Category Archives: Philosophy

Energy Transfer: Be Additive.

 by James D. Hundley, MD

            If you’ve never been a patient with a serious problem yourself, you may not have considered this.  Having a medical problem not only drags down your body, it drags down your mind, too.  I’m sure someone taught you about it in medical school, but when we get wrapped up in the technical side of our profession, and it’s absolutely necessary that we do so, this is a lesson that some seem to forget.

Do you know people who are “buzz killers”?  Within a few seconds of being in their presence, you feel your emotional energy being drained and you can’t get away from those people quickly enough.  In contrast, those who are bright and energetic make you feel good and ready to tackle anything.

This is true in the doctor-patient relationship, and it’s serious.  I’ve been around doctors who act so down in the dumps that it seems that they are the ones who need help more than their patients.  Maybe they are tired from working so hard or maybe they are internalizing their worry about the patient, but they sure aren’t helping their patients tackle their problems.  Whatever the case may be, they are sucking needed emotional energy from their patients rather than filling their patients’ tanks with the fuel they need to deal with their problem.

I’m not suggesting that you not show concern.  To the contrary, I’m suggesting that you not only show concern for and interest in your patients, I’m suggesting that you be truly concerned and show it by transferring some of your own positive energy to your patients.

You can’t be silly or trivial.  That’s not what I’m suggesting.  It might take a little practice to find your own best way of approaching this and it’s hard to describe, but it’s about being positive and upbeat to the extent possible in any given situation.

Players play better for certain coaches.  You frequently hear about it.  I’ve seen it with teams that I’ve worked with.  The same players who were losing miraculously start winning.  Surely the reasons for the sudden success are many.  Maybe it’s conditioning or technique.  They’re important.  Without positive energy, however, I don’t think it happens.

Likewise, when you rod someone’s femur or replace someone’s hip, the technical aspects are critical, but that’s not enough.  You have to take care of the other physical needs as well, and I’m sure you do, but that’s still not enough.  You must also help that patient find the energy to get up and go again.  Equally as important, no matter how tired you are or what else is going on with other patients or in your life, you must dig down and find positive energy to share with your patient.

Many will dismiss this as insignificant and/or unrealistic.  I have no scientific studies to support it.  On the other hand, I have had many years of interaction with patients and truly believe that patients do better when they want to please their doctors.  It’s like a player wanting to please his coach.  You can’t fall into the trap of thinking it’s about you personally, of course, but if it’s useful to the patient, it’s certainly not harmful.

Worried that all of your energy will be drained by your patients?  Don’t be.  In fact, the gratification of seeing your patients happily improving or resolutely dealing with serious problems is in itself a source of energy for you.  It’s like heat reflecting off an object and back to you.  Try it.  You either already know that it’s true or you’ll be pleasantly surprised.

Dr. Hundley is a retired orthopaedic surgeon living in Wilmington.  He is the founder and president of a resource website for orthopaedic and other surgeons and related professionals.

Accepting the Risks in Medical Education and Medical Practice

by Douglas Dirschl, MD

In a March 17, 2009 article in the New York Times, Dr. Richard Friedman, a professor of psychiatry at Weill Cornell Medical College, discusses the nearly universal preference patients have for a seasoned physicians over residents or physicians just out of training.  The strong perception is that physicians learn from experience, implying that the “practice” of medicine is just that – a process of continual learning and improvement.

How does one learn in medicine? Clearly, one large component has been intensive exposure to medical practice within the supervision of residency training programs.  Dr. Friedman points out to us, however, that there may be an inherent conflict at the heart of medical training: “what may be best for making a skilled, independent-thinking doctor may not always be best for patient comfort or safety”. We want our young physicians to be competent, knowledgeable, and confident, yet we also have a responsibility (and increasing scrutiny from regulatory and legal agencies) in protecting patients from the medical errors that could result from a physician’s inexperience.

All residents, at some point, leave the relative security of training and go out on their own. Some experts are now questioning whether medical training programs are striking the right balance between education and training and patient safety to produce physicians who can function optimally. Dr. Friedman argues that restrictions imposed by resident duty hour limitations, decreasing amounts of resident autonomy due to concerns of patient safety, and regulatory groups mandating that some medical complications should never occur, have combined to create a generation of young physicians who lack confidence in their ability to make judgments about patient care. In the pursuit of patient safety, we now deliberately prevent residents from acting independently on their own judgment in situations where a patient poses a theoretical risk.

It is said that 90% of orthopaedic residents currently go on to do fellowship training after residency. Is this because orthopaedics has become so highly complex that 5 years is not sufficient time to master it all, is it that residents completing programs today have less self confidence in their own abilities than the generation of physicians before them, or is it that society expectations have increased and it now expects ‘perfection’ of every physician, no matter how experienced. The answer is probably “yes, yes, and yes”.

To date, there are no reliable national data that regulatory changes in resident work hours, patient safety initiatives, or ‘never events’ (for example, CMS has determined that no patient should have a DVT after an orthopaedic procedure, and won’t pay for it if a patient does), have had a significant impact on preventable medical error or patient mortality rates. There is a cost to the development of professional identity of young doctors, arguing that it is hard to feel confident and independent unless you are given ample opportunity to stand on your own — and risk making a mistake.

There is no doubt that all physicians in training – and those in practice as well – pose an inherent risk to patients.  We should do everything we can to minimize this risk but recognize that doing so will probably impair physicians’ self-confidence.  We may end up with a generation of physicians who, by virtue of the environment in which they have trained, are more hesitant, more uncertain, and less self-confident that the American public might like.

Click here to read the full text of Dr. Friedman’s article.

Dr. Douglas R. Dirschl is Frank C. Wilson Distinguished Professor and Chair of Orthopaedics at UNC School of Medicine. He also serves on the Own the BoneSteering Committee and chairs the Critical Issues Committee for the American Orthopaedic Association.

True Success

by Tom Morris

From Plato and Aristotle to the present day, the wisest people who have ever thought about challenge and achievement in our lives and work have left us bits and pieces of powerful advice for attaining true success in anything we do. I’ve put these ideas together in a simple framework of seven universal conditions. Let me lay them out briefly and then we’ll look at each. Whether you apply them in your practice, in your life, or teach them to your patients, they can be very helpful for focusing on what it takes to reach important goals.

The 7 Cs of Success

For the most deeply satisfying and sustainable forms of success, we need to bring into any challenge, opportunity, or relationship:

(1) A clear CONCEPTION of what we want, a vivid vision, a goal clearly imagined.

(2) A strong CONFIDENCE that we can attain that goal.

(3) A focused CONCENTRATION on what it takes to reach the goal.

(4) A stubborn CONSISTENCY in pursuing our vision.

(5) An emotional COMMITMENT to the importance of what we’re doing.

(6) A good CHARACTER to guide us and keep us on a proper course.

(7) A CAPACITY TO ENJOY the process along the way.

There are certainly other concepts often associated with success, but every other one is just a version or application of one of these in specific situations. The 7 Cs give us the most universal, logical, and comprehensive framework for success.

(1) A clear CONCEPTION of what we want, a vivid vision, a goal clearly imagined.

In any facet of our lives, we need to think through as clearly as possible what we want to accomplish. True success starts with an inner vision, however incomplete it might be. The world as we find it is just the raw material for what we can make it. We are meant to be artists with our energies and our lives. And the only way to do that well is to structure our actions around clear goals.

(2) A strong CONFIDENCE that we can attain the goal.

Inner attitude is a key to outer results. Philosopher William James learned from championship athletes that a proper confidence should be operative in all our lives. In any new enterprise, we need upfront faith in what we’re doing. Sometimes we may have to work hard to generate this attitude. But it’s worth the work it takes, because it raises our prospects for success. The best confidence arises out of competence and then augments it.  It’s of course no guarantee of success. But it is among the chief contributors to it.

(3) A focused CONCENTRATION on what it takes to reach the goal.

Big dreams just lead to big disappointments when people don’t learn how to chart their way forward. Success at anything challenging comes from planning your path and then putting that plan into action. Gestalt psychologists teach us that a new mental focus generates new perceptual abilities. Concentrating your thought and energy in a new direction, toward a clear goal, you begin to see things that you might have missed before, that relate to the goal you’ve set. This focus allows you to plan and act, and adjust along the way. Even a flawed plan can start you off and lead you to where you can discover a better one. A focused concentration of thought and action is key.

(4) A stubborn CONSISTENCY in pursuing our vision.

The word ‘consistency’ comes from two Greek roots, a verb meaning “to stand” and a particle meaning “together.” Consistency is all about standing together. Do my actions stand together with my words? Do my reactions and emotions stand together with my deepest beliefs and values? Do the people I work with stand together? This is what consistency is all about. It’s a matter of unifying your energy and efforts in a single direction. Inconsistency defuses power. Consistency moves us toward our goals.

(5) An emotional COMMITMENT to the importance of what we’re doing.

Passion is the core of extraordinary success. It’s a key to overcoming difficulties, seizing opportunities, and getting other people excited about your projects. Too much goal setting in the modern world has been an exercise of the intellect and not also of the heart. Philosophers appreciate the role of rationality in human life. But we know that it’s not just the head, but also the heart, that can guide us on to the tasks right for us, and keep us functioning at the peak of our abilities.

(6) A good CHARACTER to guide us and keep us on a proper course.

Character inspires trust. And trust is necessary for people to work together well. Good character is required for great collaboration. In a world in which innovative partnerships and collaborative synergies are increasingly important, the moral foundation for working well together matters more than ever before. And good character does a lot more than just provide for trust. It has an effect on each individual’s own freedom and insight. Bad character not only corrupts, it blinds. A person whose perspective has been deeply skewed by selfishness or mendacity cannot understand the world in as perceptive a way as someone whose sensibilities are ethically well formed. Good character makes sustainable success more likely.

(7) A CAPACITY TO ENJOY the process along the way.

The more you can enjoy the process of what you’re doing, the better the results tend to be. It’s easier to set creative goals. Confidence will come more naturally. Your concentration can seem effortless. Consistency will not be a battle. The emotional commitment will flow. And issues of character will not be as difficult to manage. A capacity to enjoy the process is entwined with every other facilitator of success in a great many ways.


These conditions of success are all deeply connected. They constitute a unified framework of tools with which we can work our way toward the most fulfilling forms of achievement. They will help us to make our proper mark in the world. They will move us in the direction of true success. And why should we ever settle for anything less?

Tom Morris is the author of such books as True Success, The Art of Achievement, If Aristotle Ran General Motors, and If Harry Potter Ran General Electric. He writes weekly for The Huffington Post and can be found philosophizing on Twitter as TomVMorris.  He can be reached at or through the Morris Institute.

Dr. Morris was kind enough to guest author this article for

The Prayer of a Surgeon Emeritus

by Howard H. Steel, MD

Lord, Thou knowest I am growing older.

Keep me from becoming talkative and possessed with the idea that I must express myself on every subject.

Release me from the craving to straighten out everyone’s affairs.

Keep me from the recital of endless detail.  Give me wings to get to the point.

Seal my lips when I am inclined to tell of my aches and pains.  They are increasing with the years, and my love to speak of them grows sweeter as time goes by.

Teach me the glorious lesson that occasionally I may be wrong.

Make me thoughtful but not nosy, helpful but not bossy.  With my vast store of wisdom and experience, it does seem a pity not to use it all, 

but Thou knowest, Lord, that I want a few friends at the end.

 [Published with permission from Dr. Steel.]

Howard Steel, MD is an icon in Orthopaedics and his inspiration goes beyond Orthopaedics.   Clinically he dedicated his career to children at Temple and the Shriners.  Educationally, he taught thousands of residents, medical students and junior faculty about surgery and life.  In 1970, he founded the Eastern Orthopaedic Association and was the Society President for the first two years.  He has hardly missed a meeting since.  Recognizing there is more to life than medicine, Dr. Steel donated funding (30+ years) for a “non-Orthopaedic” lectureship for many of the regional orthopaedic societies, the AOA and other orthopaedic entities.   Howard is funny, fun-loving and bigger than life.  

Comments about Dr. Steel by Judith F. Baumhauer, MD MPH, University of Rochester School of Medicine and Dentistry

It’s (More Than) OK to Do the Right Thing

by James D. Hundley, MD

            As a retired orthopaedic surgeon, I miss the hallway consultations where colleagues discuss cases while trying to determine the best course for our patients.  Fortunately I am still consulted from time to time and get to enjoy sharing ideas and opinions.

A few weeks ago I was called by a young surgeon who was perplexed by what would be best for his patient, an elderly, emaciated, osteoporotic woman with end-stage Parkinson’s Disease.  She had suffered a displaced, four-part fracture of her proximal humerus from a fall.  He had been taught that these need open reduction and internal fixation (ORIF) if the patient is to regain good function and felt obligated to offer that as a choice.  When so offered, she had stated that she did not want surgery but would think about it.  When he called me, he was dreading that she would call him in the next day or two saying she wished to proceed with ORIF.  How should he respond?

For me the answer was easy.  Treat her with a sling and swathe until the acute pain had subsided and then begin gentle range of motion exercises.  Sure, she would never regain function anywhere near normal but she could still use her elbow and hand to eat and for other similar activities.  Even better, she could bypass the possibility of anesthetic complications and surgical ones such as infection, blood loss, loss of fixation, nerve injury, and so on.

Being the one “in the trenches”, however, and having been taught that the proper treatment was operative, the decision-making for him was more stressful.  He felt that the right thing to do was non-surgical, but feared that that would not be acceptable morally and could put him at risk for a lawsuit.  That’s when I reassured him by saying, “It’s OK to do the right thing.”

I’ve always felt that decision-making is the most difficult part of orthopaedic surgery.  Sure, you must have a significant degree of core knowledge to understand the disorder and have an array of treatments at your disposal.  Probably the biggest decision is whether or not to operate and when if ever to do it.  If you don’t do surgery, how else would you best treat the patient?  If you do surgery, what is the best procedure?  If you run into surprises during surgery, what do you do then?  In every instance, the best decision is what is best for that particular patient at that particular time.  Sometimes, “doing the right thing” requires you to swim against the tide of current opinion and/or what you learned during your training years.  Over time, however, with personal experience and through seeing a variety of perfectly acceptable ways that our colleagues manage similar problems, we can and must learn to trust our judgment as to what is best for our patients.  Thus, no matter which way the fads are pointing at the time, when you include the patient’s wishes and do the right thing, it is always OK.  In fact, it’s more than OK.  It’s what should be done.

Epilogue:  In case you’re wondering, the patient remained steadfast and decided to not have surgery.  Had she requested it, I don’t know what he would have done, but I’ll bet he would have declined to do it.  Thus, although the whole conversation was moot it was interesting and will hopefully help him the next time he is conflicted by what he thinks he should do vs. what he thinks others would have him do.

Dr. Hundley is a retired orthopaedic surgeon with forty years of experience.  He is also a founder and the president of, a free and open-access directory of orthopaedic products and services that was established in 2003 and currently lists over 10,000 products and services for orthopaedic surgeons and related professionals.

Book Review: barebones. A Surgeons’s Tale. by Augusto Sarmiento, MD

 by James D. Hundley, MD

barebones is the inspirational story of a bright, ambitious young man imbued with an iron will and an unwavering inspiration to benefit society through Medicine in general and Orthopaedic Surgery in specific.  This review is not intended to be comprehensive nor do I expect book reports to become a routine of the blog.  It’s simply that Dr. Sarmiento’s life history and his views are so interesting and compelling that I wish every orthopaedic surgeon and resident in training, indeed every physician in the United States, would read it.  As for immigrant physicians, Dr. Sarmiento’s story could well become their Bibles.

The story is well written and describes Dr. Sarmiento’s life and his family struggles when he was a young man through his medical training in Colombia to his orthopaedic residency in the U.S. as an immigrant who could barely speak English to his rise to prominence as an innovator, researcher, academician, and chair of three departments of orthopaedic surgery (two in the U.S. and one in Scotland).  Being elected President of the American Academy of Orthopaedic Surgeons, the largest and among the most prestigious of orthopaedic surgeon associations is evidence of the esteem by which he was held by his fellow surgeons.

As a resident in orthopaedic surgery in the late 60’s and early 70’s I well remember his innovative, dynamic treatment of long bone fractures as it rose to prominence.  I was fortunate to have received my training in a conservative program where the closed treatment of fractures was the first consideration and ORIF was simply one of the choices.  Moving from a long-leg cast to a PTB one for tibia fractures was a huge advance for our patients.

Dr. Sarmiento’s interest and expertise in the treatment of adult hip problems was not as well known, but he contributed significantly to that field as well.

The most compelling message from the book relates to Dr. Sarmiento’s observations of the changes in focus by some orthopaedic surgeons during his career.  Dr. Sarmiento was steadfast in putting the interests of his patients first and foremost while having to fight bureaucrats in hospitals and academic centers as well as politicians and observing and feeling the effects of powerful, fellow orthopaedic surgeons who put self interest before that of their patients and medical centers.

He also documents the efforts and effects of the powerful orthopaedic companies whose “good business” practices were not necessarily “good for patient” practices and believes that these companies have almost taken over the postgraduate education of orthopaedic surgeons.  He believes that the spiraling cost of medical care is one of the unfortunate side effects of that particular shift in source and surgeons practice “cosmetic bone surgery”, surgery that is not indicated for human function.

My only criticism of the book is that Dr. Sarmiento tends to paint our profession with a broad brush of negativity and, like most of us, is concerned that our medical profession will not continue to attract the best and brightest to become physicians.  Fortunately, the numbers and academic qualifications for those applying to medical schools have never been higher.  Hopefully those people will also make good doctors, a concern also addressed by Dr. Sarmiento.

I wish that I could require every orthopaedic surgeon, resident and practitioner, to read Dr. Sarmiento’s barebones.  As that is not within my power, I can only hope that this brief review will entice more to do so.

barebones.  A Surgeon’s Tale by Augusto Sarmiento, MD, Prometheus Books, 59 John Glenn Drive, Amherst, New York 14228-2197,, Published 2003, 379 pages

Dr. Hundley is a retired orthopaedic surgeon living in Wilmington, NC and president of

Synergistic Effects of Marketing through Service

by James D. Hundley, MD

Saturday, October 24th, 2009

Some doctors think that “being a good doctor” is all that is needed to get patients to come see them. That might work over a long period of time, but unless one is in an extremely under served location, that is not likely to be enough. Patients and referring physicians have to know of you to schedule visits or refer patients to you, so some way of getting the word out is essential to having a busy practice. Even when one is currently busy, complacency could have negative future consequences. Surgeons need a constant flow of new patients to maintain an optimal case load. So, if you agree that marketing is important, how do you best go about it? Do you do it by giving money to a marketing agency or could you do it by giving of yourself?Neither way is inexpensive since giving of oneself takes time away from family, play, and work. On the other hand, when you give of yourself in service, you’re likely to get a lot more back than you invest.

Current wisdom seems to be that marketing one’s practice is best done through paid ads in newspapers, magazines, radio, television, yellow pages, social media and so on. I do not think that that is the best way to get the word out. Anyone can say virtually anything in paid ads, so how is the potential patient supposed to know who he or she is really getting in his or her doctor?

During my over forty years of orthopaedic practice, I had some success with marketing through service and relationships. By this I mean giving of one’s time and talents in a variety of ways. In every case, I tried to be more than just a member of an organization or cause. The more you put in, the more you get back. Here are some examples:

Local Marketing

1. I was able to become the volunteer team physician for a local university. The work was a pleasure and much more extensive than outsiders ever imagined, but when they saw me on the bench at basketball games, many figured that I knew something about sports medicine. The same thing works with high schools and community colleges and the need is great.

2. The Rotary Club was a great way to meet business leaders around town. They tended to call me when they or their families had orthopaedic problems. Their employees often asked their bosses who they went to and followed suit. Not only that.  I enjoyed getting away from the grind and pressure for lunch on a regular basis and befriending a variety of community leaders. The Rotary Club is but one of many civic clubs and organizations that bring you considerably more benefit than you take to them.

3. Church is a great way to meet people. Marketing is clearly not the reason one should join and attend a church, but doing so clearly has earthly benefits.

4. Befriending the nurses in the operating room and on the wards can be a huge benefit. That is not to mean that one cannot demand excellence, something that you must do. All it takes is to treat them with respect and recognize that they bring significant knowledge to the care of your patients. By making them partners, you reward a more positive effort in behalf of your patients and the likelihood that they will both come to see you and send their friends and family, too. Non-medical people often ask those in our profession for suggestions as who to see. If I want to how skilled a particular surgeon is, I ask an OR nurse. If they think you’re a good surgeon and a good person, they are likely to send the people they care about to you. If they dislike you, they’ll guide them elsewhere.

5. By accepting appointment to the local library board, I had a fulfilling service experience and met an entirely different group of people. It doesn’t matter what boards you serve on; it just matters that you serve.

6. By working with the local medical society and ultimately becoming an officer, I met many local physicians whom I probably would have never met. It makes a positive difference to physicians to refer their patients to someone they know and feel that they can trust.

7. Writing articles for the local newspaper makes one an instant expert in the eyes of many readers. Not only does it serve people by sharing your medical information, but no matter the subject of the article, having published it makes many more people know your name and more likely to call you. You can always pay for an ad, but news outlets are often looking for items of interest and happy to accept articles written by doctors.

8. I think that word of mouth is the most powerful marketing tool you can employ. You can’t control it like an ad, of course, but if you consistently treat patients in their best interests and get reasonably good results, you will have unleashed a marketing force that is among the most effective.

Statewide Marketing

1. Working with our state orthopaedic society brought significant benefits to my practice. When someone from my city was injured elsewhere and the orthopaedist who took care of them in some other city sent them to someone they knew (i.e. me) to complete their treatment or follow-up, it enhanced my reputation at home. People talk and tell their friends; and that kind of talk is good.

2. Working (fund-raising in my case) with my medical school and residency program enhanced my reputation at home.When there is friendship and mutual respect between you and a professor of orthopaedics who speaks well of you to patients from your home town, they take note, and they tell their friends.

The above activities will only get more people in your door.Once they get there, it’s up to you to properly take care of them, and that includes way more than surgical competence. Application of the four “A’s” (ability, affability, affordability, and availability) is critical.That applies to their entire experience in your office and the surgery center or hospital.

Let’s face it. Patients generally have no good idea as to an individual surgeon’s abilities. They have powerful perceptions, but they are not likely based on objective data. If you consistently treat patients in their best interests and with respect, they will keep coming back. First, of course, you have to get them to come see you at your office.

So, if you’d like to increase your patient load without spending more money, you might just try marketing through service and relationships. Not only is your practice likely to benefit, but the personal benefits of gratification and personal growth that incur from altruism beyond your daily medical practice may pleasantly surprise you.

Dr. Hundley is a retired orthopaedic surgeon with forty years of experience.He is the president and a founder of

A Triumph of Matter over Mind

by Augusto Sarmiento, MD

January 25th, 2014 

The current pervasive and misguided infatuation with the idea that in the care of fractures it is indispensable to achieve perfect restoration of anatomy in all instances in order to obtain good clinical results continues to blind many in our profession. I have previously made reference to this obsession suggesting that we train our residents to be cosmetic surgeons of the skeleton rather than physicians/scientists1.

My belief that Orthopaedics is losing its scientific primacy and rapidly becoming an entirely technical discipline was reinforced a short time ago when I learned of a clinical situation where passion prevailed over reason with very likely adverse serious consequences.

The clinical case consisted of a 21 year old man who was involved in automobile accident rendering him paraplegic. In addition he had suffered bilateral comminuted, distal intraarticular fracture of both forearms. The fractures were treated by means of internal fixation using plates and screws as well as multiple pins that held together the diligently repositioned small fragment. Radiographs obtained following surgery demonstrating excellent reduction of the fractures.

For reasons not known to me, the surgeon chose to improve upon the fixation achieved from the plates and screws by placing on the dorsum of the patient’s right arm a long plate that extended from the neck of the third metacarpal to the mid-radius. Several screws filled the holes in the long plate. This plate, I was told, would be removed six weeks after surgery; therefore I assumed it was not intended to encourage fusion of the wrist.

I cannot express strong disagreement with the procedure performed for the care of the radius fractures that must have taken a great deal of time plus the likely possibility that the extensive dissection of the bony fragments could result in major stiffness of his wrists joints. After all this is the current party line. However, I cannot help but question the wisdom of inserting a plate that inevitably will increase the degree of limitation of motion of the wrist from which the patient will never completely recovered.

This very realistic scenario provokes an even greater discomfiture when one realizes that the young man was paraplegic and will remain paraplegic for the rest of his days. As such, his only mode of locomotion will be a wheel chair, from which he will transfer to his bed and automobiles. A bit of thought should have made the surgeon aware that transfer activities from a wheel chair require a significant degree of dorsiflexion of the wrists. In order to lift one’s body with the use of the hands, dorsiflexion of the wrists is essential. The young man, I anticipate, will not be able to do so, and if he masters s technique to accomplish the task it will be a very complicated and difficult one.

I have surmised that the surgeon performing the surgery was very likely a technically skillful one, but either because of his blind reliance on the virtues of internal fixation and perfect reapproximation of fragments, or lack of objectivity, he has condemned a young man to a disability greater than the one that the paraplegia had already imposed on him.2. It does not suffice to adhere to the aphorism expressed by Simon Bolivar, the Latin American liberator, “Good judgment comes from experience and experience comes from bad judgment”, at least not when we are dealing with the health and future of other human beings.

The rampant lack of objectivity, clearly demonstrated in this instance, can be improved if we, the educators, emphasize objective reasoning to our students. Unharnessed enthusiasm and fascination with surgical experiences must be tempered with reason. “La raison avant la passion”.


1.   Sarmiento A. The future of our specialty. Acta Orthopedica Scandinavica. 71 (6): 574-579, 2000

2.   Sarmiento A. Have we lost Objectivity?  Jour. Bone and Joint Surgery. Vol. 84A:  1254-58, 2002.

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on and has guest authored a number of other articles for this blog.

The Dangers of Unchallenged Tradition

by Augusto Sarmiento, M.D

November 27th, 2013 

     Since for the first time I find myself with time in my hands I decided to dwell on exploring issues with which in the past I was involved to a major degree. Today I will discuss an issue where long-held, rigid adherence to an unchallenged tradition has forced me to challenge its validity.

My comment deals with the Colles fractures, which is one of the first subjects in orthopaedics we come into contact during our year of internship.  We learned about the ubiquitous fracture that affected a large number of older people and were told that its treatment was simple and the clinical results good.  All that was needed:  “closed reduction” and immobilization in a long arm cat for a few weeks.

It was not until late in my career that I first began to ask questions as to the etiology of the frequently observed loss of the obtained reduction. I had followed the gospel-like lessons we had learned from the British orthopaedist who forcefully stated that once the reduction had been obtained, the cast had to extend over the elbow, the forearm held in pronation and the wrist in a position of ulnar deviation and slight flexion.

One day, however, I suspected that the recommended position of the foreman in pronation in the cast was the guiltiest party. My logic was based on my understanding of the anatomy and physiology of the wrist. I reasoned that if it is true that muscles in order to function most effectively should be placed in a condition of tension then the forced pronation of the forearm would result in activation of the brachioradialis muscle, the only muscle attached to the distal radius, and in that manner recreate the deformity. The contraction of this muscle during flexion of the elbow could easily displace proximally and dorsally the distal radial fragment. 1

I met with the neurologist who was performing electromyography and asked him for his advice and help. I brought him volunteer medical students and patients to have the studies conducted.  Without exceptions, every time the elbow was flexed the brachioradialis muscle contracted. In cadaver specimens, where we had created fractures that resembled the Colles fracture pattern, any pull on the muscle readily recreated the typical deformity.

Based on all that information we began to treat Colles fractures in supination and compared the results with those obtained when treated in pronation. The results were published, which indicated a lower incidence of re-displacement in the supination group. We went as far as developing a foreman brace that permitted limited flexion of the elbow, but prevented pronation of the forearm. It permitted limited flexion of the wrist but made impossible any radial deviation. 2, 3 I concluded that the classical position as described by Colles and faithfully accepted by the orthopaedic community was wrong.

At that time my career took a major turn toward Hip surgery following  a three-month visit to Sir John Charnley in England that resulted in my concentrating more seriously on total hip replacement and ignoring to some degree my interest in wrist fractures. I deeply regret the foolish decision since I am sure I could have been able to continue to devote time to both subjects simultaneously.

I vividly recall that during those days of romancing with Colles fractures I visited with some regularity local Nursing Homes where I followed patients I had treated surgically for various conditions. Oftentimes I took along with me one or two residents. During those visits I made it a habit to ask as many patients as possible if they had at any time in their lives sustained fractures of their wrists. As expected, many of them had. I saw many where a close look failed to indicate any deformity whatsoever. Other times I observed obvious deformities.  However, I have no recollection of a single patient who presented symptoms of osteoarthritis or complained of any serious clinical problems as a result of the deformed wrist.

No doubt, my mind was conditioned not to question the wisdom of Colles and consequently I had rigidly adhered to his well-intentioned but erroneous premise. I suspect we do this very often with many other pronouncements and treatment which overtime gain an odor of sanctity that precludes questioning. This is why I am such a strong advocate of conditioning residents to ask questions and to challenge virtually everything we teach them.

During the last two decades a great deal of enthusiasm has grown in support of open reduction and internal fixation of Colles fracture. The readers would not be surprised to hear that I have not surrendered to the new treatment modality. However, I trust I am smart enough to realize that the technique has made possible the attainment of better anatomical reduction and restoration of articular congruity and in many occasions is the treatment of chicer. 

        Approximately 10 years ago I sustained a comminuted, intraarticular Colles fracture with a severe dislocation of the radio-ulnar joint.  My hand surgeon fixed the fracture with multiple wires. When I woke up from the surgery and glanced at the radiographs I immediately commented “This will never work.” My remark was based on the recognition that the dislocated radio-ulnar joint had not been addressed. The surgeon had concentrated on reduction of the fragments in the best possible way, but ignored the dislocation of the ulna, which was the most important feature. Good fragment reduction in the presence of a dislocated radio-ulnar joint is not enough, particularly if the distal-lateral radial fragment has an oblique geometry. The reduction is easily lost when the brachioradialis contracts    . That was exactly what happened. Ten days after surgery new x-rays demonstrated the recurrence of the radial deviation of the held-together distal epiphysial bones. Soon after that I was back in surgery where a plate was used to stabilize the bony fragments.

My feeling regarding the closed treatment of Colles fractures may soon become meaningless since the current infatuation with surgery is displacing the nonsurgical treatment into the heap of history. Or maybe not. We should not be surprised if within a few years the orthopaedic profession will conclude that plating was nothing but a flash in the pan when the technique is applied to all displaced fractures and that plate fixation should be reserved for the very severely comminuted fractures with associated radio-ulna dislocation. We are already learning that the results from routine surgery are not any better than those obtained from manipulation and close reduction. Economics may the fact that triggers the arresting of the trend. Equal pay for the care of those patients may become the law of the land regardless as to whether or not surgery is performed.


  1. Sarmiento, A. The Brachioradialis as a Deforming Force in Colles’ Fractures Clin. Orthop. Rel. Res. 38:86-92, 1965.
  2. Sarmiento, A., Pratt, G.W., Berry, N.C. and Sinclair, Wm. F. Colles’ Fractures – Functional Bracing in Supination. J. Bone and Joint Surg. 57A:3,311-317, 1975.
  3. Sarmiento, A., Zagorski, J.B. and Sinclair, W.F. Functional  Bracing of Colles’ Fractures: A Prospective Study of Immobilization in Supination versus Pronation.  Orthop. & Rel.  Res. 146:175-187, 1980

Dr. Sarmiento is the former Professor and Chairman of Orthopaedics at the Universities of Miami and Southern California, and past-president of the American Academy of Orthopaedic Surgeons.  He is a contributor to Implant Identification on and has guest authored a number of other articles for this blog.

Laying Crepe

by James D. Hundley, MD

In days of yore, undertaker assistants were tasked with hanging crepe (black cloth) over the windows of homes of the deceased and were called “crepe hangers”.  Similarly, they laid crepe over the casket of the deceased.  “Hanging crepe” and “laying crepe” have become euphemistic terms for extreme pessimism.

Surgeons are castigated for “laying crepe” with patients and their families before surgery when the formal operative consent is obtained.  Critics claim this creates unnecessary fear in patients so that when the operation is successful the surgeon appears a hero or without fault if it’s not.

I disagree.  It’s neither about heroes nor about lawsuits.  It’s about “informed consent”.  Patients deserve to know the bad as well as the good before they have an operation.  Otherwise, how can they make informed decisions?

A good friend of mine was recently discussing upcoming surgery on his infant grandson.  The child has a congenital heart condition and has already undergone an open-heart operation.  The heart surgeon has apparently told the family that the second procedure is serious and will be more difficult than the first.  I told my friend, ”The surgeon was ‘laying crepe’.”

The surgeon is an esteemed, pediatric, cardiac surgeon.  He knows what he is doing in the operating room, and he knows that the family has a right and a need to be fully informed before consenting for their son to have surgery.  This is a serious situation and they deserve to know the good, the limits of good, and the bad.  They also need to know if additional surgery will be required in the near or distant future.  Thanks to a thoughtful surgeon, they are informed.

Taking this a step further, I’ve sometimes had patients tell me after the informed consent discussion, “Go ahead and do it, Doc.  It can’t be worse than it is now.”  My consistent response to that was, “Yes, it can always be worse.  I’m not sure you were listening.”

Finally, there is no way anyone can be fully informed.  Complications can occur that have never been reported or happen so infrequently that the surgeon feels these unnecessary to discuss for fear of losing the patient’s attention with such a long litany of potential problems that even careful listeners become overwhelmed and stop listening.

Perhaps the most important part of this discussion is what the surgeon may have left unspoken.  No ethical surgeon, except in dire, emergency circumstances when there is no other way to save life or limb, will perform a procedure that he is not confident can be successful.  He cannot promise a good outcome or that unexpected complications may not occur.  He can only promise that he is confident that he can perform the procedure properly and that he will do his best.

So, when your surgeon “lays crepe”, I think you should consider these things:

  1. Your surgeon would not be performing the procedure if he did not expect a successful outcome.
  2. The fact that he is telling you about potential complications tells you that he knows these things, will take measures to avoid them, and wants you to be as informed as possible before the surgery.
  3. By telling you what a good outcome will likely be, he is helping you set rational expectations.
  4. By telling you if additional surgery will be required, he is doing his best to avoid unpleasant future surprises.

What else does it tell you?  It says that he is not trying to “sell” (or talk you into having) the surgery by downplaying potential complications.  He sincerely wants you to be as informed as possible before making your decision.  You always have the right to say, “No.”, even as they are wheeling you into the operating room.

Dr. Hundley is a retired orthopaedic surgeon and the founder and president of