an important topic for all budding surgeons

1. Surgical excellence : the
triad of Three H’s
Prof.G.S.Patnaik

2. preface
 The Khoula Cafeteria conversation
 Confusion regarding Orthopedic discipline
 Need for correcting the confusion
 Target audience – Medical Students and
the Residents So that they develop a
genuine interest in this discipline

3. And…….
 Orthopedic Surgeons : Introspection of
our surgical learning and conduct and
above all reinforcing the necessity of
continuous update about the recent
trends in our respective disciplines
 Reminding ourselves the difference
between fixing and healing

4. Cushing’s Triad
More famous triad of Hypertension,
Bradycardia and Bradypnoea associated
with increased intracranial pressure

5. Cushing’s Less Famous Triad
 Pythagorean simplicity
 Many people base their career
 Physician Requires a special combination
of Head and Heart
 Surgeon requires a special combination of
Head , Heart and Hand

6. Dr.Cushing
 Founder of fields of Neurosurgery and
Endocrinology.
 Foremost surgeon of his era
 He exemplified surgical excellence
throughout his career
 His notion of Head , Heart and
Hand,though a great over simplification is
the framework for surgical excellence

7. Head
 Best surgeons make best Decisions
 Disciplined thinking and sound clinical
judgement
 Thorough and deep understanding of
basic sciences and pathophysiology
 Importance of interpreting scientific
research

8. Head
 Halstead, father of Modern Surgery believed
that contents of surgical training be
well defined
 Surgeons should be taught to think
 Research should be a part of surgical training
 It is not by chance that ‘head’ appears first in
the triad in Cushing’s description of the qualities
of a surgeon

9. Heart
 Medicine is inherently a compassionate
profession
 Compassion is what causes a surgeon to
make patient care his/her first priority,
regardless of personal convenience
 Compassion as impetus for long hours in
ward
 Donate services free when patients can’t
afford

11. Heart
 Besides compassion a surgeon’s heart
must be resilient so that he/she can
persist in the face of setbacks
 Surgeon’s heart must be courageous to
allow him carry procedures involving
significant risks

13. Hand
 Meticulous hemostasis,anatomic dissection
and reconstruction with gentle tissue
handling.
 Cushing’s concept of hand was narrower
 Concept of TEAMWORK—Hands of the
team

14. Hand
 Conception of ‘Hand’ must encompass the
responsibility of surgeons to police their
field through the voluntary monitoring of
outcomes
 They must work together to ensure the
common goal of technical excellence is
achievable by ALL.

16. Ideal Orthopedic Surgeon
 Accuracy
 Devotion
 Empathy
 Experience
 Precision
 Fantasy
 Creative talent
 scientific
 luck

17. Good Qualities
 Humility and ability to recognise and avoid
unnecessary dangerous situations .
 Treat patient as a fellow human being.
 Take RESIDENCY TRAINING seriously: In
no other profession your strengths are so
appreciated and your weakness so
exposed
 No way to prove you are a born surgeon

18. Good Qualities
 Conscientiousness,creativity,courage and
persevarance on behalf of your patients are
crucial factors & they outweigh the small
differences in dexterity amongst most medical
students.
 Being a good surgeon is a life long process
 Thoughtfull reflection on the outcomes of your
decision will gradually give you the most
important quality of GOOD SURGICAL
JUDGEMENT.

20. Qualities contd…
 Qualities crucial in a good surgeon(Sadly
Missing in Many) is to see the whole
person and to be sincerely concerned for
his/her welfare and making
communication between patient and
physician comfortable and easy .(Not only
treating one leg or one ear and forget the
whole patient)

21. ARROGANT SURGEONS
 It is natural to glorify one’s own speciality
 A surgeon becomes dangerous when he begins
to believe in the infalliability of his own speciality
 More likely to attempt more aggressive and
dangerous procedures exposing their patients to
greater risks and serious surgical complications
 Beware Of any speciality that advertises itself of
having best training.

22. Average surgeon Vs.Ideal surgeon
 Mastery Of complex problems
 Improvement and update of knowledge
 Skills with which data are used , applied
and analysed
 Adaptibility to stress ,emotional
stability,manual skills ,quick
wittedness,real clinical flair,
 Conscientiousness and solid ethics

24. C.M.E
 Very Important in any health care set up .
 More stress on Dissipation of knowledge rather
than projection of individual persuits .
 Appropriate moderation
 Education should be the Aim
 Continuous Medical Education Vs Continuous
Morning Entertainment

25. Impact of Technology on
Orthopedics
 Joint replacement, arthroscopy,spinal
instrumentations, osteosynthesis speak about
the technology
 Adverse repercussions affecting our discipline
primarily because it was a technological
revolution rather than evolution.
 Traditional procedures having a biological
foundation replaced with new sophisticated
technical methods .eg CT,MRI etc

27.  We are made to conclude that if there is a
technology to treat a certain problem it
must be used in all similar circumstances
even if the ultimate benefit is radiological
satisfaction.
 Industry dominates the orthopedic
profession : ulterior motives, misuse of
authority, financial gain vs Clinical gain

29. How to Combat
 Take technology to our stride and let it be
our strength
 Should be in the best interests of our
patients and their costs don’t jeopardise
the economic balance that society expects
us to protect

30. As Professionals
We must emphasis that Orthopedics is
certainly a well defined body of
knowledge acquired through a long and
sophisticated period of training and not a
series of surgical operations which anyone
with a modicum of manual skills should
be able to perform

32. Complications
• Aim for the least but act fast once it occurs.
• Inexperience of Surgeons , Incomplete knowledge
base and overconfidence bring complications
• Let the modern surgeon not be the most virulent
pathogen for his patients
• Polytaruma On the Roads Vs Operating Rooms

33. To Conclude
 Orthopedic Surgery is a science that
caters to one single constant in the world
of change and that is “caring for your
patients”.
 Let us revert back from being a technician
who fixes an anatomical problem to being
a physician who heals.
 Need for reinforcing strong Doctor-Patient
relationship

35. Finally……..
May we never forget that patient is a
fellow creature in pain ,may we never
consider him merely a vessel of disease