The Upper Hand: Chuck & Chris Talk Hand Surgery

Chuck and Chris talk cases and listener emails

July 10, 2022 Chuck and Chris Season 3 Episode 26
The Upper Hand: Chuck & Chris Talk Hand Surgery
Chuck and Chris talk cases and listener emails
Show Notes Transcript

Season 3, Episode 26.  Chuck and Chris return home and back to the familiar format.  After catching up, we dive into cases before pivoting to listener emails.  We close it out with pearls for the upcoming oral boards (although the tips apply to any question and answer session).

We plan a newsletter launch soon.  Subscribe here:  https://wustl.us6.list-manage.com/subscribe?u=c6fe13919f69cbe248767c4e8&id=10e0c1dd85 

Survey Link:
Help Chuck and Chris understand better what you like and what we can improve.  And be entered for drawing to win a mug!  https://bit.ly/349aUvz

As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
theupperhandpodcast.wustl.edu.  And thanks to Eric Zhu, aspiring physician and podcast intern.

Charles Goldfarb:

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

Chris Dy:

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

Charles Goldfarb:

Please subscribe, wherever you get your podcasts.

Chris Dy:

And thank you in advance for leaving a review and leaving a rating wherever you get your podcast.

Charles Goldfarb:

Oh, hey, Chris.

Chris Dy:

Hey, Chuck, how are you?

Charles Goldfarb:

I'm good. It feels like we haven't been together like this in a long time.

Chris Dy:

Yeah, we're back on Zoom. And we have some more video to power or ever so popular YouTube feed. You know, I think some of the comments are from bots. But there are some really nice comments in there, too. We'll read one of them

Charles Goldfarb:

Love it. Yep. We have both been traveling a later. lot. And I'll tell you one thing which you may or may not have heard, which I think is pretty funny. I though don't have the details, we may have to report back to the pod. You know, our residents did their annual roast. You may know more about this than I as you're laughing. So the residents get together, which is a great tradition. And it's only residents and attendings, no spouses or significant others. And over a couple of beers, they roast one another and roast us and unfortunately I couldn't make it this year. But I heard the theme was the upper hand podcast.

Chris Dy:

A play on the upper hand. So yeah, I actually have not seen it. I got a sneak preview of some of the some of the context, which I thought was pretty interesting. I look forward to hearing it. The residents fantastic. Future hand surgeon resident on your service right now. Dr. Elizabeth Grasser told me that she wants to have a personal screening of this roast with with you and me. Because I'm sure there'll be some kind of reaction video that'll be filmed.

Charles Goldfarb:

I am all in and I think it's very creative, which you know, is not necessarily my strength, and I'm really sorry, I missed it.

Chris Dy:

Yeah, well, I'm missed it because I was traveling as part of my ASSH Gelberman Fellowship, which a trip to the Mayo Clinic, which was delayed from 2020 Only by two years because of COVID. And finally was back able to get back on the road. So as as we were being roasted, I was sitting in the hotel room getting ready for this trip.

Charles Goldfarb:

And to show how kind of distant I feel from you. The only reason I knew about that was your post on Instagram. And so it looked like you had a good time in Rochester, Minnesota.

Chris Dy:

Yeah, it was great. You know, so, you know, actually, surprisingly, when I offered to my wife, you know, hey, I'm gonna go up to Mayo, from Sunday to Thursday morning. Do you guys want to come for the weekend before to Minneapolis, she actually took us took me up on that. So my wife and my two kids came to or we all went up. We flew up to Minneapolis on Friday night, and had a great time up there. Ate a lot of really good food. I had no idea there was such fantastic food in Minneapolis. So shout out to anybody up and in the Twin Cities. And so they took a flight home, I took a car to Rochester, Minnesota and had a great time there.

Charles Goldfarb:

I love it. That is awesome. You guys are really good about getting out there and not just recovering on weekends. And you guys are really good. I admire how engaged you are and the travels you guys take as a family.

Chris Dy:

We're trying obviously, it's been hard for the last couple of years to get out there. So it's almost like just like a lot of people around the country. It's this bolus of travel, trying to get as much as you can in. Right now I really feel like I need a weekend to recharge but no rest for the weary.

Charles Goldfarb:

So what's next?

Chris Dy:

Yeah, so I am actually I have a short work week this week. So we're recording this in the week of July 4. So obviously Monday was a holiday for all of us. And then I am taking tomorrow off.

Charles Goldfarb:

And what are you doing with tomorrow off?

Chris Dy:

I don't know if I should be telling this to our Executive Vice Chair. But I am taking a personal day because one of the tips from our partner Marty Boyer was to really prioritize your kids' birthdays. So while the kids are still young enough, obviously now it's summertime, and we'll be pulling them out of camp. But I've taken the day off on my kids' birthdays.

Charles Goldfarb:

Wow. And what are you going to do on this? Or how are you going to celebrate?

Chris Dy:

So on back in May when it was my daughter's fourth birthday it they both happen to fall on Fridays this year. So you know, I cancelled my clinic and we had a daddy and daughter day. We did all sorts of stuff including the zoo and pizza and various treats of sorts. And it was it was really really fun. She probably will never remember it, but I have great memories. And then tomorrow I'm taking the day off. And my son has planned out an entire day and we had to whittle down the list, but it includes going to the zoo, going to the aquarium, going to the Science Museum, getting pizza, getting treats, and I had to actually take the bowling alley arcade and Top Golf and move it to Saturday, because it was just too much. That's just cannot do it actually. Really wanted to put a cards game in there at the end of the evening. But my wife said she had a hard no on that

Charles Goldfarb:

So is Tiffany also taking a day off, or is one. this just the dad?

Chris Dy:

No, she's she, you know, this is this is my thing, apparently, for better or worse. But.

Charles Goldfarb:

Yeah, so I was gonna say Rafi has, I guess it's not such an uncommon perspective. I mean, why limit a birthday celebration to a day. My wife has a big birthday coming up. She would kill me if I said exactly what birthday that was. But she has a big birthday coming up. And it's not a day. It's not a weekend, week or a month. It's the Year of Talia. And, and she was inspired by a good friend of ours who made it the year of David and lots of travels. So I have some pressure coming my way to be available.

Chris Dy:

Yes, you do.

Charles Goldfarb:

And we have big plans. We've never been to professional tennis tournament, and she really wants to get to US Open. And there's some other crazy stuff. So I feel your pain. And it's a good day.

Chris Dy:

US Open is amazing. I remember going there, I think the last two years of residency in Manhattan going out to Queens. And it's an amazing thing. If you don't have great seats. It's just such a fun experience. Yeah, you guys are gonna love that. It's tons of fun.

Charles Goldfarb:

Yeah, I don't know that I can sit for multiple days like she can. But it'll be fun. Nonetheless, it'll be fun.

Chris Dy:

Well, so I'm curious. So if you have to cancel a clinic day, it actually really bothers me to cancel the clinic day, especially when my other clinic days already gone for a for a holiday. So I actually ended up putting on a clinic yesterday, which was not my normal clinic day. And our hand therapist said, one of the hand therapists that works with me, she was like, remember when you just used to take a day off to take a day off? I was like, No, I kind of got obligations, I kind of have to keep this thing going. So I really need to be better about truly taking a day off and not just filling in some

Charles Goldfarb:

So it's a great point. For our listeners, other time. I'd be curious if any of you guys want to reach out and share your philosophy, because like Chris, I miss my big Monday clinic. And so I thought well, I should probably just do a quick post op clinic today, which is Thursday. And that was the plan that you know, like 10-12 patients, that I just needed to see. Well, that ballooned in the half day to 30 patients with a bunch of news. And thankfully, it went smoothly. And a number of surgeries came in and including some you would like. But yeah, I was just enjoying the fourth and not trying to make up for it.

Chris Dy:

Yeah, I told I think it's a total pathology. So then I complain about it. And then somebody says, Well, you actually chose to do this. You know what, you know, you're right. I'm trying to jam a five day work week in three days. And, you know, it's just busy. But that's okay. I did ask for it. Yeah, I'd be curious to hear what other people do. I was told, I think maybe by you that, you know, it's much easier to cancel a day of cases because it's just less people. As opposed to when you're canceling clinic. And and obviously, changing a clinic has implications on your practice building, etc. So when you're at my phase, and it's still, I think, pretty critical. I still like to have a clinic at least once a week, if I can, if I'm not out the entire week.

Charles Goldfarb:

Yeah. And look, one of the other wise things my wife has, is that look, if you ask for something, or you asked for a position, you know, she'll listen to me gripe occasionally or just, you know, whine, but ultimately, it's, you know, we make our own choices.

Chris Dy:

Exactly, exactly. So listeners are getting insight into who we are, and the decisions we make. But yeah, we can so we should talk about the visit, and the Gelberman travels at a different point. And because I think there's a lot I've enjoyed and learned about before we have a cool, really cool episode today. We've gotten some really great emails in the last month or so from listeners. So thank you to everybody for sending in those emails. Before we get into mostly non clinical topics. I was wondering, Chuck, if there's an interesting case you wanted to share that might be a nice way to get started?

Charles Goldfarb:

Yeah, I did have an interesting case. And I want to just be a little vague about it. But they had a very nice lady who, several years ago I excised a fibrous lesion from the volar surface of the finger. It came back benign. And it recurred. And it was palpable, nothing dramatic on clinical exam. I didn't image it. But what was interesting is, it was volar. It was adjacent to the flexor sheath originally but didn't really impact the sheath. And when she came back, you know, it was recurrent in a similar location, and she developed a significant swan neck deformity. So we took her to the OR and did a much more extensive volar approach. And this lesion, still appeared benign, was multi lobular, and had significantly affected the FDP tendon. It was still at least 50% intact, but it did not look good. So I debride it extensively. I opened a four and a five pulleys left everything else intact. Sent it to methodology, of course again, and then I went ahead and treated the the swan neck deformity with a lateral band transfer, which is a procedure I love, where one takes one of the lateral bands, and brings it forward to the axis of rotation that PIP joint to help prevent that hyperextension of the PIP joint. And patients generally do really well with it. So it was just super interesting. And I haven't seen anything quite like this. I'm not, it'll be interesting to see if the lateral band transfer helps the distal joint. I think it'll help the PIP joint. But some of this is just pathology related to the FDP tendon. So super interesting.

Chris Dy:

Interesting, two things, as you would say, lateral band transfer, is that better performed the way? And how instantaneously do you see an improved improvement in at least that PIJ hyperextension?

Charles Goldfarb:

I've never done it awake, it's often in a younger age group for me. And sometimes CP patients, I haven't had trouble balancing it because part of the trick is in the OR achieving a resting posture and slight flexion with the ability to passively extend fully, but just to kind of spring back mechanism. And then our therapy colleagues are key. And so I generally let them rest for a couple of weeks. And then at about two weeks, I put them in a dorsal block splint like we might do for a PIP dislocation. And I block them and about 10 degrees of flexion. And when all said and done, they end up between zero and 10 degrees. It's pretty reliable. But I like the way you think and I think in the right patient, that would be a good choice to local only.

Chris Dy:

Do you think that the do you leave the DIP joint free in that dorsal blocking splint to allow that DIJ to cycle and hopefully get rid of that flexion posture at the DIJ and use those lateral bands almost like a because it sounds like you're recreating an oblique retinacular ligament or creating one because the ORL may or may not exist.

Charles Goldfarb:

Yeah, you're definitely that's exactly what you're doing. Because for those of you who aren't familiar with this mysterious anatomy of the ORL, I've never seen one despite doing lots of anatomical dissections, and in old school treatment for this was actually literally a tendon graft reconstruction. I don't think anybody Well, shouldn't anyway, and most people don't do that anymore. I like the idea. And we do get the distal joint moving early. Yes, that's exactly right. What's your second point? Or maybe that was it?

Chris Dy:

So the second one is. How often do you image finger masses because this comes my way quite a bit. And if it for me, if it doesn't look like a classic, you know, a retinacular cyst or a mucus type variant, I have a low threshold to image just because I don't like surprises. And I think it helps them with counseling.

Charles Goldfarb:

I would estimate that I do fewer than you I don't aggressively image especially if it seems like I'm going to be performing an incisional biopsy. So like, you know, some are classic, and neither of us would image I don't tend to image if if the patient wants it out. And it doesn't seem alarming. And it's the you know, the presence of pain or rapid growth. If those factors are lacking, I tend to just perform an excisional biopsy. If I really just feel uncomfortable, then I agree with you. Imaging would be helpful in this case it was recurrent. So I really wasn't necessarily worried about what it was. I don't think it would have changed my treatment. So I don't think I missed an opportunity. But it's again a fair point.

Chris Dy:

And then when do you send the specimen for pathology?

Charles Goldfarb:

The only time I don't is if I it really unless there's a ganglion cyst. Even for clear giant cell tumors and tendon sheath, I just think it's the right thing to do. I don't ever send ganglion cysts. But I don't want to be caught without having done it. Do you have the same approach?

Chris Dy:

Pretty much if it's if if it isn't exactly what I expect it to be, which Typically, it's a ganglion type variant, I will send it. And I have been surprised every now and then. And I think it does help in counseling afterwards. And I think there are obviously other reasons to do it.

Charles Goldfarb:

I want to share another quick story slash case, the case is not interesting, particularly, but one of our partners and I will leave that person nameless did a carpal tunnel release. And that partner injected, it was a wide awake, injected in the operating room and immediately started cutting as the patient described to me. And she was okay and you know, a little uncomfortable and asked for a little more medication and did fine. And really wanted to get the second side done. So I agreed to do it. And did what I usually do, which is what you do, I believe, which is in the pre op holding area, inject a little lidocaine with epinephrine, and then it's the wide awake local anesthetic, no tourniquet. And she's like, This is crazy. I don't feel anything.

Chris Dy:

Refreshing.

Charles Goldfarb:

You let the numbing medicine set up. So funny. We were joking in the operating room. It was so funny. I'm like, Oh, I care about, is you have a better outcome on this side.

Chris Dy:

Right. Exactly. For so many reasons. Yeah, no, I think that the the heart one of the hardest parts for me early on in setting up the wide awake local anesthesia tourniquet program was just figuring out how to make it work to get out to the holding area to do blocks. And so if you listened to the master Don Lalonde talk. Sounds like he gets everybody there. And I don't think he's doing the block, either is nurse or somebody else is doing the block, they're all just sitting there blocked, like 10 or 12 patients in a row. And I'm like, that sounds great. I don't have that. And, you know, I tried to do my best to have our trainees kind of focused on the surgical part of things. So just like you, I'm like doing discharge orders, paperwork, etc. And then going out and putting on a face out in the holding area to you know, get everybody ready for surgery. And sometimes that includes many times that includes doing the block.

Charles Goldfarb:

Yeah, is same same problem here. And I usually have two or three local onlys each day, I have evolved in this is a whole nother topic. But I have evolved, I push now for local only for carpal tunnels for triggers. Those are the two that I really push on. I discuss it occasionally with other things. But those two I push and I did not use to push I used to accept if they wanted that.

Chris Dy:

Yeah, I mean, I think that it's all about how you frame it. Right? So the anchoring bias, but I mean, I tell him, I do this surgery on your local. And that's, that's the default. Now that I know there are some surgeons who say I only do it on the local and I'm gonna send you to somebody else if you want it done under sedation, which maybe because they do an office space, which obviously would make a difference. But I don't take that hard line. Honestly, if somebody wants to go to sleep, I'm not going to fight them on it. I try to tell them that the convenience part of it you can drive yourself or your drive yourself home no IV no fasting and that usually sets the stage up pretty well. But there's just some patients who are just too nervous about the whole thing. And I've I used to kind of push a little bit back but I don't push anymore.

Charles Goldfarb:

No, me either. Hey, Chris, did you notice my shirt?

Chris Dy:

Oh, is that wow, it's been a long time. I feel like the you know, you're wearing your Golden State Warriors shirt. And I feel like the NBA Finals were a long, long time ago.

Charles Goldfarb:

Never stopped summer leagues on and it's great. But I had the I feel like, I don't know if I should share this or not. But hey, this is the upper hand podcast. I got to I went to Game Six of the NBA Finals.

Chris Dy:

So uh, you haven't shared it with anybody. But you shared it with me because my flight out of Providence that night was canceled and I was scrambling trying to get a flight. I was like, oh, yeah, I could fly out of Boston. And then I was like, I need to get into Boston tonight. How do I get in Boston? So Oh, yeah, Chuck's going to Boston, maybe I'll catch a ride with him to watch the game and you and you were long gone. So how was Game Six?

Charles Goldfarb:

A couple of you know statements number one I've never seen Steph Curry play in person. I'm I'm a big fan of his and the team and the team dynamic. Number two. So I love the Warriors. I just liked the way they play basketball. I grew up a Celtic fan. Now that's a little weird growing up in Alabama, but my uncle was a Celtics fan and there was not much professional basketball in Alabama. So it really was my two teams and I really was hoping the Celtics Win Game Six which would make it was in Boston and it would make for a more exciting atmosphere and then go back to Golden State and see what happens and it didn't happen that way. The first five minutes. Golden State didn't look good. Boston was all over them and the arena was going crazy. And then it was over. But even the warm ups were good. It was it was really super fun.

Chris Dy:

Did you get to catch the, did you get to catch the routine?

Charles Goldfarb:

That Steph warm up routine.

Chris Dy:

Yeah.

Charles Goldfarb:

Yeah, yeah, it was great.

Chris Dy:

What's what's the deal about, what is that?

Charles Goldfarb:

I think it's become, you know, it's become a huge if you're a Curry and Golden State fan then you get there early he does, but it's just really impressive shooting and I don't know what it's evolved from but he goes through shooting in different spots with a defender. And then one of the cooler things he does is he starts at the free throw line and you know, every shot's a swish, and he steps back he goes from the free throw line to the three point line to maybe three or four feet behind the three point line to kind of halfway between the three point line and halfcourt and then closer to midcourt, and then midcourt, hits all those shots, and then turns around and goes back the other way. And when I was watching he hit all of them but one, but the skill level is just insane. He usually shoots one from the tunnel. He didn't do that before game six, but he often makes those it's something.

Chris Dy:

One last comment before we actually get to our topic, do you you you are old enough. And I am young enough and to remember this and listeners, maybe somewhere in between or completely younger than me. But do you remember when MTV had their celebrity basketball game on the regular and one of one of the it was like crazy that you would shoot from that far back and try to make it and now it's like totally routine.

Charles Goldfarb:

Part of the game, part of the flow.

Chris Dy:

Unbelievable. I'm glad you have your Warriors shirt on. I'm sorry that your Celtics lost Game Six. But what an incredible experience.

Charles Goldfarb:

For sure. And you've had more flight trouble than I have. I've really gotten lucky. And I know that our listeners will sympathize. Flying is like rolling the dice these days. And trying to fly in last minute. It may be a thing of the past I don't know.

Chris Dy:

Well I think I paid my penance going to London, on the way back from Providence because knock on wood. This is crazy. But when I was coming back from Mayo, I actually took a flight that was their first flight of the day was gonna land at nine something and I put a clinic on in the afternoon, really rolled the dice on that one and I nailed it. I got home, I got home, I got home in time to get some work done, got a quick workout in and went to clinic. And it was amazing.

Charles Goldfarb:

That is a feel good story if there ever was

Chris Dy:

Again, again, the pathology of not being able to one. I'd be happy to after I say thank you for the very kind stop having clinic I don't know what's wrong with me. There we go. So So one thing that I wanted to do is start to look through our YouTube comments. And we have a great review from from Paulvalery Roulette. And he actually watched the episode on previewing the annual meeting in which our friends Glenn Gaston and Peter Rhee joined us and he says, May I quote five stars. This is my first listen because you had my mentor Dr. Gaston on. I already love the flow of the hosts and this will be saved to my Spotify for future listening. Keep up the good work. I also agree hand therapists are our biggest fan when it comes to online media from us - Doctor Roulette. So Dr. Roulette, thank you for leaving that comment on YouTube, we've actually got some more some more great reviews on iTunes to read as well. So I'm sure we got roasted on the resident podcast or the residents roast about reading our reviews. I can't wait to hear that part of it. But, you know, one of the things that I did talk about when I was in Rochester, at Mayo was, you know, the podcast, and it's amazing. People listen, and you know, it's one way to reach a lot of folks. And we're very fortunate for people leaving reviews and giving us great topics to discuss. So I have a topic and an email if you wouldn't mind Chuck I'd like you to answer this young hand surgeon in practice and maybe give some advice from an old man. What do you think? review. We are grateful. And Chris and I sometimes have existential crises around what the podcast should look like and balance. And Chris has got a much tougher gig than I because he has little kids in his life. And I have old kids in my life. And we that that is as we've said before, that is our fuel. So thank you. Yes, absolutely. And Chuck has the task of being the executive vice chair of a very big department. So he's got a lot going on too, don't be too modest. So this is a great email from Chase Kunker. And he has actually written us before and we know he listens. So thanks chase for listening. He wrote enjoying the podcast, what about an episode on passing oral boards, tips and tricks, horror stories over the years, what not to do et cetera and just look just in time for those taking it this year. Well, it looks like that's actually around the corner and this episodes gonna drop just a week or two before the oral boards.

Charles Goldfarb:

Wow, we should thank you Chase. We should have come up with that one. I was actually reviewing a few cases with a former fellow you might have done the same and it's a skill set. You know, I I've actually never examined because traditionally I go to New Hampshire the last week around the last Week of July, I think is probably in my future because it sounds super fun. But there's absolutely a skill set. And I do think there's some tips that you and I can go back and forth on. Does that. Does that sound okay?

Chris Dy:

Yeah, I mean, so I took my boards not that long ago since I'm a youngish hand surgeon, I think I took them, I guess, five years ago, five years ago, I think. And we were in person at the time. And I know this year, they're back in person doing in person exams. And it seems to be at least for those thinking, the ortho oral boards, not plastics, but plastics is a different experience. But if they do this in Chicago, at the Palmer House Hotel.

Charles Goldfarb:

Yeah, it's a it's a seen as an experience I, I have not five years out, I have, I've done my I guess, re-cert once, and I'm in the process of doing it a second time. So I did have to collect cases and the like, but that experience of preparing for oral boards is one that you never forget. And it's about preparation, it's about practice, it's about really mastering those cases, and putting the work in, and then generally, the results are going to be very, very good.

Chris Dy:

So for those of you that are unfamiliar with the process, at least in orthopedics, when you start practice, you've got six months to get started, then six months of case collection in which you know, the second that last half of your first year, every case gets sent, you have to send to the ABOS, the American Board of orthopedic surgery, and you have to list pretty detailed data about the patient and what surgery you did. And then you have to talk about complications, at least that's what it was back. Earlier, I don't know if they've may have changed it in terms of what data you need to include. And then from you know, that list, you submit, an orthopedic surgeon actually goes through and picks cases for further discussion. And then you get a list of I think it's about 12 cases that could be brought up, and you have to prepare your tail off and get ready to defend your actions in front of two senior orthopedic surgeons, at least, you know, I remember I some of the surgeons that examine me are some of the names that we know, throughout our world of hand surgery. So that's the process. One thing that I think you know, this isn't going to help those sitting for the Board's in the next couple of weeks. But your data collection process needs to be set from the first few months of your practice, if not from day one of your practice. Because you need to be ready to roll when it's actually time to send the data in.

Charles Goldfarb:

Yeah, for sure. For sure. And again, careful preparation. And I don't know the exact format today, you know, I had no books for each case, I don't think that's the current. It's more electronic. Today, but yeah, you have to be prepared, you have to have all the data there, you have to look like you own the material. And that's the first step. If you look like you're sloppy with your preparation, you're behind the eight ball before it even starts.

Chris Dy:

Yeah, those sharks can smell blood, it's it's pretty obvious. So you mentioned going through cases with a former fellow, I actually think I'll be doing the same thing with that fellow in a couple of days. And, you know, it's, it's important to engage with your mentors from fellowship from training. Because oftentimes, not only do you get the practice, you can blame a lot of stuff on them. How they taught you.

Charles Goldfarb:

Well, that's one of the pearls for sure. Yeah, this is you can prepare on your own, and you can do just fine. But if you can run through cases, with a mentor who has some skill with, you know, pimping and really tracking down the issues, identifying the issues and tracking them down with you. It's there's a lot of value. So let's, let's start there, let's come up with, I don't know, five pearls. So the first Pearl is, don't be afraid to of course, you want to cite the literature to defend your actions or defend your choices. But, you know, some of what we do is level five evidence, meaning it's expert opinion, and if you trained with experts, you should feel comfortable saying, here is why I chose this course of action. And then and then add, you know, I trained at Washington University, and the attendings there appreciated this approach. Now, you don't want to be arrogant about that. And you don't want to throw that in anyone's face. But it is a reasonable explanation if it can be defended, in fact, and in principle.

Chris Dy:

Yeah, I absolutely agree with that. I mean, I think all of us rely on a lot of what we do is not necessarily based on the highest level evidence and a lot of what we do is how we were taught for better or worse and, you know, as long as you can cite that in a you know, thoughtful and gracious way. I think you're ahead of the game and like you said you want to be We'll have a command of the literature, but you also don't want to throw that in people's face and come across come across as professorial. Because again, that doesn't come across the right way. You know, so I think that is an important one, too. To mention for sure.

Charles Goldfarb:

Yeah, I think the second one I'll just build on what you said is humility, you know, you're gonna have it don't always pick your cases with complications. But it's not just the cases you're defending, which require that we be humble, you know, medicine requires that we be humble, because just, when you're patting yourself on the back and thinking, you're so great, you're guaranteed to get a complication or challenging patients, but just the way you interact with questions and answers, and, you know, admitting that you do not have all the answers, and perhaps you should have considered a different track, or different course, you know, that's, that's really important, because the examiners do not want to see arrogance, and a refusal to accept that there is a different way that might have achieved a different outcome.

Chris Dy:

Absolutely, I completely agree with that. I think one pearl I would have is to be self critical. But don't bash yourself. You need to have really thought about what you could do differently. But you also need you need to own up to any mistakes that you made. Think about, you know, how would I have done this differently even for cases that went? Well? Always think about that. I mean, in Yes, of course, during board collection, during your oral boards, you're going to be at the peak of that. But that's still something where every case that doesn't go exactly how I wanted to and I do this as a teaching exercise to at the end of the case with our trainees, I'm like, how could that have gone better? Even today, just thinking about cases? How could that have flowed better? So I think being able to, you know, if somebody asks you at the end, what you learned from that case, having some good pearls, when you, when you get ready for your boards for each case.

Charles Goldfarb:

I think that's really well said, I mean, our practice of medicine is just that. And not to get too, you know, philosophical, but every day is a learning opportunity for us. And if you're not trying to engage in that learning process, then you're missing an opportunity. And that can be reflected in the boards. The other the next pro, I would say is, you know, as you're preparing, so, for example, there was a teenager with a distal radius fracture, which was displaced a bit treated in a cast patient came back three weeks later, and it was markedly displaced. And just the simplest little decision points may not be ones that you are thinking about as an a, as a, someone who's about to take the test or present. And so you know, the fellow chose to go volar. And that is perfectly appropriate. But I asked why didn't go dorsal. And we got into a nice discussion about pros and cons. And that is a very simple example. But as you're preparing for the test, the decisions that seem obvious to you might be different than the decision making process for the examiner. So you have to be prepared to a defend your choice and be understand why someone might do it differently. And that's part of test taking skills.

Chris Dy:

Right? Absolutely. And I'd like to think that, you know, all I know, are the two training programs I did for my residency and fellowship, and at least those programs prepared me for the verbal sparring that sparring is probably not the right word. But I mean, you know, that exercise of like, thinking like somebody's coming at you in conference, and in a nice way, well, not always nice, but being able to defend your actions and think on your feet. And I think that, you know, we talk about generational differences, I admit that we are gentler in conference than we used to be. And I don't know if that's a good thing or a bad thing, because maybe then you come across a border examiner who may not be as gentle. Now, maybe they're being instructed to be gentle, though, I don't know. But you know, it may not come across that way. And you need to be ready to think under stress.

Charles Goldfarb:

Yeah, that's really, really well said. And what do we do when we stress? Most of us tend to just talk, right, if I get stressed? And maybe if I'm stressed, because I don't know the answer. If they asked me to cite the literature, not sure most of us respond by battling, and that's on the ward, or that's in the OR, or that's during a test. And so that was one of the pearls I gave to our former fellow, which is don't over talk because all you do when you over answer, or try to add additional information is you give the examiner another line of questioning and you may not have said exactly what you wanted to say. And so you want to answer questions directly. You want to give substance and you want to cite when it's appropriate. But answer the question in stop. There's no crime and silence is not a crime.

Chris Dy:

Right. Well, I mean, it's it's not a deposition, but you almost have to treat it like a deposition. Many most people who are in oral boards probably haven't done many depos, but you know, that's the way Do you think about like fracture conference, like in most places fracture conference was usually the way that type of questioning and, you know, yeah, don't, don't give them any more than they need to have.

Charles Goldfarb:

They have plenty of fodder. Don't, don't give them any more.

Chris Dy:

So one additional pearl that we've kind of mentioned. But practice, like, you know, practice everything, be ready to, you know, have your X rays up like it's in a PowerPoint, like, they're going to essentially have a PowerPoint type program in the exam room, you'll have to work through your images, practice presenting the case, practice presenting the image, practice it on your own, practice it with other people that are taking the boards that year, and then practice it with your mentors. I remember sitting in your dining room, which I still cannot sit in your dining room, because there's too many memories of prior prior educational experiences, to put it nicely, sitting across the table for you, and Marty, and going through all of my cases. And that was an incredibly helpful experience to me. Because I knew if anybody could bring out lines of questioning that were out of left field, and obviously appropriate and appropriate, it would be the two of you. And that was super helpful. So obviously, in the era of zoom and FaceTime, there's no reason you can't do a reasonable job getting. Getting with your mentors, I think, you know, sometimes former fellows would fly back here to do that in past years, just to like, you know, do an exam.

Charles Goldfarb:

For sure, for sure. My last pearl, you may have one more. But my last Pearl is don't be defensive. All of the examiners have had complications, and they've had worse complications than you're presenting guaranteed, we all experienced that. And so don't you know, you have to defend your choices. Some complications could have been avoided, many complications could not have been avoided. But don't get defensive, the factual, you know, almost approach the case as an outsider. So that you can be objective as you respond to questions. And if you get defensive, that's when again, the examiners will see the blood in the water, and they'll they'll get more aggressive guarantee.

Chris Dy:

The last thing I'll say is something that we alluded to earlier, arrive early. Arrive the night before, try to don't try to thread the needle. This is one in which you just have to give, give it and enjoy the extra night in Chicago or wherever you take your oral boards. And it's the worst though it was the worst I remember being ushered into that ballroom, and then just having to wait, that was the worst. And you get the whole talk about the ABOS. Blah, blah, blah. It's It's nobody's thinking about anything else other than getting through the darn exam.

Charles Goldfarb:

Survival.

Chris Dy:

So yeah arrive, arrive early, celebrate when you're done, and then cross your fingers until you get scores back.

Charles Goldfarb:

So true. All right. Well, that was interesting, that was kind of fun.

Chris Dy:

Indeed. So with that we have some other listener grab bag, things to get to in coming episodes. We've had some great suggestions, little clinical pearls questions, follow up questions about prior episodes. So look forward to discussing those in the future.

Charles Goldfarb:

Yeah, that'll be that'd be great. Yeah, a second part of this conversation would be fun. And then we will jump back in more of our routine. But it's good to see you back on our turf. And hopefully life calms down a little bit for you, but have a good Rafi birthday day off.

Chris Dy:

I hope I survive. It'll be like running two rooms and pace will be fast all day. And to anybody taking the boards out there. Good luck. We'll be thinking about you guys. And we'd love to hear your experiences this year. So feel free to send us an email or hit us up on social media. So good luck.

Charles Goldfarb:

Good luck. Thanks, all. Hey, Chris, that was fun. Let's do it again real soon.

Chris Dy:

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

Charles Goldfarb:

Mine is @congenitalhand. What about you?

Chris Dy:

Mine is @ChrisDyMD spelled dy. And if you'd like to email us, you can reach us at handpodcast@gmail.com.

Charles Goldfarb:

And remember, please subscribe wherever you get your podcasts.

Chris Dy:

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

Charles Goldfarb:

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