The most difficult thing about being in clinical practice is learning good clinical judgment. Clinical judgment is not something they teach you during residency training. Residency training provides you with the technical and didactic knowledge in the care of a patient, but the nuances of proper patient selection are not directly taught. My favorite quote from Clint Eastwood is “A man’s got to know his limitations”. I think this is critical in being a good physician. At some level the lack of experience can be a limitation. A young practitioner does not have years of experience to guide him or her.

An example is my first surgical case out of residency. This is a 68 year old active female with a 5th metatarsal fracture.

Without hesitation I thought that surgical correction would be the best treatment option for this patient. The radiographic configuration indicated an oblique fracture that would be amendable to ORIF with screw fixation in a lag fashion. Simple right? When I got exposure I was able to see how comminuted the fracture was, further the bone was extremely osteoporotic. I attempted to place (2) 2.0mm screws which did not have any bite. I then attempted k-wire fixation which lacked stability. Hence, I ended up placing a circlage wire around the fracture fragments.

The patient was then cast immobilized. The surgical wound then promptly dehisced and the bone was delayed in healing and hence I began local wound care and I started the patient on an external bone stimulator. The circlage wire did not provide sufficient stability hence the reduction was not maintained and bone went on to heal slightly angulated.

I discussed the case with a colleague with many more years of experience than I have. His response was “why did you take the patient to the OR in the first place, these fractures heal nicely with cast immobilization”. Although the patient is happy with the result, I am not sure I made the right decision for this patient. I guess with more clinical experience some of the pitfalls of doing surgery will become less cavernous. Good luck!