. And I also use that whether it's funny when Marty was giving his talk, I I use some of the expressions so often I think they're mine. And so I wonder whether he's stolen from me, but most likely I stole it from him. It doesn't matter but the it might hurt you but you're not going to hurt. It is a really good one.

Chris Dy: 38:51

All right, well, this was fun. Hopefully, you know, our listeners, whether you're a therapist, surgeon, resident medical student fellow, if you picked up something that that you can use, and please feel free to tell us if you have some insights or you vehemently disagree with with anything that we've said so Han podcast@gmail.com Yeah,

Charles Goldfarb: 39:09

we would love to hear your thoughts or your sayings or your not saying I would be awesome. And again, maybe there's another episode here, but super fun learned as always, and have a good day. You too. Hey, Chris, that was fun. Let's do it again real soon.

Chris Dy: 39:24

Sounds good. Well, be sure to check us out on Twitter at hand podcast. Hey, Chuck, what's your Twitter handle?

Charles Goldfarb: 39:29

Mine is at congenital hand. What about you?

Chris Dy: 39:32

Mine is at Chris de MD spelled dy. And if you'd like to email us, you can reach us at hand podcast@gmail.com.

Charles Goldfarb: 39:40

And remember, please subscribe wherever you get your podcast

Chris Dy: 39:43

and be sure to leave a review that helps us get the word out.

Charles Goldfarb: 39:46

Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand. Come back next time