I commend Dr. Kim for a very thought provoking editorial last week. In this segment, he discussed some of the challenges faced in the OR as a new practitioner and some of the difficult clinical decisions that don’t always have a direct answer...

On this topic, I would re-iterate that if you are honest with yourself and your patient, you are more likely to make the right decision. HOWEVER, the outcome of any clinical decision is depend on many more factors than what the text book would have said to do…or how good your fixation was…or what kind of suture you used. The clinical practice of medicine has lots of highs and lows, but if it was any easier they wouldn’t call you a doctor.

Please see below for 2 selected reader feedback notes on Dr. Kim’s column:

Editorial Comment #1:

The title "A Man's Got to Know His Limitations" is misleading. Dr Kim certainly had the skills to adequately (and eventually) fixate the fracture in the OR. He also was smart enough to do the correct things when his post op course did not run as uneventfully as he would have liked. He also was willing to discuss this case and its outcome with an older colleague.

What he really learned was that "experience" coupled with his "training" can be key. (I am sure that you are aware that most hospital credentialing committees consider "experience and training" as the rationale for granting various surgical privileges to one physician or another.)

Let me suggest a new subtitle.- "Experience is a Great Teacher"

NAME WITHHELD

Editorial Comment #2:

I very much appreciated the article presented by Dr. Kim, residency insight 14, and would like to take the opportunity to relate my personal insight on this very subject. After practicing Podiatric Surgery in Florida for the last eighteen years, my perspective has become useful to the residents and externs that I help train. Having a purely surgical practice in a 12 member Orthopaedic group, I have without question observed distinct differences between the typical Orthopaedic Surgeon and Podiatric Surgeon in my community. In reference to the types of cases that are considered surgical, the difference becomes quite apparent. It is never safe to generalize, but consistently the management of fractures, and really trauma cases as a whole, have routinely been and continue to be too aggressively treated as it relates to the recommendation of surgery by Podiatric Surgeons. I see at least 10-20 patients a year for second opinions for patients who have suffered minimally displaced metatarsal fractures, non-displaced fibula fractures without medial side injury, etc., whom have been told by their podiatrist that they need surgery. I can't recall one occasion when the same has occurred to the contrary from an Orthopaedic Surgeon. In general I believe the Podiatric community may see less trauma in the office, than the average Orthopaedists, and in a reactionary way, tend to over recommend surgery to this type of patient. In the end, we as Podiatric Surgeons take on an unfavorable appearance to the community as a whole. In response to my observations and experience, I think it is important to spend allot of time with our residents in the office stressing the surgical cases from the non-operative ones. I have found it best to show my successful outcomes of fractures treated non-operatively to best drive this point home. I treat a fare amount of fractures, probably 350-450 a year, but operate on maybe only 200-250 a year, which is just over half of them, and most of those are ankle fractures. It might be wise to keep in mind that if you don't see a significant amount of ankle trauma in your office, then the fractures that you do see probably DON'T need surgery, and if in doubt it is always better to suggest to your patient that they get a second opinion first, before they just get one on their own. The income that you may lose from not doing the unnecessary surgery will come back ten fold in the goodwill and referrals that will result.

James T. Clancy, D.P.M. FACFAS