Episode 32, Season 2: Chuck and Chris talk Operating Room (OR) efficiency, specifically about running two rooms. We discuss tactics, when a surgeon might be ready, and how to make the most of the opportunity.
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 32, Season 2: Chuck and Chris talk Operating Room (OR) efficiency, specifically about running two rooms. We discuss tactics, when a surgeon might be ready, and how to make the most of the opportunity.
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 very well, but not as good as you.
Chris Dy:You know, I like to think I'm doing well. It's kind of a crazy time. still figuring out the whole where we're gonna live thing. We know where it's just a matter of when. But things are good. It's exciting. We're, we're wishing our current fellows Good luck on the rest of their careers. And we're welcoming some new fellows. So that's, that's been a fun thing this week.
Charles Goldfarb:Absolutely. And I know you're heading off for vacation next week, which I'm jealous of because it's going to be spectacular.
Chris Dy:I hope I hope everything goes as planned. It's a little spooky, with the whole you got to test before you come back deal but this has been a trip that has been oft delayed. And we're gonna lose, we're gonna lose our money if we don't go now and we think it's gonna be okay. So we're excited about that.
Charles Goldfarb:It's gonna be great. So my wife who does not typically listen to your, and my conversations on the podcast, saw that we had posted about vacations and she before she listened, she called and said, You better have been friggin honest in that. And then she called me after and said you were, you're honest.
Chris Dy:That is so good. So good. So I'll tell you, I want to ask if we have any burning questions from a listener, no pun intended on that one. But I will tell you if I had a funny encounter recently, in which I actually saw a patient who found us because of the podcast.
Charles Goldfarb:Found us, the Royal us.
Chris Dy:But it was really interesting. It was through a physical therapist, who then referred them and they called us up. The Royal us, the Washington University orthopaedics. And they ended up with me, I'm pretty sure they tried to see you, but they ended up with me.
Charles Goldfarb:I love it. That is awesome.
Chris Dy:It was great. Because I was like, Well, you know, like, we said on the podcast, bla bla bla bla bla. So it was, it was fantastic.
Charles Goldfarb:We don't know how many people are never coming to Washington University because they heard the podcast. That will be our unknown denominator.
Chris Dy:Yeah, that I'm cool with that. That's fine.
Charles Goldfarb:All right, I have a great listener question. I'm not going to share the listener's name just because I'm not sure that person would want me to. But if it's okay with you, this is really a little more up your alley, although I have an opinion. So here we go. Um, my, I hope you are well, my co fellows and I are big fans of your podcast, we often quote you and Dr. Dy, what you and Dr. Dy do for various pathologies amongst ourselves and even bring it up in our weekly conferences. There's gonna be a lot of haters from our colleagues across the country if they're quoting me and you at their conferences.
Chris Dy:And I bet that's how they're going to find out about the podcast. Yeah, I'm waiting. I'm waiting for the tomatoes to get thrown at the hand society.
Charles Goldfarb:I'm going to keep going. I'm a bit behind on the queue, but recently listened to the deep dive episode on technique for cubital tunnel release, assuming the sensation was brought up. And you mentioned using two point discrimination, I understand that it's the gold standard for assessing sensory function. But I know there's also some support for using a monofilament test, I wanted to get your thoughts on using the monofilament versus a two point discrimination. Personally, I find using the monofilament test less subjective and faster to perform, and he goes on from there. But I think I'll stop there. Give us your sense of A, what you do in practice and B, why you do it.
Chris Dy:I think it's a great question. I think there's a lot of disagreement among the various professionals that evaluate sensibility as to what the right measure is. And it also depends on why you're assessing it. You know, a lot of our neurosurgery colleagues will and spine colleagues will just do you know pinprick because that honestly is probably the most important thing for their world. And hand therapists will do things a little bit differently than we do. I like static two point discrimination. A few disclosures, I was trained to do static two point discrimination. I do have some sense filaments in my office. And for some cases, when I'm trying to do a really comprehensive assessment of sensibility like, you know, recovery after nerve repair, and I'm trying to demonstrate, you know, the breadth of the recovery. I will ask our therapy colleagues to map that out. But I think it's easier to just carry a two point wheel in my pocket and do it that way. Although there is a lot of inter and intra relator variability with a two point for example, even how hard to push when you're doing a two point and then also the does the patient truly understand the test. Couple biases I mean our literature is clearly structured to use two point discrimination. So if we're ever looking to publish results, that kind of thing, having two points in the charts are very helpful. And I think that two points do give you a spectrum, you know, it's more of a continuous variable than a monofilament. Now, clearly, you can use different sizes of monofilaments and different thresholds, I just think it's a little bit easier to understand on you know, as a, as a continuous variable. And a couple other thoughts about that, but I'll ask you what you what you think about it.
Charles Goldfarb:I do use static two point discrimination. And I am kind of a nerdy hand surgeon in that regard, and do a two point on every patient with a nerve pathology. I know, not everyone does, but I almost always do it. I use static two point I do believe in not trying to test deep pressure, you're trying to test light pressure and I always demonstrate on quote, unquote, normal fingers. And not every patient is capable of really cooperating with two point as you suggest, and so it doesn't work for everyone, but I think it works on 98% of people. I mean, it really is really is a good, easy, fast test. And then the point I made to the students in the residence is honestly and you may disagree with me, but my philosophy is I don't care if it's better than five millimeters. So I start with a five millimeter two point if it's five millimeters then I consider it normal. And then if it's greater than probably 12 millimeters, I considered greater than 12 millimeters, I don't keep going up. And so I may check at five millimeters and eight millimeters and just try to get a sense. So I'm just trying to get a precise but but not perfect sense of what the discrimination is.
Chris Dy:Yeah, I don't, I don't typically go below five for that reason. You know, the papers that I've read said that eight is the threshold for normal, you know, although, you know, five would be ideal. I remember during fellowship, my two point wheel, the tip, like one of the points got bent. So I stopped checking five. So I just started using six. I don't think it really mattered.
Charles Goldfarb:And that's how it happens, folks. That's how it happens.
Chris Dy:And then, actually, I had to check two points on somebody today, I was in enrolling in a study, and we didn't have it, and that actually was my wheel from fellowship, because I haven't used that in a long time. So I couldn't do five. But, you know, one other point that I think is useful, you know, I think the SEMS is really good, you know more of the in the, you know, small fiber model neuropathy, or, you know, polyneuropathy, excuse me type of setting when you're looking at, you know, diabetics and protective sensation, it's really useful there. When you do when you do SEMS, and you do happen to get that, you know, that variety of thresholds to use the the chart is beautiful, and it is great for presentations. And then the other thing is that, you know, when checking any kind of sensation, there's always that possibility of overlap. So if you're looking to purely get a quick look at the median nerve proper, and the ulnar nerve proper, sometimes I just check index and small, because all the other fingers can have overlap from the other fingers. And if you're looking to do an efficient examination, not the most comprehensive, but in some settings, just an efficient exam, I found that to be useful.
Charles Goldfarb:I think that's great. And that's really good advice. I mean, we you can do this super quickly, when the time you know, when you don't have the time. And when you need to do a more careful exam, you can do it in multiple different ways. So I love that advice. I still use my two point discrimination, which is not a wheel, but I still use the one that I was provided in fellowship all those years ago, as you like to remind me, I still have it and still use it.
Chris Dy:So you have the calipers, right.
Charles Goldfarb:I have the calipers, which because Dr. Dy, we are on YouTube now, I can show my calipers, which are beautiful, and they are easy to use and fast and they're 21 years old.
Chris Dy:That's fantastic. I remember trying to look for some calipers, because I wanted to be like you and Dr. Calphee and Dr. Wall who did the the Mary S. Stern hand fellowship, and was not able to find one that was of suitable quality. And I will say there is a, you know, I attended and an Axigen course as a fellow and at what that year, the swag they gave was an amazing set of two point wheels, which, you know, of course, showed up in my like sunshine act disclosure for that year, because they had to charge for that, but it's a great wheel, you know, and it's not made by Axigen. It was just given out at the meeting. So it's pretty neat.
Charles Goldfarb:Love it.
Chris Dy:So I had a burning question I wanted to ask you just because right now in my practice, I have the opportunity to do a pilot where I am assigned two rooms on one of my outpatient surgery days. And I'm in the midst of this pilot and you know the perioperative Services has given me certain goals to meet to or to run two rooms and make it worthwhile on there and, and your practice is one and also Ryan Calphee's, which I know both of you have have run to rooms for a long time at our Orthopedic Center in how do you how do you approach that process? I mean, even backing up to like when you're first assigned one room as a young attending, how do you organize your day? Like how do you say which cases do i do first? So how do I maintain efficiency in one room? And then how do you make that jump to two rooms?
Charles Goldfarb:Yeah, I think it's a great question. It's a, it's a concept that I take very seriously because I take my obligations to fully utilize my room or rooms, I take it very seriously. And so I'll start by saying, for those young attendings, you don't want two rooms, it comes with stress. And it comes with a lot of planning both on the front end, and a need to assure yourself and your surgery center that you can be predictable. And so you don't want two rooms to start, you want to take as much time as you need, you want to get comfortable. So I think there is a reason why there is typically a ramp up to one's clinical practice, because you get better during that ramp up. And it's nice that you get better and you get busier, and you get more efficient, and you get better and you get busier, and you get more efficient until potentially you have two rooms. Does I'll stop there and ask if that resonates rather than just giving a soliloquy.
Chris Dy:Yeah, no, I like that. I mean, I think that you know, when you're when you think about because when you're a fellow, you're a resident, you look at the people who you admire the most in terms of their clinical practice and their efficiency, and they all tend to have you know, two rooms, you just got to know that you're not going to you don't want that right away. Because you may be tempted to ask for that. And then it's really careful what you wish for. Because if you can't fill the two rooms, it's just a it's not gonna look good. Be you're not going to feel good. And see, it may have implications on how you are treated as a negotiating partner in the future.
Charles Goldfarb:Yeah, that's right. I mean, look, your goal as you start, and what does start mean? And how long does that last is different for all of us based on our practice parameters, but you just want to provide great patient care, great surgical outcomes in a non rushed fashion. And that means different things to different people. But when the time comes, I think there's a couple of factors. Now every surgery center is not going to offer you two rooms. Because what we know about two rooms is that two rooms are a win for the surgeon. And not necessarily for the surgery center. Because a surgery center would rather have two surgeons going full tilt, and filling each of the two rooms 100% of the day, rather than one surgeon bouncing, of course, that raises the question of does the surgery center have two surgeons to fill the two rooms? Or is it better for both the surgery center and the surgeon to make the surgeon more efficient, but two rooms makes me more efficient. I can do more surgeries, provide better patient access to operative care, and do it in a safe and timely fashion. And I feel really comfortable saying that I do not believe are compromised care. But I am able to do that. And again, I take this very seriously by a lot of planning.
Chris Dy:Yeah. And I remember being on your service and seeing the art of running that second room. And the thought that you put into how you sequence the cases in which cases go when and when you want them rolling back. Talk me through how you how you arranged a schedule visit. And I guess the caveat for me is that, you know, I have all the locals and I gotta go to all the blocks, which can throw things off. But how do you finesse the schedule so that you know you start? Well, you're bouncing between rooms, and I You were always there for closure, you know, during the cases, and you somehow managed to talk to all the families see all the pre ops and do all the paperwork, while keeping the rooms flowing.
Charles Goldfarb:Yeah, so I put the schedule together myself, I don't trust anyone else to do it the way I would want to do it. My general philosophy is very simple. I do a few smaller cases first. And that's you know, the triggers the carpals, the ganglions, the small lumps, things like that those that are not choosing local only, then I evolve into bigger cases. And I'll come back to specifics. And then now I end the day usually with a few locals, local only that is I think you have to be careful, you don't want a little case in one room and then a big case in another room. And another little case because you can't it doesn't work. So you kind of want your size of case to be symmetrical in the rooms. And so for example, I do a carpal tunnel in the first room and a trigger in the second room. And then if I get bigger and do a wrist scope and ulnar shortening, I don't want to go back and do a small case because the timing of the closure and the dressings and all that stuff won't work out. And so you have to think about what I tend to do is I start the skin closure, and then I scrub out. If I have a trusted fellow typically or high level resident. I do the EPIC computer work, I walk out to the pre op area to talk to the last patient's family, talk to the next patient and walk directly into the second room. So in my perfect scenario, and I can you know I think when you get experienced this You can do it pretty well is the patient comes to the second room while we are closing the first room such that the next room is prepped and draped and ready to go as I'm walking back from the preoperative area.
Chris Dy:What percentage of your days? Do you pull this off in the way that you want it to?
Charles Goldfarb:95.
Chris Dy:That's amazing. I mean, just like to the point where it's just, you know, seamless in terms of your cases, stacking up appropriately, that kind of thing.
Charles Goldfarb:I guess I would prefer that I wait to the patient waiting under anesthesia for me. I don't know that all listeners would agree with that, meaning, maybe I shouldn't do it that way. But I just don't think it's right, I don't think is right for the patient to be waiting for me. And so I think the error is on the side of not getting the second patient back to the room early enough. I'd rather be safe and know that I'll be there when they're ready for me.
Chris Dy:Okay, I see what you're saying. Okay. And then how do you? Do you? We've done You and I have published on this in the setting of the OC and I've heard a separate paper on this before. I mean, what do you think about, you know, just the concept of concurrent versus overlapping surgery. And even, you know, I know that you would never compromise these kinds of things. But sometimes the optics are what matter to?
Charles Goldfarb:Well, in this day and age, you know, the or managers have, usually have graphs, which will plot out the surgeries, and there'll be a bar here and a bar here and a bar here and, and a case within a case becomes completely obvious, I never do that. I don't think that's fair to the patient at all. And so I would never do that, you know, barring some emergency situation, obviously, my goal is simply that the overlap is for maybe some of the closer the overlap as in, I have a patient in two different rooms. But I don't compromise in my availability to be the surgeon. So I could probably be more efficient, by not being in a room for opening. And or not being in the room for closure, as long as I have, you know, a resident and a fellow in each room. But that's not my goal, my goal is to simply eliminate turnaround time, so that I'm not going from staying in one room and just killing time between cases, because I don't need to as hand surgeons, we can use that time and take care of a whole nother patient. And so it's not 100% efficiency gain, you know what, I'm not doing twice as many cases. But I am doing significantly more. And for bigger cases, like elbow scope. So yesterday, I had two elbow scopes, three wrist scopes, a couple of bigger wrist cases, in a couple of small cases. And the elbow scopes are the gold. Because the setup said the block away, this was in a pediatric facility. So the block, and the setup time is 20 minutes, maybe 25 minutes. That's gold, because with one room that kills your day.
Chris Dy:So I won't point in your practice, did you move to the second room? And then on? How much clinic do you need to do to potentially fill the second room with your same level of indications and same maybe variability because of trauma? That kind of thing?
Charles Goldfarb:Yeah, the tricky. That is the tricky part, you, I think you, were all different, I would say you kind of need to I need I need a day and a half of clinic to fill one busy two room or day. That's kind of the classic and it depends on you know, we have all the stats about how many new patients we need to see for surgery and all that kinds of we should get into that one time. You know, one, one podcast, I think that'd be interesting. But I feel stress, I feel an obligation to the fellows because I want to help educate them. I feel an obligation to the or because I don't want to waste OR time. And so I you know, it's just not all of us. I think some of the listeners are probably rolling their eyes saying why why do you feel stress about it? Well, I want to be a good citizen, I guess.
Chris Dy:And now you're in the you know, you're high up in a department you're, you know, the big deal, and you are helping to hire new surgeons, you know, for example, pedes you've got Zach Meyer starting up now. And how do you as the leader, try to secure block time for your new faculty? And how do you advise your faculty on how to use that and also, we know that new surgeons aren't going to fill that block time right away. They're gonna need a lot of time to ramp up. How do you kind of hold off the peri-op people from saying, hey, they're not using their block time. This is a long term investment.
Charles Goldfarb:So for those of you who are about to start fellowship, or senior residents, when you are looking for a job, you have to trust that the people you interview with are going to follow through on their promise to provide you block time, because I know of several horror stories of block time that was never provided, or insufficient block time. Well, that's a Deal Breaker because you can't build a practice, if you can't look at the patient in your office across the table from you, and say, I will do your surgery next Wednesday. And if you have to say, I will figure out when to do your surgery, I'm not sure when I'm gonna have time, and they're already questioning you because you're young. And if you don't have confidence in when you will take care of that patient, then that is really tough. And so you have to know that wherever you're going to work, they will follow through on that, and honor their promise of block time. And the other part of that is exactly what you say, the department chair and the division chief, and whoever else needs to have your back because there is a ramp up period and the ORs know that. But if the ORs are tight, they may push you on it. And so you have to who knows what the ramp up time is depends, again, on so many variables, but you need to be given sufficient time to build your practice.
Chris Dy:And I think the one of the other pearls that I noticed when I was in training was that you're very good about telling the or exactly what equipment you need for everything that day. And I've tried to do that at the very beginning. I have not been great about it recently, but have started to get back into it just because I've had to wait for equipment and nobody likes waiting and interrupting the flow. So do you have any thoughts on how to make sure everybody on your team is ready for the OR day?
Charles Goldfarb:I'm sure you do what I do, which most of our listeners do is I guess when you schedule a case, you fill out a form and say I need this, for some reason, I don't ever feel great confidence that's gonna happen. Part of it is maybe that the case doesn't happen for six weeks, or if it gets delayed or something, I mean, maybe three months, four months. So what I do for what I do religiously, and I really liked this system is I send an email 48 hours before my OR day, I have my lineup as I want as I construct my lineup by email patient name, date of birth, phone number, and I'll come back to that procedure. And then my two rooms are lined up at the top of that I list exactly what I need for special equipment. So whatever the ulnar shortening plate is, or whatever the wrist arthroscopy setup is I list that specifically, it serves double purpose for me, as we've talked about on this podcast, is it on my drive home, I use that same list to click the phone number and call the patient post op and check in on how they're doing. I don't know if you've done that. If you haven't, I think it's worth it. It does. It's another time suck. But it doesn't take that long because my nurse will send me all the info and I just have to arrange it.
Chris Dy:Well, I admit, having been a Goldfarb fanboy. When I came out of fellowship, I called every patient initially I have lost that, but I do have my, my MA put Every patient's phone number in in their outlook entry, so that I can call them if I want to call them without having to dig through a chart or other paperwork. And I do a similar process with my lineup. But I have been bad about keeping all the equipment stuff on there. But I've now been better about putting it back on after having to wait around a bit.
Charles Goldfarb:It's funny. I used to do the outlook thing as well put my cases on the calendar. I didn't find that helped me. I mean, EPIC is such a big part of my life. I don't think seeing the patient on the calendar helped me and I think it's an effort for the nurse or the MA or your secretary to do it. Again, that's your workflow. And that works for you. I for me, it stopped being helpful.
Chris Dy:Yeah, I do. I'm like you I do everything I can to not log into EPIC. So if I'm just trying to see what my day is gonna look like, you know, in terms of structuring meetings, I just need one stop for all my calendar stuff. And I really don't want to log into EPIC, although, you know, the EPIC app, the Haiku thing is really useful in terms of, you know, reading notes and stuff, etc. But All right, great. Well, thank you for answering my question and helping me and I hope the listeners learn something along the way.
Charles Goldfarb:You need no help. Dr. Dy but, it was a fun conversation. Thank you.
Chris Dy:I'll take all the help I can get.
Charles Goldfarb:Alright, have a good day.
Chris Dy:See you next time.
Charles Goldfarb: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 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.