This document discusses the triad of Head, Heart, and Hand that was coined by Dr. Harvey Cushing as essential qualities of a surgeon. Head refers to using sound clinical judgement and understanding of science. Heart represents compassion for patients. Hand symbolizes surgical skill and teamwork. The document emphasizes the importance of these qualities, as well as continuous learning, humility, and prioritizing patient care over personal or financial gain. Technology is discussed as both enhancing the field of orthopedics but also potentially being misused if not guided by clinical benefit for patients.

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

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

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

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

5. Cushing’s Less Famous TriadCushing’s Less Famous Triad
 Pythagorean simplicityPythagorean simplicity
 Many people base their careerMany people base their career
 Physician Requires a special combinationPhysician Requires a special combination
ofof HHead andead and HHearteart
 Surgeon requires a special combination ofSurgeon requires a special combination of
HHead ,ead , HHeart andeart and HHandand

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

7. HeadHead
 Best surgeons make best DecisionsBest surgeons make best Decisions
 Disciplined thinking and sound clinicalDisciplined thinking and sound clinical
judgementjudgement
 Thorough and deep understanding ofThorough and deep understanding of
basic sciences and pathophysiologybasic sciences and pathophysiology
 Importance of interpreting scientificImportance of interpreting scientific
researchresearch

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

9. HeartHeart
 Medicine is inherently a compassionateMedicine is inherently a compassionate
professionprofession
 Compassion is what causes a surgeon toCompassion is what causes a surgeon to
make patient care his/her first priority,make patient care his/her first priority,
regardless of personal convenienceregardless of personal convenience
 Compassion as impetus for long hours inCompassion as impetus for long hours in
wardward
 Donate services free when patients can’tDonate services free when patients can’t
affordafford

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

13. HandHand
 Meticulous hemostasis,anatomicMeticulous hemostasis,anatomic
dissection and reconstruction with gentledissection and reconstruction with gentle
tissue handling.tissue handling.
 Cushing’s concept of hand was narrowerCushing’s concept of hand was narrower
 Concept of TEAMWORK—Hands of theConcept of TEAMWORK—Hands of the
teamteam

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

16. Ideal Orthopedic SurgeonIdeal Orthopedic Surgeon
 AccuracyAccuracy
 DevotionDevotion
 EmpathyEmpathy
 ExperienceExperience
 PrecisionPrecision
 FantasyFantasy
 Creative talentCreative talent
 scientificscientific
 luckluck

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

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

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

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

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

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

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

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

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

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

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

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

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