记著名骨盆专家Joel M Matta 教授和对成为优秀医生的建议

 

       JM Matta 教授是美国St. John"s Health Center医院骨科主任，著名的骨盆和髋部疾患的专家，是至今个人骨盆和髋臼骨折手术例数最多的专家，设计多种手术床和骨盆复位器械，并提出臼顶角的概念和复位标准。武汉同济医院创伤外科易成腊

     多次访问其个人网站，对其对如何成为优秀骨科医生这篇文章非常感兴趣，阅读多遍，认为对我们年轻医生的成长有非常重要的指导意义，特此将其翻译成中文，与大家共勉。

EXCELLENCE IN CLINICAL PRACTICE

成为优秀的临床医生

HOW TO IMPROVE YOUR CLINICAL RESULTS

如何提高你的临床治疗效果

 

What is the formula for excellence in orthopaedic clinical practice? Certainly there is no set formula for all but I will give you my thoughts based upon what I have learned from others as well as my personal experience.

成为优秀的临床骨科医生有定则吗？当然没有，但是我给你来自我向其他和我自身的经历的一些建议。

There are a number of ways that excellence can be measured but I think the most important is by the benefit we provide to our patients which is our clinical results. Top clinical results exist in many settings and are not necessarily related to the notoriety of the surgeon or institution.

许多可以作为衡量临床医生优秀的方法，但是最重要的为患者提供益处是我们的治疗结果。最好的临床结果可以存在许多情况，而不必与医生或机构的声望联系起来。

My first recommendation is to pursue the type of practice you have a passion for. You should find your niche according to your interests and your abilities. Monetary reward will to a degree direct our activities however you sell yourself short if you place money first. In Orthopaedics we can have our “cake and eat it too”. Our position allows us to enjoy our work as much as sport, gain personal satisfaction and community recognition, and in the bargain also be well compensated. I think the key to all of these benefits however is our passion and commitment to our work. There are few careers available that combine the pleasure of both manual and intellectual challenges.

我的第一个建议是从事你有兴趣的专业。你应该根据你的兴趣和能力寻找你的位置。如果你把金钱放在第一位置的话，物质的报酬很容易左右我们的活动而出卖自己。在骨科专业，我们有我们的“蛋糕并吃掉它”。我们的工作能够象体育运动一样享受我们的工作，获得个人的满足和社会的承认，并在物质上得到一定的补偿。我认为这些利益来自我们对热情和工作的实施。很少的职业能象医生一样将体力和脑力的挑战和取得的愉快结合起来。

Though we are surgeons and the job we do in the operating room is probably most important we must also take pride in our one to one skills with patients. If the patient is able, the more he understands about his problem the better. Pre and post operative detailed explanations can help the final result. I also rely on patient information publications and my own web site to inform the patient and family.

可是我们是外科医生，我们的在手术室的工作非常重要。我们必须以对病人实施一个接一个手术技术自豪。如果患者能够的话，让患者了解其病情越多越好，术前和术后手术详细的解释对最后的结果有很大的帮助。我也通过患者公共出版物和个人网站通知患者和家属。

In the acute high energy trauma situation be disciplined regarding the physical examination. The patient should be completely undressed and all skin areas visualized. As well as a neurological exam, palpate and move all extremities that do not have obvious deformity. Use x-rays liberally.

在急性高能量创伤情况下，必需进行严格体格检查。患者应该完全裸露，所有皮肤可直视。象神经系统检查一样，触诊和运动肢体如果没有明显的变形的话，做X光检查。

For the sub acute or chronic problem listen carefully to the patient. You need to always assume that the patient is telling the truth and is not crazy or a “crock”. There are many problems we don’t yet understand and everyone does not fit neatly into a category. Many old trauma problems such as mal unions and non unions require a unique solution that you need to invent. The extra time you spend in planning and consultation will make the difference.

对于亚急性和慢性患者仔细聆听患者的主诉。你需要经常设想患者告诉的是事实，而不是发疯或废话。有许多我们还不知道的问题，并不是每个患者的疾病适宜归纳某一分类。许多经典的创伤问题，例如骨折的畸形愈合和不愈合，需要你设计独特的解决方法。你在计划和会诊所花的额外时间将会带来不同的治疗结果。

At times we find ourselves at a loss with patients, particularly those with chronic pain problems who will often say “you’ve got do something” or “I can’t live like this”. The justification for surgical treatment however should not be based on such desperate reasoning. Surgery should always have a probability of success when undertaken. You may have nothing to offer the patient and in that case it is best to say so. In a few cases I have gone so far as to tell patients that they should quit seeing doctors before somebody operates. A large proportion of these difficult patients are chronic narcotic users. I believe it is our responsibility to limit prescription of these medications to acute situations or terminal situations such as neoplasm.

有时候我们面对有些患者的感到不知所措，特别是那些慢性疼痛患者经常说“你要为我做些治疗”、“象现在这样我不能生活”。然而外科治疗的选择不能依靠这些不合实际的理由。外科手术的实施应该有成功的可能性。你有可能不能为患者做什么，这些病例你最好这样讲。有些患者我告诉他们在某人手术前停止看医生。一大部分这些困难的患者多半是长期服用麻醉药品的患者。我相我们有责任对于急性患者和肿瘤晚期患者减少使用这这些药品。

Be expert in interpretation of x-rays, CT and MRI. These combined with the clinical factors provide the main indications for surgery. Maintain indications for surgery and not just operate because there is a fracture. The integrity of you and our specialty suffers with application of faulty indications. Operating without the proper indication is not just unethical it is an assault.

熟悉阅读X光片、CT和MRI。这些和临床症状结合起来为提供手术指征的主要因素。外科手术和非手术的的主要适应症主要取决于骨折。你和我们的专业知识的要求免遭错误的手术指征的申请。没有合适的手术指征而手术是不道德。

 

Performing high quality Orthopaedic surgery is a goal we all aspire to. Within your chosen niche do everything you can to learn from the best. Read publications and texts. Attend courses. As we interpret medical data, large multi center studies can tell you the standard level of care that is present as an average across centers. Pay attention also to the results of experienced and knowledgeable single surgeon series. The large single surgeon series can represent the level of results that can be obtained with dedication to the subject.

做高质量的骨科手术是我们追求的目标。在你所选择的手术范围可以向做得最好的学习。阅读文章和专著，多参加学习班。当我们解释医学数据，多中心研究能告诉你的是通过多中心之平均的标准水平。同时注意实验和多个著名医生结果。大量单个医生的研究代表此领域当前所取得的研究水平。

Visit and observe patient care and surgery with the field’s best. Most orthopedic surgeons are open to this. A corollary to this is: learn and adopt the best existing techniques before attempting to modify or develop new ones. In learning a technique, the technique must be learned and adopted completely in order to expect the maximum benefit to the patient and in some cases to avoid disaster. As a resident in 1978 I attended my first Swiss AO Course. Upon returning home I was delighted to be presented with a tibial plafond fracture. I operated enthusiastically but as the months progressed I watched in horror as green bone fell out of the wound. I had learned how to plate and screw the bone but not how to make the proper incision and handle the soft tissues. Acetabular fracture surgery is successful by a specific combination of the table, patient positioning, surgical approach, reduction techniques and implants. I have quite a few visitors who wish only to peer into the open wound. Learn and adopt the best existing techniques in their entirety before attempting to modify and develop new ones. This knowledge will keep you from repeating the mistakes of past failed techniques and forms the basis of our technical evolution.

访问和观察此领域做得最好病人护理和手术。大多数骨科医生对此是欢迎的。这种做法的依据是：学习和采用当前最好的技术，以后再改进和发展新的方式。学习一项新技术，此技术必须完全掌握为了患者取得最大的益处，有些病例避免灾难的发生。1978年我还是住院医生，我参加了我的第一次AO学习班。回来之后，我做了一台胫骨平台骨折非常兴奋。我很热心做此手术，但几个月后，我惊恐地发现伤口下露出绿颜色的骨质。我学会了怎样对骨折放置螺钉和钢板，但不知道选择合适的手术入路和处理软组织。髋臼骨折成功的手术治疗取决于手术床、病人体位、手术入路、复位技术和内固定物。有许多来我这里的访问者只希望看看切开的伤口。在想改进和发展新技术之前，完整地学习和运用已存在的最好技术。这些知识能防止你重复犯一些不成功技术和方式所带来的差错，最新的技术是从这些技术发展而来的。

Is everyone created equal as surgeons? Of course not. Surgery is a combination of intellect and motor skill. I would say that intellect is by far the most important factor. Understanding the fracture before surgery, establishing a good plan including set up, approach, reduction and fixation strategies are the most important factors. Concentrate your plan more on how you will reduce the fracture rather than how you will fix it. Reduction is typically a bigger problem then placing the implant. For a given surgery, one of several implants may be applicable and you familiarity with a device may be the reason to use it.

是不是所有的外科医生能取得相同的成就呢？当然不能。外科是体力和脑力的结合。我会说理解力是最重要的因素。在手术前对骨折的理解，建立好的手术计划，包括设备、手术入路、复位技术和固定策略都是非常重要的因素。对于一个外科手术，会从集中内植物中选择一种应用，当然你所熟悉的内植物是你选择的理由。

I think that surgeons are often best judged not by a surgery where everything goes well but by how they react when things start to go wrong. I have witnessed “flails” triggered by panic with the situation going from bad to worse. The high stress of a problem situation should ideally trigger your mind to a higher level of focus to deal effectively with the unexpected problem. Experience and contingent strategies can help.

我认为判断外科医生好坏的最佳方法不仅是外科手术做得好，更重要的是对开始出现错误的反映。我经历过当情况变得越来越糟时所触发的连环恐慌。出现问题所带来的精神压力会使你的思想集中有效处理意外问题的发生达到更高的水平。经验和暂时的对策会有一些帮助。

Following surgeries we need to critically assess the result. I would say that a minority of my surgeries are performed completely to my satisfaction particularly regarding acetabular fractures. I like to have a think after surgery in the presence of the post op x-rays regarding how things could have been done a little better.

手术后我们需要严格地评估治疗结果。我想说的是对于髋臼骨折，只有少部分我完成手术完全令我满意。我喜欢手术后对术后X关片的情况作些思考，哪些情况需要做更进一步改进。

How important is speed in performing surgery. At the beginning of my career I did not consider speed to be very important but I think it is an important factor though admittedly not the most important one. I think speed is a benefit in limiting tissue trauma and infection. It is also an economic factor for you and the hospital as well as one that limits the number of patients you can benefit. During my early years of operating acetabular fractures I was assisted for the first time by my chief, Gus Sarmiento on a Kocher-Langenbeck approach to a transverse plus posterior wall fracture. If you know Gus Sarmiento you know he is not particularly patient. Gus’s first words at the scrub sink, “Joel, how long is this going to take?”. My response, “Gus, relax and get ready for a four hour case.”. His response, “Four hours, I’ll give you 2!”. The case took 2 hours and the result was as good as my 4 hour cases and from that time forward similar cases took about 2 hours. On the other hand you need to take the time necessary to achieve the desired result. Speed is not a primary goal but should increase progressively with your years of experience. When you watch a good surgery go quickly you will not see particularly fast movements but rather well planned and effective ones.

提高手术速度也非常重要。在我的职业生涯开始期间我认为手术速度不是非常重要，但是我认为它显然是一个非常重要的因素但不是最重要的因素。我认为手术速度对减少组织创伤和感染有益。它也是影响你和医院的经济因素，影响收治病人的数量。在我做髋臼骨折的早期，第一次是有我主任Gus Sarmiento帮助我采用Kocher-Langenbeck入路完成一例后壁+横行骨折病例。如果你了解Gus Sarmiento的话，他不是特别有耐心的。在刷手池的第一句话是“Joel,手术要花多长时间？”我的回答是：“Gus，放松和准备要花4小时的”。他回答道：“4小时，我给你好小时。” 此病例花了2小时，和花4小时的病例同样好结果，从此以后类似的病例花2小时。另一方面你需要花费达到预期的结果。速度不是最初的目标，但是经过几年的积累应该逐渐提高。当你看到一个好的手术进展很快的时候，你不必看快的动作，而是好的计划和有效的操作。

As an orthopaedic surgeon you are the organizer and leader of the OR team. Regardless if you think that you are inherently organized or an obvious leader type this is your role. I don’t think that personal charisma or forcefulness is a prerequisite for leading an effective team. The factors I consider most important are planning, providing respect, education and encouragement for your team members and working with the team in a hands on way. The concern you show for the patient and the commitment you show for achieving an excellent surgical result will rub off. By all means don’t be the one who is responsible for delays or your tardiness and lack of efficiency will also rub off. Leading the team, trying to improve performance and efficiency is a job that never stops.

作为一个骨科大夫，你是团队的组织者和领导者。不管你是否认为自己有天生被组织或显著的领导类型，这是你的角色。我不认为个人的领导才能和强制力是领导一个团队的先决条件。我认为最重要的因素是为团队成员的计划、尊重、教育、鼓励和同团队一同工作。你对患者所表现的关心和对获得好的治疗结果手术实施有时困难。领导团队，尽力提高手术质量和效率是一项坚持不懈的工作。

Surgical complications are inevitable and the indication for any surgery must be judged in relation to their potential incidence. When a complication occurs an honest discussion with the patient at an early time is essential. There is a tendency to feel guilt and a wish to avoid the inevitable discussion with the patient and family. It is important to use the word complication and confront the situation openly and directly. The patient will at least take comfort that you are still with him in his care and will do everything possible to take a positive course. Surgical wound complications such as hematoma and infection are some of the most difficult to face and potentially harmful to the patient. Three orthopaedic surgeons can look at a wound regarding infection and say no, maybe or yes. It is easier to pronounce a colleague’s wound infected than your own. Saying infection is present to yourself, the patient, and writing it in the chart aids in getting on with effective treatment.

手术并发症不可避免和必须判断每一个外科手术指征和并发症发生率的关系。当一个并发症发生后，应和患者早期真诚的交流。医生倾向感到内疚并希望避免与患者和家属交流。运用并发症这一词语并开放、直接面对这种情况非常重要。病人至少感觉你仍然关心他，为下一步采取积极的措施提供可能性。象血肿和感染等伤口并发症很难处理，对患者产生损害。三位医生能对看同一伤口的感染情况判断可能说是、可能或没有。对同事伤口感染的判断比对自己的容易得多。感染出现时对自己、患者说明，并在病历中记录下来和积极有效地处理。

The public often believes in the myth that miracles in medicine are the norm. The truth is that we treat most problems with significant limitations of our understanding and that we will look back at many of our current treatments as primitive. Getting good results following orthopedic trauma entails great difficulties. We therefore need to practice with honesty and humility.

公众经常相信医学能创造奇迹是正常的。真实的情况是我们非常有限的理解力处理大多数问题，再回头看我们现在的处理是非常原始的。通过创伤骨科所取得的好的疗效非常困难。所以我们需要诚实和谦虚的态度行医。

I believe that a simple documentation system including diagnosis, treatment, complications and results is a big help in quality control. Simple data forms that can be coded in a prospective manner and entered into a computer data base may not add a great deal of time and expense. This information can guide the evolution of your practice methods. To improve results it is very important to have results to compare to. Changes to improve results are best addressed to groups of patients or fractures with a high level of bad results and/or complications.

我相信包括诊断、治疗、并发症和结果的简单的文件系统对质量的控制有很大的帮助。用前瞻性性研究方法编辑简单的数据表格并进入计算机数据库不回增加大量的时间和花费。但这些信息能指导你的实践方法的改进和发展。比较治疗结果对提高医疗效果非常重要。好的治疗结果或有大量的差的结果或并发症变化影响医疗人群。

I like to give credit to my mentors. In my own career my most important mentors have been Augusto Sarmiento and Emile Letournel. I take pride in my own contributions to orthopedic knowledge but recognize that the huge basis of my practice is what I have learned from others.

我得益于我的启蒙老师。在我的职业生涯中，Augusto Sarmiento 和 Emile Letournel是我最重要的导师。我为我在骨科领域所取得的成绩而自豪，但我承认我的很大一部分来自向他人的学习。I

I consider health and lifestyle to be important in my performance as an Orthopedic surgeon. Some restraint with food and alcohol as well as exercise benefits you and your patients. I think a mistake most of us make is not taking enough time off. I once asked Harald Tscherne how much vacation he took. He answered, “Six weeks”. I said that must include your educational travel. “No”, he said, “six weeks vacation”. None of us would question Prof. Tscherne’s commitment or productivity.

我认为作为骨科医生健康和生活方式同样非常重要。控制饮食、酒精和锻炼对你自己和患者有益。我认为我们大多数犯的错误是没有足够的时间放松。我曾经问Harald Tscherne教授他休多长的假期。他的回答是：“6周。”我说包括他的教育旅行。“不”，他说：“6周的假期”。没有人怀疑Tscherne教授的贡献和成就。

You have carefully selected your career and have also passed an extensive training and selection process to be an orthopaedic trauma surgeon. The evolution of your practice toward improved clinical results will make it all the more exciting and rewarding.

你认真地选择了你的职业并且通过广泛的培训和挑选才成为一个创伤骨科医生。随着你的临床工作不断取得的良好的治疗效果将令人激动和得到更多的回报。