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to modify the natural history of the slipped epiphysis. I studied the scientific basis for all of these procedures, but this caused me further doubt and I drifted gently into an atheistic phase from which I have yet to recover. I began to realise that most of the theories I used to hold dear were destitute, and that few interventions were of predictable benefit. It was obvious that total replacement of the hip, intra-medullary stabilisation of long bone fractures in adults and the surgical management of intra-articular sepsis did not need to be decorated with scientific theory, and common sense dictated that these were worthwhile endeavours. I became unconvinced about the rational basis for other areas of my practice and began to adopt an heuristic method for navigating through the average working day. I tried to define a practical approach to management and was left with a five-point discriminator, which I continue to use. In my clinical universe, Type 1 patients are ‘normal’ and when they can be assigned to this group, they are encouraged to leave hospital without delay and retreat to a place of safety. One of the most dif ficult par ts of children’s orthopaedic surgery however, is confidently defining normality in its many guises. This is part of the dark art of the ‘Plasterpod’, and perhaps a subject for another day. Type 2 patients ‘can be made normal’ and as contemporary medical practice largely involves the management of chronic conditions, restoration of normality is a rare treat. As bone is
the only tissue which heals without scarring, this is possible in trauma care; giving evolutionary biology a nudge and taking all the credit is good work if you can get it. I have noticed, however, that I am complicit in an increasing number of interventions which may be unnecessary. There seems to have been a gradual drift towards a defensive practice of medicine in general, and orthopaedics in particular, and I am uncomfortable about subjecting a young child to general anaesthetic to straighten a minor bend in their wrist. Type 3 pat ients ‘can be made better’ and this is a matter of careful definition. One of the main reasons for dissatisfaction in current practice is the failure to meet patient expectation. This is due to the setting of over-optimistic goals and is part of the retained zealotry that I have discussed in previous paragraphs. This is essentially an exercise in the communication of complex ideas and one that is difficult if these tendencies are retained. The notion of the Surgeon Messiah remains in all of us who practice surgery but this has to be repressed when dealing with the informed public. The consequence of failing to define ‘better’ in a way that it is understood by both parties predictably leads to a successful surgical procedure, with an unsuccessful outcome. Type 4 patients ‘can be made worse’ and whilst this is a characteristic of all patients in all medical specialties, it is particularly obvious in surgery because of the inevitable breeching of the integument. This is also a fundamental part of the art of communication that
is required of a practicing surgeon: a degree of agnosticism is generally helpful to remind me of the limits of my skills. It also serves as a warning of the everpresent danger to my fellow citizens if I approach them or their progeny with sharp instruments or powered tools. Type 5 patients ‘can be left alone, at least for the time being’ and these are most of the patients in whom it is clear that there is no life- or limb-threatening ailment. Natural histor y will often prevail and difficult problems, parked for a suitable amount of time, will often resolve or become substantially more straightforward. I have deliberately or intuitively limited my practice to things I think are sensible and believe, without evidence, that bent bones are generally better straightened and that fractured bones are generally better splinted, whether from without or within. I am also convinced that any operation for Perthes’ disease, DDH and slipped epiphysis is only legitimate if it does not interfere with future replacement of the hip. As I float towards my dotage, I am sure that the profession I have chosen is intrinsically worthwhile. I think that the fundamental requirements of a good surgeon are a critical appraisal of conventional wisdom, an honest evaluation of personal skills and careful matching of patients to decisions that are made on an individual basis. This is probably no more than redefining egocentricity and eccentricity, but for me it is likely to be more productive than believing most of what I have read over the last three decades.
A uthor
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Fergal Monsell Consultant Orthopaedic Surgeon, Royal Hospital for Children, Bristol fergal.monsell@btinternet.com
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