Tips for Success: new attendings and new fellows

Chuck and Chris share thoughts and tips for success for new attendings and new fellows.  Things such as the 3 A's and the 3 E's (tune in for this new one) and many other pearls.

See www.practicelink.com/theupperhand for more information from our partner on job search and career opportunities.

The Upper Hand Podcast is sponsored by Checkpoint Surgical, a provider of innovative solutions for peripheral serve surgery. To learn more, visit https://checkpointsurgical.com/.

As always, thanks to @iampetermartin for the amazing introduction and concluding music.

For additional links, the catalog.  Please see https://www.ortho.wustl.edu/content/Podcast-Listings/8280/The-Upper-Hand-Podcast.aspx

Transcript

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Fellowship/ Practice Pearls

 Charles Goldfarb: Oh, hey, Chris.

Chris Dy:  Hey, Chuck. How are you?

Charles Goldfarb:  I'm great. How are you?

Chris Dy:  Great. It's, uh, it's still sort of summer here in St. Louis.

Chris Dy:  It's sort of hot. It's going to get hotter again this weekend.

Chris Dy:  Um, there was a nice respite, I think, uh, recently. But, uh, yeah, weather's still good.

Charles Goldfarb:  Well, it's all perspective-driven. I— I visited Alabama last weekend to see the family, and, uh, it was hotter. So yes, we can complain, but others maybe more.

Chris Dy:  Well, it's not complaining. I'm actually just realizing that, thinking a few months, I'm going to be saying, "Man, remember when it was, you know, 85, 88 degrees, we were in the pool, etc." Um, but, uh, yeah, just making a comment.

Chris Dy:  You know, small talk. Talk about the weather, you know.

Charles Goldfarb:  It is. I'll say one thing that struck me this morning. I did bicycle in, um, and love that.

Charles Goldfarb:  Again, one of the best things I've ever done is trying to bike at least a couple times a week to work. But it's now pitch black at 5:30, and I miss the, you know, June and July when it's— it's light out at 5:30.

Charles Goldfarb:  And so it's just how rapidly that changes is something. Something crazy.

Chris Dy:  I can imagine. When we don't have daylight savings time, whenever that comes, it's going to throw everything off.

Charles Goldfarb:  Yeah. That's usually when I stop. It's too cold.

Chris Dy:  So we've got a, uh, uh, we've got a fun episode today. Uh, for a while now, we've been talking about having an episode about starting off your fellowship year well. I mean, uh, I think probably folks are about, you know, 3 or 4 weeks into fellowship.

Chris Dy:  Uh, and then also, people who are— who finished fellowship and are starting practice, you know, most people take a little bit of time off, um, you know, might be starting up pretty soon. So we'll do some pearls, uh, for both of those.

Chris Dy:  And, uh, and hopefully, uh, we'll give some good advice for people.

Charles Goldfarb:  Yeah. We'll give advice. You know, you get what you pay for.

Charles Goldfarb:  It's a free podcast, so hopefully it's good.

Chris Dy:  You get what you pay for. That's what I definitely tell all the nurses when they— when they ask, like, "Can I— can you check this out for me?" I'm like, "Sure, but."

Charles Goldfarb:  Oh, yeah. Yeah. Along these lines, interestingly, and I'll leave out some of the details just because I should.

Charles Goldfarb:  My— one of my daughters is in— living in another city, and she has this derm thing she wants to get checked out, and she called and she could get in, like, you know, derm, 6 months or something. But said— they said, "But we have a cash-only evaluation visit on Monday for 150 bucks, and we'll get you in and check it out."

Charles Goldfarb:  And, uh, my first response is, "That's BS. We're not doing that."

Charles Goldfarb:  My second response is, "You know, pay the 150 bucks and get in on Monday." And then I'm thinking, "How can we apply that to orthopedics?"

Chris Dy:  Ah, that— what, uh, I'm— I— we won't say the details, but I know she's in a bigger city. Um, I wonder how that would play in our market. I think everything is different, uh, in the different places.

Chris Dy:  And perhaps in one of our kind of ritschier, uh, suburbs, it would work, but maybe not where I practice.

Charles Goldfarb:  Well, yes. I— I don't— I don't know. That's— it's good.

Charles Goldfarb:  I think for some people, they would gladly pay, but in— instead, we just add another person on the clinic, and they'll do anything different. But I made the point, and we— you and I have talked about this.

Charles Goldfarb:  Concierge care is totally understandable. I support it for our primary care colleagues, because I just think things are tough.

Charles Goldfarb:  Uh, I personally don't pay for a concierge position. I don't need a concierge position.

Charles Goldfarb:  But we're like the— we're— you and I, uh, and we're— we're happy to see the patients, or sort of why concierge medicine works. Because the concierge doctor calls you and I and says, "Hey, can I get so-and-so in?"

Charles Goldfarb:  And we say, "Sure." But, you know, we're not getting paid extra, which is okay, but it's just a fascinating thing to me.

Chris Dy:  Yeah. So it's a different— it's a different model, and it's definitely exploiting, uh, for lack of a better term, um, you know, a need. Um, so kudos to them, I guess, whoever's running their business office.

Chris Dy:  Uh, but yeah, I'm the sucker, just like you, who— when somebody calls, "Yeah, of course, add him on." Whatever you need.

Chris Dy:  Another patient. You know, the longer I sit doing my dictations after clinic, the more times I get, uh, just curbside by the orthopedic injury clinic.

Chris Dy:  "Can you take care of this?" "Sure."

Chris Dy:  "I was about to leave, and then I had to go reduce a distal radius fracture." I was like, "Sure.

Chris Dy:  Let's do it."

Charles Goldfarb:  But— but what's so interesting to me is, and again, I'll date myself. I remember being in clinic— and you and I have talked about this, we don't need to rehash it— hours after end of clinic getting my notes done. And now, you know, we use a bridge AI.

Charles Goldfarb:  Um, it just doesn't happen anymore. I mean, I am done in a timely fashion, no matter how busy my clinic gets.

Charles Goldfarb:  Amazing.

Chris Dy:  It is very helpful. I have not noticed as big of a sea change as you in terms of getting notes done. I still feel like I probably— I mean, it's hard.

Chris Dy:  It's the recency bias. I feel like I still leave around the same time, but maybe it's— I'm just remembering it differently.

Chris Dy:  Uh, or I'm seeing more people, and then I'm actually just finishing around the same time. Um, but, uh, that actually probably segues into one of our first, uh, pearls for— we can just talk about this for those that are starting practice, but availability.

Charles Goldfarb:  Yeah. I mean, it— there is.

Chris Dy:  At least in the US system.

Charles Goldfarb:  Yeah. In the US system. Um, and I love the— the saying, and many of you listeners have heard this, that the— the three A's for clinical success.

Charles Goldfarb:  Um, we talk about these a lot: availability, affability, and ability, in that order. Or some people say, in 2026, it's availability, availability, availability.

Chris Dy:  Yeah. I— I would agree with that. I mean, you know, I think it kind of depends on your goals, right?

Chris Dy:  So everybody starting out, I mean, you— you want to build a practice. Um, you know, so some of those goals may be different based on the compensation model that you're in or the expectations that your practice director has for you.

Chris Dy:  Um, I think that the most people coming out of American training systems who are going to practice in the States want to emulate the people that they, you know, worked with. So for me, when I was starting out, you know, I— I saw people like you and Marty Boyer and Ryan Calfee, and, you know, just always saying yes to, "Yes, of course.

Chris Dy:  We'll see people. We'll help."

Chris Dy:  Seeing emails fly around saying, like, "We have a patient who needs this, that, or the other," or the call centers, you know, calling into your clinic saying, "Can you see somebody?" And you guys would always say yes.

Chris Dy:  Um, so it was easy for me to see stepping into practicing in the same institution, in the same model, uh, what it took to help out. Um, but there are other people who kind of start in a practice like this and just say, "I want to get comfortable.

Chris Dy:  I just want to take care of the stuff that comes in. I'm happy to be a good team player, but I'm not seeking those other additional kind of, um, opportunities to be available."

Charles Goldfarb:  Yeah. And— and, um, I will say our model's different than— than other places where, you know, we don't have a nurse practitioner or a physician assistant/associate, as the name is changing, I understand. A PA.

Charles Goldfarb:  Um, and, um, because if you do, then maybe that add-on goes to your APP, uh, and not to yourself. But I don't know.

Charles Goldfarb:  It's— it's part of, uh, I think this— a certain mentality that we certainly have, and we're not alone in that mentality, that— that, you know, we want to see patients, and we want to, um, you know, be a— be a— be a resource to our colleagues. And that is incredib— one thing I think is incredibly important.

Charles Goldfarb:  Many practices, especially orthopedic practices, have an orthopedic urgent care of some sort. Ours is called the Orthopedic Injury Clinic, or OIC.

Charles Goldfarb:  And being available for that group, as you mentioned to start out, is just really important that we provide support for our colleagues who may not have the super subspecialty expertise in hand surgery, wrist surgery, forearm surgery, uh, but be there for them.

Chris Dy:  Yeah. To that point, I mean, we have a new APP that's onboarding for the, uh, injury clinic. Uh, and he was in my clinic, and I said at the end, I was like, "Here's my cell phone number.

Chris Dy:  If you have any questions, call me. Text me.

Chris Dy:  I don't mind. Even if I'm not at the site you're at, if you just need help figuring out where to— what to do with somebody.

Chris Dy:  Does this need a reduction? Should this go to the ER?

Chris Dy:  Should this come into the office tomorrow?" I think it's just helpful for them.

Chris Dy:  And, you know, I'm not going to lie, it is a bit— you know, there's a self-serving component to that. Um, you know, because, uh, when I've done that with people that have gotten busy in the OIC, I get cases.

Charles Goldfarb:  Yeah. That's right. I mean, we've talked about this repetitively, but it bears mentioning again.

Charles Goldfarb:  That same concept holds with relationship with therapists, relationship with athletic trainers, uh, relationships with outside urgent cares and emergency departments. Those relationships just pay— you know, they're incredibly valuable.

Charles Goldfarb:  And, um, I never regret it. I never regret giving my cell phone to anyone in those groups.

Charles Goldfarb:  And it— it always benefits, again, hopefully the patients first. It benefits me because you're seeing the right kind of patient in your office.

Charles Goldfarb:  So, uh, totally, totally agree with that.

Chris Dy:  So how do you, um, I agree with you on that. How would you advise somebody starting out in practice to develop those relationships? Since you're kind of in charge of our clinical enterprise, how do you advise a— a surgeon starting out in practice?

Chris Dy:  How do you get those relationships with therapists, with VATs, with the APPs? I mean, is this something where you just kind of let it come to you, or do you have to be a little more proactive?

Charles Goldfarb:  Yeah. Maybe before I answer that question, I'll think, uh, one of our sponsors. The Upper Hand is sponsored by practice link.com, the most widely used position job search and career advancement resource.

Chris Dy:  Becoming a physician is hard. Finding the right job doesn't have to be. Join Practice Link for free today at www.practicelink.com/theupperhand.

Charles Goldfarb:  So for most of us, and I don't know if it's universally true, I would think there's some truth to this. When you start practice, you're not immediately busy. And that's really good, and it's really important.

Charles Goldfarb:  You know, there's typically—

Chris Dy:  And very— and very frustrating.

Charles Goldfarb:  And very frustrating. But my— part of my point is, it shouldn't be. Because if you can get beyond the frustration of not being as busy as you want, you can use that time.

Charles Goldfarb:  You can use it by not feeling any source— source of time pressure in the OR. You can take as much time as you need.

Charles Goldfarb:  You can schedule those 45-minute carpal tunnels. We'll come back and talk about that.

Charles Goldfarb:  You can, if you're in an academic setting, get some research efforts underway. And then, to your question and to your point, you can develop relationships.

Charles Goldfarb:  How do you develop relationships? Well, one, you prove yourself clinically by providing great care, getting great results, getting great feedback.

Charles Goldfarb:  But two, you put yourself out there. You do the lunch and learns.

Charles Goldfarb:  You speak to the therapy groups. You go talk to the athletic trainers.

Charles Goldfarb:  You work with the APPs. Um, those efforts may seem like they don't, you know, uh, have an immediate payback.

Charles Goldfarb:  I would say they always do, and the payback is over the long term. And so those touch points over time are important, but you have to start somewhere.

Charles Goldfarb:  And that's putting yourself out there and— and going to visit people and talk to groups and talk to therapists, etc.

Chris Dy:  So I think we've talked about this in the past. You know, I think the lunch and learns are high yield with therapy groups. How about the, you know, the going to a PCP's office and, you know, giving them a talk while they're trying to get their notes done and whatever?

Charles Goldfarb:  Yeah. Probably. I mean, I don't know what you think.

Charles Goldfarb:  I think probably less valuable. There— you know, it's a nice touch point.

Charles Goldfarb:  Like when we recently started a new hospital for us, and some of our physicians went around and just did some meet-and-greets. Because let's face it, the doctor's lounge is no longer the place where you can meet your colleagues.

Charles Goldfarb:  So you have to— they— they want to face with a name. They want access.

Charles Goldfarb:  And— and so it's probably not quite as valuable, but there's still— there's still value there, in my opinion.

Chris Dy:  One thing that I thought was interesting I did recently, I haven't done before, was I did a, uh, a lecture at a sports medicine CME conference that a department put on, which I— I've had a lot of people say, "I saw your lecture there." I was like, "Oh, cool." Like, and they're like, "I— this was really great.

Chris Dy:  Blah, blah, blah." Like, that's not a, uh, an access point that I had thought about before.

Chris Dy:  Uh, from an academic perspective, it's like, it's not a— a— a— you know, it doesn't give me any points for that. And then it obviously is time away from other things I could be doing clinically.

Chris Dy:  But I was surprised by how much, uh, that talk resonated and how many connections that made. So you never know what opportunities are going to come up.

Charles Goldfarb:  Yeah. It gets back to the point where we started. Just say yes.

Charles Goldfarb:  I mean, especially as you're building your practice, as you have time, just say yes to everything. Um, you know, clinically especially, but you could argue for all domains.

Charles Goldfarb:  Say yes. Put yourself out there.

Charles Goldfarb:  You know, pound the pavement, as they say, and, uh, it'll pay dividends. And— and that includes one other thing.

Charles Goldfarb:  Um, the emergency department's tricky, right? It used to be that one could not build a practice without a strong emergency department presence.

Charles Goldfarb:  I think a lot of us, uh, don't enjoy that as much, perhaps, or don't want to be on call. And different environments dictate different things.

Charles Goldfarb:  But the ED is an incredible source of patients for and reputation-building opportunities for orthopedic surgeons. So I strongly think it's an important part of one's early practice.

Chris Dy:  Yeah. And that's a very, I think, a local thing. Uh, the frustrating part is that the EDs oftentimes will have established referral patterns, um, whether that's decided at a systems level or it's decided on, you know, who's working that day.

Chris Dy:  Um, but you can, you know, kind of elbow your way in there. Um, but it will lead to a decent number of phone calls and kind of unofficial call and that kind of stuff.

Chris Dy:  And I— and one of our partners, our new partners, is kind of navigating that, uh, right now. But, uh, I think, you know, they're a hustler, and they're going to— they're going to make it work.

Chris Dy:  But, uh, it does have its own set of challenges.

Charles Goldfarb:  Yeah. So what about— so we'll continue with this conversation about, uh, getting your practice up and going. What pearls do you have in the clinic for a new physician?

Chris Dy:  Um, I guess it's, you know, I think it's being— well, finish your notes on time, uh, which I think that you don't want to get on the bad side of the, uh, the admin folks who, uh, uh, who will be auditing your notes. Um, don't overbook initially. Um, I think that, you know, even yesterday, I was in clinic alone, and somehow I got behind.

Chris Dy:  Like, I got— I was in the weeds. And to the point where I came out of my— I came out of my set of four rooms, looked up, and then the athletic trainer I work with, Hannah, saw me just take a breath and turn around, shoulder slumped, and got back into it.

Chris Dy:  She was like, "I noticed you didn't do any notes today during clinic." I'm like, "Yeah, I was just getting run ragged."

Chris Dy:  So even, you know, uh, being "mid-career," uh, you know, it's easy to get behind if you just don't stay on top of it. I think it is stay on offense in terms of, you know, trying to work efficiently.

Chris Dy:  It doesn't mean you rush interactions. Um, I think it is the quality of those interactions that matters more than the time spent.

Chris Dy:  Um, and a bridge, when you walk out of the room, tells you how long you've been in the room. Uh, you know, I— I should not be answering this question because you're the one with the perfect patient satisfaction scores, because I saw them yesterday.

Chris Dy:  Because Nermina was in clinic with me. So I don't know.

Chris Dy:  How do you advise, uh, starting in clinic, uh, given that you are so well-reviewed?

Charles Goldfarb:  You know, age has a few advantages. My back is killing me now. That is not one of them.

Charles Goldfarb:  Um, you know, when you get older and you're more established, you— you're given more leeway by patients. There is no doubt about it.

Charles Goldfarb:  Um, the goal, to be very blunt, and this— I hope this doesn't come out wrong because it's not intended to, but you want to develop a connection. You want to demonstrate empathy, and you want to, you know, touch the patient.

Charles Goldfarb:  You want to do it while you're sitting down at eye level, and you want to do that all as efficiently as you can. And that's— those are skill sets.

Charles Goldfarb:  You know, walk in the room, introduce yourself. I always say I'm using an artificial intelligence helper, ha ha.

Charles Goldfarb:  I wash my hands in front of the patient. Sit down.

Charles Goldfarb:  And, you know, I've often been briefed by a fellow about what's going on, kind of briefly rehash that. And then it is touching the patient.

Charles Goldfarb:  It is demonstrating empathy. How do you demonstrate empathy?

Charles Goldfarb:  You do it with your eyes. You do it with your— the way you talk, the way you listen.

Charles Goldfarb:  Uh, but you're trying to do that as rapidly as possible. That's the world we live in in the United States.

Charles Goldfarb:  And it— it, you know, that speed. You can do this.

Charles Goldfarb:  This is something that can be done. You can see a lot of patients and give all of them, or 99.5% of them, what they want.

Charles Goldfarb:  Um, yeah, it's just— it's, uh, energy. You know, I am exhausted at the end of the day.

Charles Goldfarb:  It's energy. It's enthusiasm.

Charles Goldfarb:  And it's empathy. Those are the three E's.

Chris Dy:  There you go. The Goldfarb three E's in clinic. Uh, you know, you talk to people that work in different worlds, and they— they get it.

Chris Dy:  You know, like, "Man, my meeting— my day was so hard. I had all these back-to-backs.

Chris Dy:  I had 10 meetings today, and, you know, it was really challenging." Think about clinic.

Chris Dy:  Like, that's like 60 back-to-backs. Like, where you are, like, on.

Chris Dy:  Like, that is their one interaction with you, perhaps, uh, ever. Or it's a longitudinal interaction.

Chris Dy:  They've given you the privilege of letting you do surgery on them after meeting them for probably a total of 15 minutes sometimes, maybe less than that. Um, and you're following them through.

Chris Dy:  And it's— it's an incredible amount of trust that patients put in us. Um, and you want to make sure that you are, you know, accomplishing the Goldfarb three E's, um, you know, in— in a manner that allows you to, you know, feel good about yourself, deliver really good care, but then also, you know, remain efficient.

Charles Goldfarb:  Yeah. And I— I said this to someone recently. I don't remember the context.

Charles Goldfarb:  Um, oh, actually, it's— it's a little preview of the Hans Sadi in one of the— one of the talks I'm giving. But— but if— if you are a younger physician and you see a complicated patient, resist the urge to have everything wrapped up and tied in a neat little bow for the patient to depart.

Charles Goldfarb:  I've been doing this a long time. I still tell patients that I don't know the best thing at this point.

Charles Goldfarb:  I'm going to consult with either some of my partners or some of my peers across the country. This is unusual.

Charles Goldfarb:  This is difficult. I will get back to you.

Charles Goldfarb:  And it shows humility. It shows that you're going to work on the patient's behalf.

Charles Goldfarb:  And then when you call that patient, and, you know, I do call a lot of patients, um, they are— they are universally grateful. And I'll say that, and I'd love your comment on that.

Charles Goldfarb:  And I would also say, if the patient's not exactly right for me, I'll send them to one of my partners, like I did recently with you, where I could tackle and be very confident about 80% of the issue, but I thought you brought a different level for a real nerve challenge. And so send it on.

Charles Goldfarb:  Again, it's easier to do at my stage, but I think both of those things are important.

Chris Dy:  Yeah. I think for the latter, I mean, the sending off is harder starting out because you want to feel like you're— you've been eminently trained and you're ready to rock. And, you know, but sometimes you got to realize when you might be, uh, out over your skis too much.

Chris Dy:  Um, and that's— that's a really hard thing to admit. I remember feeling that way sometimes.

Chris Dy:  Uh, but as you become more established, to your first point, you know, my line, which is super easy for me, is to, you know what, let me talk to— I got to talk to a few partners with less hair or grayer hair about, you know, your case, and I want to make sure that we're doing everything that, uh, you know, doing the best for you, and I'll get back to you. Um, you know, because I think even, you know, we'll— we'll talk in our next episode about

Chris Dy:  some of the interesting fractures I've been treating. Um, even some of those, I'm like, I think I know what I want to do, but let me just get a, you know, another person to just give me their thoughts. And I think the patients certainly appreciate that.

Charles Goldfarb:  Yeah. Absolutely. Um, you know, there's some that'll be like, "Well, if you don't know the answer, why am I here?"

Charles Goldfarb:  But that's pretty rare. I think most patients give you grace and appreciate the extra effort.

Chris Dy:  Yeah. You can send them to Rochester. So before we move into, uh, pearls for our fellows, I think that, uh, we should acknowledge that if you're attending the ASSH annual meeting in Boston in a couple of weeks, be sure to add this educational session to your schedule.

Chris Dy:  Check Point Surgical is proud to host "Advancing Upper Limb Spasticity Care," a case-based discussion exploring how nerve-based surgical techniques are transforming the treatment of upper limb spasticity.

Charles Goldfarb:  Here are practical insights, challenging cases, and expert perspectives from Dr. Wee Lam, Dr. Carolyn Leclerc, Dr.

Charles Goldfarb:  Peter Rhee, and Dr. Sammy Tufaha.

Chris Dy:  Tufaha.

Charles Goldfarb:  I thought so. Um, and I know Sammy, uh, but just not very well. Uh, join Check Point this coming— actually, join Check Point on Thursday, September 17th at 11:30 a.m. and visit booth 1831 in the exhibit hall.

Charles Goldfarb:  I am psyched about the Hans Sadi.

Chris Dy:  Yeah. It's going to be a great meeting. I think it's going to be really exciting.

Chris Dy:  Um, you know, so that session is, uh, you know, that's a star-studded cast, uh, for those in the world of spasticity. Um, so you're— that's going to be a great session.

Chris Dy:  And then we have a fun session we're going to be doing on the following day, Friday, September 18th.

Charles Goldfarb:  Friday, September 18th, 4:00 p.m., live, uh, from Boston, uh, the Upper Hand Podcast. So we'll have a good time. I think we have a little swag we can share.

Charles Goldfarb:  And, uh, we always have fun. And, uh, uh, I— I enjoy connecting with people.

Charles Goldfarb:  And— and this is when you're in your element. You love this.

Chris Dy:  Me. I think you're the one that rises to the occasion here. Uh, but bring questions.

Chris Dy:  Uh, you can either email them to us in advance, handpodcast@gmail.com, or bring them in person. I'm looking forward to— it's— it's always a fun interaction.

Chris Dy:  Uh, hopefully we can get Chuck to loosen up a little bit. Uh, but it'll be Friday afternoon.

Chris Dy:  We'll be the last thing between you and Happy Hour. Uh, so it'll be really fun.

Charles Goldfarb:  Absolutely. All right. So new fellows, um, have started August 1.

Charles Goldfarb:  So by the time this drops, they'll be 30 days in or so. And that's a super exciting time.

Charles Goldfarb:  And we have three great, eager fellows who are all off to a wonderful start. And we want to just provide a handful of pearls, uh, to making sure that they get the most they can out of fellowship.

Chris Dy:  So I think that one thing I noticed about the fellow that I'm working with now, her name is Sharika. She's wonderful. Um, she has a great note-taking system.

Chris Dy:  Um, and I think that this is probably something that most people who are— if you're listening and you're a resident, you've probably developed along the way. Um, but for your cases, uh, develop a note-taking system.

Chris Dy:  Obviously, thoroughly prepare. You know, read the charts, understand kind of the big picture, and then prepare for your cases appropriately.

Chris Dy:  Uh, and in some cases, if it's, you know, uh, more of a critical thing, examine the patient in pre-op. Um, but, you know, having a way to digest, uh, what's happened in the case and your learning points and recording them systematically, I think, is a very helpful thing.

Charles Goldfarb:  Yeah. Totally agree. I mean, look, you— each of the fellows is an adult learner.

Charles Goldfarb:  And so how you learn, how you process information, is sort of up to you. And, you know, different programs, different faculty at different programs have different perspectives.

Charles Goldfarb:  My own is that you're an adult learner, and I can give you resources, and I will give you resources, but I expect you also to ask for help or guidance or direction when necessary and to, you know, take notes, however that mean— whatever that means for you, that, you know, what frustrates us is when you're doing something for the third time and you don't remember how we did it the first two times. Um, and that— that's really important.

Charles Goldfarb:  And that goes for clinic stuff too, as far as, you know, how exams go, what— what Christy wants from you in clinic. There's a reason that you do things the way you do.

Charles Goldfarb:  And ultimately, the fellows' job is to learn how you do it, learn how I do it, learn how our partners do it, and then put it all together and figure out how they want to do it after the year is over. But while you're in your fellowship, really try to dive deep with the attendee you're with and learn everything and write everything down about how they're doing things to make it your own.

Chris Dy:  Yeah. Uh, just one example. Uh, and this is not anything specific, but if— if somebody's coming back around, uh, towards the end of the year, I shouldn't have to, like, tell you again about how it's done.

Chris Dy:  I know it's been a few months. Uh, but yeah, I like two-point discrimination.

Chris Dy:  So do it. Like, just, you know, I'm happy to do it for the patient in the meantime.

Chris Dy:  It's another point of touch, etc. It's another interaction.

Chris Dy:  It doesn't take long. But this— the wheel has not been— does not need to be reinvented, uh, you know, the second time around.

Chris Dy:  Um, you know, I think that is— the EQ part of fellowship is really hard. Um, you know, picking up on all the different personalities.

Chris Dy:  Every rotation is different. The culture, uh, of each rotation is different.

Chris Dy:  The vibe in clinic is different. How the attending wants to teach you is different.

Chris Dy:  Um, and it is just picking up on that as soon as you can and, you know, um, code-shifting to make it work. Um, or code-switching, I guess, is to make it work.

Chris Dy:  So that's a challenge. But I think the people that excel, uh, in getting the most out of their training are able to pick up on those, um, different vibes and shift their personalities or just, you know, kind of how they're approached to things to make it work.

Charles Goldfarb:  Yeah. That's well said. And— and, you know, it's— it, uh, it is about how do you learn, but how do you get the most out of your environment.

Charles Goldfarb:  Um, you know, asking the right questions at the right time. Uh, asking for a little more detail on how someone does a clinical exam.

Charles Goldfarb:  You know, it— it's all the balance. Like, if you're getting killed in clinic, no, I'm not going to take five minutes to go over this exam now, but I'll be happy to do it later.

Charles Goldfarb:  So kind of reading the room, which hopefully is innate to most, but it won't be innate to all, um, is— is a really, really important quality. Um, yeah, I think that— that's a really important point.

Chris Dy:  I think reading the room is— is hard. Um, I think also just realizing that this is your one year of education, uh, for hand surgery, dedicated to hand surgery. I remember when Rick Wright gave a grand rounds here a few months ago, he was like, "You only have 60 months for orthopedic education.

Chris Dy:  It's only five years." So as I can only speak for this fellowship because it's what the one that I did and the one that I helped, uh, organize for a few years and the one I've been a part of for 11 years now, this is a hard fellowship.

Chris Dy:  Like, it is, but it's busy. You will get a lot out of it, though.

Chris Dy:  Like, it is literally drinking from a fire hydrant. Um, but realizing that, you know, you got to stay engaged the entire year.

Chris Dy:  Uh, it is super hard to do considering how busy it is, but there's just so much to get from here. Um, David Bergen, our partner, says, "This is a buffet."

Chris Dy:  You know, you can get one plate and be full and be done, and you can do that. Or you can keep coming back because all of us have so much to teach you.

Chris Dy:  Like, we've held off on doing, like, a nerve conference every month because we know it's just another conference that our fellows have to do. And, you know, and then when people talk about the congenital journal club that you and Dr.

Chris Dy:  Wahl do, they're like, "Yeah, I'm not doing congenital, but God, the opportunity to, like, talk about these articles with two people that are at the top of their game and are internationally known." Just that opportunity to have that conversation is amazing.

Chris Dy:  Uh, because you do learn some principles, and you just get to nerd out about something. Um, so it is just kind of realizing while you are drinking from the fire hydrant, this is your education.

Chris Dy:  You're an adult learner. You can get so much out of this if you want to.

Chris Dy:  You can also just get the bare minimum. And, you know, nobody loves that, but, you know, you will graduate a competent hand surgeon.

Charles Goldfarb:  Yeah. And maybe to close, let's briefly talk about a few OR pearls. I would say a couple.

Charles Goldfarb:  Uh, number one, you know, while— while doing a surgery is fun, you can learn a ton and sometimes more by observing. Um, preparing for the OR is critically important.

Charles Goldfarb:  And we all think about the preparation in advance. And I would say the kind of post-hoc assessment after is really important.

Charles Goldfarb:  And I talk about this all the time. If you're doing a case with an MRI, always look at the MRI after because you'll learn something.

Charles Goldfarb:  And that obviously is true for arthroscopy, but not just arthroscopy. And so, um, you know, you can show up to the OR and get something out of it, but if you show up prepared and ready to go, you're going to get a lot more out of it.

Chris Dy:  Man, it's the same thing with the nerve studies. You know, like, here's how things responded in surgery to the stimulator. Let's go back and look at that study.

Chris Dy:  Or, you know, um, do the X-rays. Like, unpack that pre-op CT after you've seen it live.

Chris Dy:  Um, and the OR is a whole different ball of wax in terms of reading the room. And, you know, I think that obviously you don't need to ingratiate yourself to the OR team, but, you know, kind of learning how they do things and learning what you can do to help and where you can insert yourself.

Chris Dy:  This is for every level of training. Um, I think that, you know, I— I this is wrong probably, but show up before the attending.

Chris Dy:  I mean, that's usually a good thing unless there are circumstances that prevent it. Um, you know, and then I think that most of us try to be conscious of kind of what we as the faculty will do, you know, to keep the day moving along, uh, versus what the fellow can do.

Chris Dy:  And all of us have a different balance of, you know, the logistics of how to run two rooms and how to run, you know, uh, an OR day successfully. But we do want to educate you, but sometimes we got to hit, you know, the X button or the turbo just to keep the day moving along so we get the staff home by 5:00.

Chris Dy:  Um, and knowing that that's not on you, that you— most of us are good about saying, "All right, just let me tell you why I'm doing it this way." Um, you know, and then I think, you know, really thinking about the entirety of the case, uh, as you're closing, thinking about the post-op plan, not only what the immediate post-op plan, but thinking about what, you know, we're going to do in clinic in terms of post-op protocols, motion, splinting, therapy, etc.

Charles Goldfarb:  Yeah. All of that. And therapy, my God, there's so much to learn from our therapy colleagues.

Charles Goldfarb:  Um, bottom line is, as you said, drinking from a fire hose, love it, take it all in. It's an amazing opportunity for a year of learning that'll set you up for success for the next 35 years, 40 years.

Charles Goldfarb:  Who knows however long you practice.

Chris Dy:  Is that how long you're going to— is that how long you're going to do it for?

Charles Goldfarb:  No.

Chris Dy:  I have a hard stop in my mind. I won't say it out loud, but I definitely do not want to be going for terribly long.

Charles Goldfarb:  Uh, it's great. We're very lucky. I say this all the time.

Charles Goldfarb:  I'm very lucky. We are very lucky to do what we do and have the opportunities that we do.

Charles Goldfarb:  And— and hopefully I show that. I know I don't show it 100% of the time, but hopefully I show it most of the time.

Chris Dy:  Yeah, it shows. Your love for the game shows. Um, so email us any, uh, ideas you have, uh, for future episodes, including the live episode at the Hand Society.

Chris Dy:  Um, so handpodcast@gmail.com. And good luck to those of you that are starting in practice and starting your fellowships.

Charles Goldfarb:  All right. That was fun. Thank you.

Charles Goldfarb:  Okay. Um, let's log back on in a couple minutes, like two minutes.

Chris Dy:  Done. Sounds good.

Charles Goldfarb:  Okay. Thanks.

Chris Dy:  Yep. Thank you.