Episode 16, Season 2. Chuck and Chris talk about two manuscripts that we both really appreciate. The first is from HBR on Mentoring, "Making Mentorship a Team Effort" published on March 17, 2020. This article suggests that mentoring should be a team effort with a Launch Team, a Cruise Team and a Boost Team.
The other is a recent J Hand Surgery manuscript, a prospective, randomized trial on scaphoid nonunion care. by Hegazy, et al. "Structural Versus Nonstructural Bone Grafting forthe Treatment of Unstable Scaphoid WaistNonunion Without Avascular Necrosis:A Randomized Clinical Trial"
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.
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
Episode 16, Season 2. Chuck and Chris talk about two manuscripts that we both really appreciate. The first is from HBR on Mentoring, "Making Mentorship a Team Effort" published on March 17, 2020. This article suggests that mentoring should be a team effort with a Launch Team, a Cruise Team and a Boost Team.
The other is a recent J Hand Surgery manuscript, a prospective, randomized trial on scaphoid nonunion care. by Hegazy, et al. "Structural Versus Nonstructural Bone Grafting forthe Treatment of Unstable Scaphoid WaistNonunion Without Avascular Necrosis:A Randomized Clinical Trial"
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.
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
Welcome to the upper hand, 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 aspects of hand surgery from technical to personal.
Charles Goldfarb:Thank you for subscribing wherever you get your podcasts.
Chris Dy:And be sure to leave a review that helps us get the word out.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:I'm quite well and yourself?
Chris Dy:I'm doing well. Now I'm going to say we're going to talk about scaphoids a little bit in this episode. And I did listen to the episode from March of 2020. About scaphoid nonunions. And you sounded very tired in that episode. And now you're telling me you have a very busy week now. So what's going on in your world?
Charles Goldfarb:Well, I was hoping you would say we both sounded erudite and super intelligent. And our banter was very refined way back when we did this,
Chris Dy:The, you know, the banter was great. The discussion was really good. I think it was quite crisp. The episode dropped on March 9 of 2020. So pre pandemic shutting everything down. I was gonna say you sounded like you had a cold, but I don't want to stir up any drama.
Charles Goldfarb:Wow, that is super interesting. I've kind of been afraid to go back. Because not that we're so much better. But I don't know. I hope we're better.
Chris Dy:It was it was the pre pandemic era. I think that we, we had a good banter. It was very formal, and I totally get why people were saying we sounded very formal in the beginning. I think we've loosened up quite a bit since then.
Charles Goldfarb:Well, I think that's funny. I think it's like anything, right? You you're recording yourselves. I mean, we were both kind of like, what if I say something ridiculous is going to be there forever? And eventually, you're like, screw it. If I say ridiculous. It'll be there forever again.
Chris Dy:I mean, you know, just, you know, they got tapes, I guess. boys being boys, I guess you can't say that. Right. So?
Charles Goldfarb:Yeah, probably not so good.
Chris Dy:Listen, I think that everything we've done has been honest, truthful, and at least current, to say the least. So
Charles Goldfarb:And hopefully mildly entertaining.
Chris Dy:Yeah, exactly. So what's going on in your world? You said you've had a busy week. Sounds like you got some stuff you're preparing for?
Charles Goldfarb:Yeah, it's interesting. It's been a lot of department work over the last year or so. But this week, it really feels intense, because there's a number of presentations coming together. And you know, traditionally, I don't know how you work. But when I work, I put my talks together pretty early. And then I forget them. And I just leave them. And then when I'm on the plane, I review them. And maybe the night before I review it, and I'm done. And it has worked really well for me. Well, I don't know, maybe some people in the audience would disagree. But it seems to have worked. But now I have a couple recording sessions. I have a couple of live meetings this week. And and I have actually two local presentations. And so it's just bizarre that it's all come together and then next week's not much better. And then hopefully things quiet down again. It's just a weird Confluence. I don't know, how's your speaking schedule? And have you think about presentations?
Chris Dy:Well I mean I guess I wanted to ask you, were you always like that, because I know that one thing that a lot of people aren't comfortable with is giving presentations in public? And you seem like you're very comfortable talking on a podium, you know, on a, you know, for conferences, that kind of thing? Is that something you started, you know, always being comfortable public speaking, you know, because, obviously, along the way you give presentations as a resident and your local conferences, and then also, you know, you start to give more national presentations as you start to deliver research, you know, talks and get invited, you know, ICLs, that kind of thing. Have you always been like that?
Charles Goldfarb:I think the answer to that is not really. But while it may have seemed like torture along the way. During my training, I put together a lot of talks, and I gave a lot of small group discussions or led a lot of small group discussions, whether in residency as a, you know, chief resident, or during fellowship, and those were honestly painful. But the lessons learned really made the next step of my career easier, and the nerves that were present the first few years in practice, I don't wanna say they've gone away, but they're really I don't worry about things, you know, the talks that are worried about timing or only the scientific, you know, four to five minute podium presentation, then I then I really concentrate on every word. But, you know, I think a different kind of talk a national talk or review, talk, so to speak, doesn't really stress me out and I can add to or subtract to it and feel comfortable on the fly. The last thing I'll say sorry, I don't mean to monopolize this, is this has helped me, you know, we just speak extemporaneously and some might argue to no good end. And it just it makes you think off the cuff and you have to respond and, and, you know, say hopefully somewhat intelligent things.
Chris Dy:You know I used to, I gave a lot of talks in residency, and a lot of case conferences, indications conferences, and you're in front of a firing squad, it was the Pedes service, home to your home, but at HSS. And that really helped me prepare in terms of getting comfortable giving presentations, speaking in front of people and trying to think on your feet. Certainly, there were a lot of trials and tribulations along the way, if any of my co residents are listening, but you I think, before when I used to give like an actual like hour long lecture on a presentation on a topic, I would script the whole thing. And I'd say I very rarely do that now. And I will only do it for like the four minute scientific presentation kind of deal. Because you really want to make sure you're on time there because you don't want to be that person that's slowing down the entire schedule. But right now, you know, if I have to give a presentation on a topic, I typically don't script it, I usually leave my slides to the very last minute, I'm not gonna lie, unlike you, I don't have everything ready, and then just review it. Um, I'm the person that's making the tweaks in the hotel room the hour before.
Charles Goldfarb:Yeah, and you You didn't live through the slide days, because you're, you know, young, but the there was a benefit to creating your physical slides. Because when they were when you had those slides created, you were done, you couldn't really practice, you know, you just you put the slides together, and that was your talk. And obviously, you could prepare, but you couldn't change things and so different.
Chris Dy:Outside of, you know, the scientific paper presentation, do you still practice your talks?
Charles Goldfarb:If it's a new talk I do, if it's a modification of another talk, I will absolutely look through it, I don't want you to think I'm one of these just completely off the cuff people. But most of the things that I'm talking about these days are things I'm really comfortable with. But if it's a new talk, for example, for the AOA, I put together a really super interesting while I may be the only one. But
Chris Dy:If I do say so myself, it's super interesting.
Charles Goldfarb:I find it interesting because I like you know economics and finance, but it's a it's a talk about the impact of the pandemic on our department financially. And obviously, I've never given that and some of these, you know, the subtopics are not familiar. So I will spend time practicing that one, for sure.
Chris Dy:And how much are you into slide aesthetics, like really making sure that the slides are not just blocks of texts, like making sure that they are what people can follow? How much time do you spend tweaking your slides? Because I probably spent a little too much time on that. But I think it makes a difference.
Charles Goldfarb:I think it makes a big difference. And a couple of things. Obviously, we're both hand surgeons, for those of you out there who are not this May this may help the characterization. You know, I'm anal retentive about the slides, you know, typos are not okay. And this, the symmetry matters. And for me, the simplicity matters. And one of the things that I think is, is a truism, but as you become more comfortable, the number of words on your slide to go down, the number of pictures may go up, or maybe you just present a picture and then talk through it. And that I think is where I am now and where I'm trying to get better, fewer and fewer words, more and more conversation. I think it's the goal.
Chris Dy:Yeah, I absolutely agree with you. And I think that it comes with being comfortable with the topic. Just really knowing being confident in your knowledge base and knowing where you might get pushed a little bit, knowing where you want to lead the conversation. That's the good thing about giving the talk is that you can lead the conversation wherever you want to go if you want it to be a conversation. But, you know, I guess to wrap this up, I mean, tell us about what you're preparing for. I think you have something that's already gonna have happened by the time this drops, but people should be able to check it out on demand.
Charles Goldfarb:Yeah, well, two things, a couple of, you know, less dramatic things AOA recording, which will be fun. And then the congenital world is getting together a little bit at least our United States space world. There's two meetings this week for that once called the PH-PHSG, which the pediatric hand study group, we're meeting on Thursday night for a couple hours. And normally that meeting, this time of year would be at POSNA. But most of us aren't going to POSNA, even though POSNA is a live meeting, which I think is super interesting. And then the second meeting is really, it's put on by the hand society, it's meant to replace the world congenital upper extremity symposium, which I was going to host and it was quite an honor to host this with Anne van Heest and Michelle James in Minneapolis. And we've been planning this for several years, and it was supposed to be this May, and we made the challenging decision in September to cancel it. That was after we had accepted submissions for podium presentation. And this is a tri- you know, this meeting happens every three years. And it's somewhat of a big deal in my little world. And we decided to put this meeting on both to provide a review of pediatric and congenital issues, but also to give the best of these submissions a chance to present because in two years, when we do this meeting, we're not doing it next year, because it's the London IFSSH meeting. So in 2023, when we do this meeting, there'll be new submissions. And so it's kind of a cool idea. And I think registration has been robust. So hopefully, you know, I'll report back but hopefully, it'll be a great meeting.
Chris Dy:That's great. Make sure everybody check that out on the hands society website, you know, big props to the hand society staff who gave complimentary registration to one of my medical students. So thank you, Chuck, for connecting me with them. And it was great. She's really interested she's at Georgetown right now and wants to pursue a career in orthopedics and was clearly drawn to the pediatric hand surgery topic.
Charles Goldfarb:Well, it's a natural, it's a natural draw for the for the young, eager and interested in new things, not just this old nerd stuff, you know?
Chris Dy:Yeah. Well, I mean, that's that's what the hand surger world needs is yet another pediatric congenital hand surgeon just like they probably need another nerve surgeon, right? You got it again.
Charles Goldfarb:Fair enough. How about I provide a review what do you think?
Chris Dy:Yeah, let's do it. This is from a recent survey. Thank you. For the people that have been filling out the survey online. Next week we will draw from the survey for the next mug winner.
Charles Goldfarb:Okay, this says awesome conversational style which I think Chris and I were just alluding to we didn't know it was awesome but thank you when commuting and previously listening to high yield topics for exam prep often found myself driving and missing core information and having to rewind all the time your podcast allows me to jump for a second and easily latch on to the topic also I never heard of Dr. Goldfarb and Chris but now all I see is Dr. Goldfarb's papers all over the literature Did you write this Chris?
Chris Dy:No, I wanted you to read though cuz I thought it'd be awesome if you read it.
Charles Goldfarb:Dr. Goldfarb's papers all over the literature. When reading like a workman with a hammer, they keep seeing nails Keep it up. Wow, I don't know who wrote this, but I owe them some serious cash.
Chris Dy:Oh, yeah. All right, the Goldfarb children are writing reviews now. whoever wrote that and filled out the survey. Thank you so much. That's a great review. We love doing this. And, you know, stuff like that, that really keeps us going. And honestly, Chuck is all over the literature. And you know, I think Chuck has a knack for writing papers that are timely and important. Just like, you know, a lot of us at Wash U. But and Ryan Calfee is somebody we've talked about that, too, who writes papers that matter. So, you know, I think that Chuck is just filling the mold.
Charles Goldfarb:Well, it's interesting, well it's very nice of both you and our reviewer. It is interesting. I think as I started my career, volume was important to me, and not that it isn't still but impact is way more important. And there are some really creative thinkers. And I would encourage trainees to try to, you know, think about things differently. It is an acquired skill. It's one thing to go about a procedure, and just learn to do it well and do just that. It's another thing to think conceptually about a procedure, what might be done differently, or if a different procedure could accomplish a similar goal. And so again, that like an ability to talk about your favorite topic comes with time, you have to have the base knowledge and the experience. But that's a super interesting concept. And we should probably talk about innovation at some point, but that, you know, usually we say innovation, we were talking about product development, but innovation surgically is interesting as well.
Chris Dy:Yeah, I think that, you know, honestly, there's a very privileged period in your career where you are, you know, kind of at your peak innovation, not that you can't innovate very early or very late. But once you've established, you know, a foundational amount of knowledge, but you still have a bit of an outsider perspective. And honestly, one of the things I love working with residents and fellows and medical students is that their perspective is so different, that they will actually push you a bit to think about, well, why do we do it that way? And I've honestly changed some techniques, you know, little subtle things on how I do, you know, certain procedures based on comments from residents and fellows, they have different perspectives, some their own some from what they've seen elsewhere. I'm like, you know that makes a lot of sense. And I think that I'm reading a book right now, by Adam Grant, about, you know, being stuck in the same perspective and how we really need to take a step back and maybe keep, you know, open to new ideas. And, you know, honestly, that that is really, really relevant to what we do in medicine and particularly in surgery and hand therapy.
Charles Goldfarb:Yeah, I would say this the concept of keeping an open mind to the ideas of residents and fellows is a relatively new one I'll never forget during residency, one or more of my attendings, when I would ask why do you do it this way? Or would you consider doing that way, not even getting a response not getting a backhand either, but just getting a look like, just keep quiet, Goldfarb. There's no need for you to be talking right now.
Chris Dy:Well, I think without being open to change, you might get stuck behind, like we've talked about for some topics. You know, I guess, when we're talking about the Goldman Sachs thing, just culturally to and how we train, you know, without, if you're not receptive to how other people are thinking you're gonna get left behind. Now, I had a recent case that it was really it was, it was intriguing to see follow up it was. So I can't get into too many details, but it was somebody who I had treated for a brachial plexus injury, you know, at the beginning part of my practice. And now I'm proud to say that I've established relationships with a few patients who have come and see me along the way, and I've been very happy, and privileged to see how they've responded to the treatments that I've, you know, that I've performed, as well as their rehab along along the way, and, honestly, the natural history of their healing, it's just so educational to see people back. And I ended up doing, you know, a secondary procedure on somebody who had a Plexus injury before. And it was for the reason that you don't believe, a swollen nerve that had regenerated. But it was it was real, and I have ultrasound proof that it was swollen. So that also has been really helpful. But um, you know, it's, uh, it's just so nice to see people back. And, you know, I've talked with residents and fellows, you know, before about developing relationships with patients in terms of how much you connect with them. And it was actually one of our current fellows, Jocelyn Compton. And you know, she, she had a good point, she's like, you don't want to remember every carpal tunnel, and you don't want every carpal tunnel to remember you. But something like a Plexus or something like a syndactyly. Not a syndactyly, maybe, but like a pollicization like, those are cases that you immediately see their name, or you see their face, you're like, I remember everything about your case. And it's just nice. And I'm so early in practice, still, but I mean, it's just a nice thing to see and to know how people do from big surgeries.
Charles Goldfarb:Yeah, to comments on that, I think it's a great point, it is a challenge in our current medical society or medical state to do that, because we have high co pays, and patients aren't so interested in coming back. And in my experience, they just want to be done. I mean, there's certainly exceptions to that. One exception, was today, when I have a delightful patient who had a mirror hand, and you know, complex reconstruction. And not only have I maintained a relationship with her over the last five years, she's become an ambassador for the Shriners Hospital. And she's an ambassador for the work that Dr. Wall and I do interacting internationally with other mirror hand families. And so she came to the office today, it was great to see her She played her ukulele, she did some acro. And seriously, it was awesome. So super fun stuff. And I there's such value in that. But you're right, it's not gonna be every patient. And we're fortunate to have practices that might lend itself more to that, compared to, you know, a bread and butter type practice.
Chris Dy:Yeah, I mean, so did that patient come back as a visit and then just hung around and played the ukulele at the shrine? Or is that somebody that you just happen, loves to pop into your clinic and, you know, bring muffins and hang out?
Charles Goldfarb:No, she and her family are just diehard supporters. And so this was her annual visit for some of the kids, you know, annual or every other year, we see them back as long as the growth plates are open just to kind of preempt and keep an eye on things. And this was just a visit. And she wanted to show off with the ukulele and show off with some of her manipulation stuff. It was cool.
Chris Dy:That's awesome. I hope you took some videos, because those things are so powerful. And you started to get videos on patients not only about their actual clinical outcome, but you know, the them narrating how they've done because I think we've talked about this before like giving presentations, nothing carries the day like a good story. When you're looking for funding when you're trying to win over people that are a bit skeptical on your approach. You know, those stories and seeing videos is so powerful.
Charles Goldfarb:Yeah, as much as I love still photography videos are so much better. And so I still am making that transition to always making video first. But you're right. So important.
Chris Dy:So I think one one thing before we transition to our actual, you know, topics of discussion for today, I think that the patient advocate thing is going to be super, super important going forward. And I know that you are an early believer in this concept and I think inspired by you know some of the work that you've done with with hand camp and everything else. I've started to engage with the United brachial plexus network, not only just to learn about their programs and what they do, but also academically, you know, and we've done some we've written some grants that are in the process in terms of involving their patient advocacy, you know, their volunteers, as as research participants to help us understand how to get better perplexus stuff. So I think it's really exciting stuff. I think it's the I think it's the way forward for some of the clinical research and health services stuff that we do.
Charles Goldfarb:Yeah, obviously, you're doing amazing work in that area. But you're right, it's clearly the way forward, clearly. So I think we're going to get to the meat of the matter. And we're going to talk about two articles, one in Harvard Business Review, and the other from Journal of Hand Surgery.
Chris Dy:But yeah, we're doing our first kind of opposite ends of the spectrum Journal Club. So as I say, we've got a business type article, which is actually written by some, some people from Michigan, and they're at their medical school, and a very hand surgery type article. So let's have at it.
Charles Goldfarb:Yeah, so we the business article that you suggested resonated with me. And we've been talking about this departmentally because it's about mentorship. And one thing that has struck me and for some listeners, you're going to be like, questioning why this would strike me as a primary desire of an applicant, but for applicants to join our, you know, for for interviewees, I should say, to join our faculty, one of the questions that I have gotten every single time I've done an interview over the last two years, and that that's a lot I interview all the time, is what's your mentorship program. And it you know, we have a mentorship program, but it's not truly well developed. It's somewhat informal, we have a more structured interview per, you know, program for our residents. We could do better probably with our fellows as well. But for our faculty, it's pretty vague. Once a year meeting with the chair, somewhat regular meetings, perhaps with the division chief, but we've developed a more structured program, because it absolutely is what people want. And not only that is absolutely the best way to assure success of faculty.
Chris Dy:Also to provide some context for our discussion. When you started. I don't even know when that was, but when you started, and Dr. Gelberman was the chair, how often did you meet with him? Because I've kind of heard stories along I won't say horror stories, but I've heard stories about how Dr. Galvin used to meet regularly with each junior faculty member. And I think a lot of people felt they came out better for it. But How often would you meet with the chair when you were faculty?
Charles Goldfarb:Once a year, my end of the year review unless there was a purpose driven approach, you know, like an issue that came up or I look for advice, which I felt very comfortable going to Dr. Gelberman. But there were there were no quarterly mentor meetings. There was no, you know, there were suggestions for my research program. And there were discussions about my clinical care program, but no, once a year.
Chris Dy:Yeah, I think that they may have shifted, you know, I think even before I started, he would meet with the junior faculty much more regularly. And, you know, it was, you know, I think, a bit intimidating at times. But I think they all found it very useful at, you know, at the end of it. And, you know, when I started, I started on the faculty in September of 2015. And I remember walking in the hallway and running into Ken Yamaguchi, who at that time, was still in the department full time and, you know, RO1 funded investigator, you know, kind of doing all the things that, you know, I wanted to do. And he's like, Chris, so who are your mentors? And I may have told this story to you before, I think I might have told it on the podcast. And I was like, Well, you know, nobody's assigned me a mentor yet. I'm still kind of waiting to hear. He's like, Chris, nobody assigns you a mentor. You go find your mentors. So next thing you know, I'm monthly mentorship means with Ken Yamaguchi and Richard Gelberman every month, which were intense, but 100% totally worth and I actually started building I didn't realize this what it was I started building my own launch team, which is a concept that's in this article. You know, I didn't know if you wanted to introduce the article.
Charles Goldfarb:Well that is interesting. And we're going to do better. We have developed a program we need to vet it with all the faculty, but we just want to put some guardrails around, you know, the basics of mentorship. And, you know, assigning a mentor may or may not be effective because ultimately, we have to decide directionality for our career and finding the best person is probably something that can't be accomplished on day one, right? I mean, this is something that we have to grow into. Just like with our residents, you know, we are assigned a resident to mentor but the residents ultimately figure out who's going to be the best person.
Chris Dy:Yeah, and I think that you know, it's it's, it's a struggle right from, I think a department perspective, because you want to provide guidance, you want to put some guardrails around the program, you don't want to be overly prescriptive. You want the you want to be flexible and responsive to what the junior faculties evolving needs are and where they evolve. But you really just don't want to leave them out there entirely which I thought this article was really interesting. It was from the group at the University of Michigan's medical school. The authors are Vinod Chopra, Justin Dimmick and Sanjay Saint. And I will say I found this article on Twitter, because one of Justin Dimmick's junior faculty members had tweeted recently, and it came out, you know, actually the same time, as we were talking about earlier, March 2020. And they talked about setting up three different types of teams, for a junior faculty member, or a junior person, I guess you could put this into any context, like you're in private practice, and you're just starting, but really a team of people from different backgrounds to get you through different phases of your career. So this wouldn't just be one mentor that you would be assigned at the very beginning. But there is clearly one primary mentor that is, you know, clearly within the discipline that you're working in, for example, hand surgery, but then some external mentors, not external, but you know, outside of your immediate discipline, that can provide some guidance on different topics, like research or technical parts of, you know, the surgery, or it or even in kind of an area where you want to work it's like, you know, leadership within the hospital, that kind of thing. And I thought that was super interesting, the team concept, is that something that you have talked about with the department in terms of exploring?
Charles Goldfarb:No, well, I mean, the first thing is, you introduce the article beautifully, but the title of the article is making mentorship, a team effort. And so no, honestly, you know, we've talked about different people providing mentorship. But no, we have not talked about the concept of a team and, and the the role that the primary mentor plays, you know, is expected to play in the choosing of helping the choice of members of that team, because the primary mentor is someone who's been around for a while, and knows different people's strengths and weaknesses that could serve as part of the mentorship team, to an inexperienced person launching their career. And so I love this concept of the launch team. And while again, things will change. But getting off to a good start and pointing the new faculty member, or the new partner in the right direction is incredibly important.
Chris Dy:And they talk about this launch team really being in existence for about two or three years, probably for most people meeting maybe every other month. And you know, the primary mentor and the mentee really working together to pick the other people on the team, and even including people that could, you know, help guide the mentee on things like work life balance, so really looking at it from different perspectives. And I found that, you know, personally, having lived through this recently, having different sounding boards for different things was super important. So when I was in starting my practice, you know, in orthopedic surgery, at least at that time, the first six months of your practice, you're not in board collection yet, but that second six months of your practice, you are in board collection. And I remember from the very beginning going to Ryan Calfee, and he was kind of my clinical mentor at the time in terms of presenting cases to him and making sure that I was, you know, doing all right, in terms of indications and asking him questions about follow up that kind of thing. And that was super helpful. And then I had Dr. Government kind of guiding me from a high level career perspective. I had Ken Yamaguchi guiding me from the perspective of a clinician scientist. And then I had Margie Olson, who is administrative data research guru at washu, helping guide me for my actual research that I was starting off. So it was a lot of meetings. But at that point, you know, it was certainly worth it.
Charles Goldfarb:Yeah, as you start your career, you have time, right. And you can use that time, as you try to build your practice, you can obviously spend time outside of work, but there's no better use of your time. I applaud your efforts. And certainly they had paid off. It's interesting. So you moved from the launch team, to the cruise team. And I think this is critically important. So sometimes the article says, and I agree, the launch team and the cruise team might have the same numbers. But if the faculty members interest develop, or deviate, then you might need to add new people or take certain people off the team. And what they don't talk about is goal setting. And I think that's incredibly important. And goals will change goal posts will change, so to speak. But But goal setting i think is incredibly important. And I think the right mentors will help you set achievable goals and also long term goals. And that certainly has to be part of the cruise team. Because there that's a danger time, right? You've gotten through the launch period, you've established your practice, maybe your research program, and you just have to keep taking steps forward. And that's what a great one mentorship team will do for you.
Chris Dy:Well, I would argue that the goal setting should really be something that's planted from day one, you know, because that's how that's how you pick the the launch team is well who do you, where do you want to be in five years? 10 years, what are your goals because let's let's surround you with people who may not be doing that exact thing, but can give you the perspective to get there. And, you know, one question I had for you is somebody who, you know, kind of rose through the ranks both you academically and then also had a very busy clinical practice and still do. Did any of these relationships or sets of relationships, you know, early launch and cruise team that kind of thing, did they fall into place organically for you, or are you as much of a self made man as we all want to think?
Charles Goldfarb:That's funny? Of course they did. I guess you know it. But it wasn't. It wasn't something that was established for me. I just looked for different mentors when I needed them. And I wouldn't even call them mentors. You know, I just went to ask questions. I don't know that I had, you know, other than Dr. Gelberman, from a leadership and business perspective, other than Dr. Manske from a clinical care perspective. Those were the two primary figures and kind of just those two. And granted, those are two amazing people. And I don't want to neglect, you know, thanking many, many, many people. But no, I think it was more of a problem solution effort rather than a mentoring team that took in the big picture.
Chris Dy:That's just so interesting, because I think in general relation generationally, that's so different, you know, from when I started versus from when you started, and even from when people that are in training. Now we're going to start I think, like you said, when people are asking you questions, when you interview them, the expectation is that there is a program. You I think I was more of, you know, I'm going to go build the team myself and look at it that way. But I was I was deliberate in doing that, because I knew I needed the mentorship in terms of getting where I wanted to go. And I just think it's interesting how different it is.
Charles Goldfarb:Super interesting. And it's interesting to think of what might have gone differently in my career, had I put that in place had I set early goals, because I just didn't do it. And we've talked a little about goal setting and five year plans and the like. And this is a little bit different. Fascinating. Absolutely.
Chris Dy:Well, so what did you think about the concept of the boost team that they described, you know, so essentially, the boost team is a mentoring team that comes in, after you know, the junior faculty or the partner established themselves pretty firmly with their own identity, perhaps if they're in the research world, they've gotten grants, and they've written papers, and people know their name. But this concept of a boost team is really to take somebody and stop them from plateauing and really keep them moving towards their end goals. So say somebody that wants to move into a leadership role within the hospital or move into a leadership role nationally. You know, you seem like somebody who has kind of benefited from, you know, taking on different leadership roles throughout your career. So becoming co chief and hand service. And then number of years past, you become chief of pedes ortho, and then you eventually become Executive Vice Chair, like, is that something where you thought of those things ahead of time? And you, you know, sought counsel from others? How did that all happen? Because it seems like you had a boost team making this happen for you.
Charles Goldfarb:It's interesting that I don't really think of it that way. But I think, first of all, let me just back up. It's incredibly important. This concept is incredibly important, you know, mainly for academia. Because you can settle into a role, provide great patient care, do good research. And you can just see that extending, it gets easier. And you may get some of your time back. But if you don't look to take the next step, or have someone push you to take the next step, or have someone offering you opportunities for the next step, then it's easy to see how what- it won't happen. And I you know, it's interesting for me is thinking about Lindley Wall and our relationship and, and kind of what she is looking for. And she is looking for different things than I have. She's looking for university involvement, and she's aggressively looking for national involvement. And those things you need, you need a team, you need mentors, you need people looking out for you. I have been lucky to have I guess I would say role opportunities that fit or somewhat fit my interest that needed someone to step into those roles. So I want to say that I stepped into roles, leadership roles without a clear, big picture plan. And those have all worked out well for me. And that perhaps is just luck.
Chris Dy:Oh, you know, there's I can't remember, I think it's Yogi Bear that says the harder I work I find it the more luck I have or something like that. So, you know, I give that I use that quote. And when I was when I give my Plexus talk about knowing your anatomy, and practicing your dissections, but yeah, absolutely true for for you. You know, I don't think it's luck. It's more of you know, doing the homework, doing the work, most importantly and you know, one thing that I think is interesting that they point out in here is as you rise, you know, higher up in leadership. They quote Marshall Goldsmith, who actually if you read the book that they talked about, you know, what got you here won't get you there. They talk about how the people skills become that much more important, the higher up you get. Can you talk a little bit about that? Because, you know, clearly we've like we said, you know, move from role to role and up and moving up that ladder.
Charles Goldfarb:And this article also cites the importance of connectors, right? These are people that have been there done that know people across your institution that can help you meet other people. And so yeah, the soft skills become increasingly important, because once you get to a certain stage, there is an assumption fair or unfair, that you know the clinical stuff you're taking care of, and the research stuff, you're doing good job. But if you're looking for leadership opportunities, it is about who you know, and who can expand your world. And that's how I think about it. Because it's very easy to stay in your world. And if you want to take a step out of your world, or engage in a different way, someone has to help you get there. And that probably is the most intentional thing that I've tried to do is meeting those people that can help me understand what else is out there from leadership programs to, you know, as silly as it sounds, hospital committees accomplish that goal, you meet people in different disciplines. So that part for me is intentional. But I totally agree with your statement. I think that the interactive skills, dispelling notions of you know, surgeons being a jerk when you're working with the the pediatric physicians, I mean, there's lots of things about it that really are important to moving forward.
Chris Dy:So do you see a role for us trying to get the these mentorship teams going? Our department, I think it'd be great. You know, one question I have is, what's in it for the people that are spending all this time mentoring somebody else? You know, how much goodwill is generated by this? Because that's the question I have is like sustainability, like, What? How can you ensure that people are going to dedicate the time and the energy to this?
Charles Goldfarb:I think the further, and Marty Boyer probably taught me this more than anyone else. And I think the further you get into your career, you realize the impact you achieve with patient care is fantastic. And the impact you can achieve with scientific publications is great. But your real impact is with your partners and with mentees, and people that you positively influence in your career. And so unfortunately, you know, our department is crazy busy. We're all crazy busy. And so asking people to do one more thing is tough. But ultimately, this is the kind of thing that should resonate, and should create impactful relationships and really joy in watching others succeed. And I think there's enough senior people in our department that should appreciate that, I hope.
Chris Dy:Yeah, I think they even talk a little bit about in this article about how you know, somebody who has gone through this perhaps is they're into the cruise or boost phases would want to, you know, be part of a launch team. And, and I have said like, I think I would love to help people that may have similar interests along the way. Because I think, at this point, I've tried to establish myself, and I think I've established myself in the lane that I want to be in. And I don't want anybody having to learn the hard lessons the hard way that I did. So.
Charles Goldfarb:No, it's true. And let's be honest, it's always a two way street. I mean, you give what you get, you get what you give. And I think it's so clear to me that that the reward you get from entering a relationship like this are immense. On that soft note, let's change gears. We talked about keeping this podcast relatively short, we have not succeeded. So there was a great Journal Club article we discussed on this week, which is entitled structural versus non structural bone grafting for the treatment of unstable scaphoid waste non union without avascular necrosis. That's a mouthful, a randomized clinical trial. The first author is Hegazi. And the senior author is Hassan. And they are-
Chris Dy:From the Kingdom of Saudi Arabia.
Charles Goldfarb:I thought this article was super interesting.
Chris Dy:I did too, all think about how hard it was for them to probably pull off this study, to provide some context in the article. So it's JHS for anybody who wants to read it, but you know, what they did is that they took patients as the title states, who had scaphoid nonunions, without any AVN, but they were at least six months out from surgery. And they prospectively randomized almost 100 people to this study, which I mean, that's A lot of work, it's really impressive. You know, so they randomized 102 people and eventually ended up with 49 patients in each group. And for these patients who had scahpoid nonunions, more than six months, without any prior surgery. Regardless of what the initial x rays were, they randomized them to either receive cancellous only grafting from the iliac crest, or a cortical cancellous strut from the iliac crest as well. And they did the standard radiographic outcomes, which I mean, they did a great job capturing that, including CT scans, I mean, CT scans on the regular until things were healed. And then also some range of motion and patient reported outcomes in the form of a DASH that was blown away by how much effort went into this. Just to provide some context, from our perspective on the podcast that we recorded in March of 2020. In scaphoid, part two, Chuck, you talked about how for a scaphoid non union, you almost you very rarely or never will use a cortical cancellous graft. So is that that I summarize that correctly?
Charles Goldfarb:You did? Absolutely. Yeah. And this article, the findings were interesting as well. And I do recommend if you treat scaphoid nonunions, you should read this article. But the findings were very basic, the cancellous grafts, healed faster, healed slightly more reliably at about 94%. But the cortical cancellous grafts, while healing slower, also healed reliably, about 90-90 plus percent. And actually maintained corrected alignment of the scaphoid better. And the screw they chose was a Herbert screw. And I won't be critical of that even though it's not something I use, I think it does two things. I think it makes all of us think about whether we, from a carpentry standpoint can achieve our goals with only cancellous craft, or whether the benefits of of a more complex, designed graft are worth it. Can we do it? Do we want to do it? And is there benefit to the patient? So it's really interesting.
Chris Dy:Yeah, we presented this article in Journal Club this week. And we were split down lines in terms of whether we would you know, I think there were two people that were saying you know cancellous only all the time. And they were two that were saying they would use cortical cancellous Why would you only use cancellous and there were two that were kind of like I do whatever depends on the case, that kind of thing. And I found that really interesting, probably prompted, you know, some future studies for us. But the disagreement is striking, you know, for, you know, for a somewhat, you know, a problem that I think can be addressed a lot of different ways. It's really interesting to see this and I think that the results of the trial are, you can make it whatever you want. You could you can use these results to support doing cancellous only you can find a way to use these results to support doing a cortical cancellous. Because in their post hoc analysis, they stratified by the the lateral inter scaphoid angle. So basically the humpback deformities, and for the humpback deformities with an inter scaphoid angle over 70, the cortical cancellous performed better, like you're saying held the reduction better. And I thought that that was really interesting. And I can't say that it's different than what I would have, you know, what I would have done if I hadn't read this article. But it was striking.
Charles Goldfarb:It absolutely is. And it's believable, because if you choose the cancellous only approach and Dr. Wall likes a little Roussy technique. So taking a little piece of cortical bone from the distal radius and using that as a strut and that is different than what I do. But if you choose a screw only technique, that screw has to be placed perfectly, you need a derotation wire, you have to place the screw perfectly, you can't compress it has to be volar in the scaphoid it really has to be a perfectly placed screw. And you know, clearly we're not perfect as surgeons, and so it won't always be perfect. And I think if you take the time to contour an iliac crest graft, it probably is more reliable. I do think it bears consideration for those fractures that are particularly tough.
Chris Dy:I would say that the gray area here after this paper is that the cut off they use for the lateral inter scahpoid angle, it was 70 which seems kind of dramatic because honestly the Mayo paper, you know class from Amadio, I think in the mid late 80s said that anything with a lateral inter scaphoid angle of over 45 was a malunion. So typically, that's the cutoff I've used in terms of whether I need some kind of strut if I'm considering that or at least a volar approach. So I think that that moves the goalposts a little bit You know, I don't know what I would do with the lateral inter scaphoid angle of 60. So that's something I have to think about myself.
Charles Goldfarb:Just to be clear, what, remind the audience your preference. So if you have a scaphoid non union at the waist level, that's at least six months old. And let's say there is a 45 degree, inter scaphoid angle on that lateral view. Number one, will you go volar? Number two, what type of graph will use?
Chris Dy:I will go volar. And like you mentioned in that other episode, I try to make that decision when I'm booking the surgery because it you know, it's a longer surgery, and I need to mentally prepare for that. So I need to, you know, say okay, this is going to be a bigger case. And you know, if you're looking for technical pearls on the approach, etc. Chuck gives a lot of pros in that episode, especially on how to get put that derotational wire in too, but honestly, I'm usually going cancellous unless it's a crazy humpback deformity. So probably in that over 70 camp, I really would do cortical cancellous. But if it's anything less than that, get the correction from volar. Because I think that's where you get a more effective reduction of that. humpback deformity, and packing cancellous graft in and make that score as perfect as you can, like you're mentioning.
Charles Goldfarb:Yeah, I think we see it the same way. I will think about cortical cancellous, grafting for those severe problems, because it can be hard to get that lunate corrected with a proximal to scaphoid and those that are severely angulated. It's a super interesting topic. And this is a huge I mean, we also talked in our general call about when, in 2021, can you really do a randomized trial? This is a perfect example of how you can do it, how it can influence, you know, the literature, and I think this is really just remarkably well done. And I think it's a real contribution.
Chris Dy:I will I will say, also, it shows our reticence and hesitation as surgeons to interpret literature that is contrary to our primary set of beliefs. You know, because we asked one of the cortical cancellous always people about whether this changes what they do? No, no, I don't think so. I think that you really need this, I'm like, so does this level one evidence? At least think allow you to question it, Nope, nope, gonna still gonna do what I do. I'm like well, that's the limits of research.
Charles Goldfarb:Well, and I think something's changed slowly. Right. But as we were talking earlier about impactful work, these authors should be proud. I mean, this is impactful work.
Chris Dy:Great paper, and a ton of work, if anybody is involved in any prospective trial, let alone a prospective randomized trial. As you know, Chuck, as you know, too well, it's hard. So.
Charles Goldfarb:Yeah, my career, you know, historically has been based on small retrospective studies. Hopefully, I'm doing better now. But we are we have embarked and it's been a couple years on a prospective randomized trial on treatment for CMC arthritis. It has been mean, thank God for my partners who have contributed. It's been it's been tough. It's been tough.
Chris Dy:And I quote, like a workman with a hammer that keeps seeing nails.
Charles Goldfarb:I can think of no better way to end this podcast.
Chris Dy:All right, well, we didn't keep it as brief as we wanted. But I enjoyed this. And hopefully, if you listen to the end, you actually learned a little hand surgery, or at least heard us talk about his surgery. I hope you learned a whole lot.
Charles Goldfarb:Absolutely. All right. Thank you. 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 d y. 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 podcast
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.