在临床实践中成就卓越----------如何提高你的临床水平

教授设计的骨盆复位器械-球端弯钳

What is the formula for excellence in orthopaedic clinical practice? Certainly, there is no set formula for everyone. These are my thoughts based on what I have learned from others, as well as my personal experience.
    什么是能在骨科临床实践中成就卓越的程式？诚然，对所有医生而言没有所谓的程式。以下这些是我基于学习他人及个人经验的一些思索。谨供参考。

  There are a number of ways that excellence can be measured, but I think the most important one is the benefit or the clinical results that we provide to our patients. Excellent clinical results exist in many settings and are not necessarily related to the notoriety of the surgeon or institution.
    有许多可以衡量临床诊疗卓越性的途径，然而，我认为其中最为重要的一条是我们医者所能提供给病者的收益，或者说是临床效果。然而，优越的临床效果可得自诸多情境，其并非一定与医者或诊疗机构相关。

  My first recommendation is to pursue a type of practice based on your passion. You should find your niche according to your interests and abilities. Monetary reward will influence our activities to a degree; however, you sell yourself short if you place money first. Fortunately, in orthopaedics we can “have our cake and eat it too.” Our specialty allows us to enjoy our work as much as sport, gain personal satisfaction and community recognition, and also be well compensated. I think the key to all of these benefits is our passion and commitment to our work. There are few careers available that combine the pleasure of both manual and intellectual challenges.
    我的首要建议是追求一种扎根于激情与热爱的临床实践。根据兴趣和能力找到适于自己的临床实践领域。薪资报酬将在一定程度上促进我们的临床诊疗行为；然而，当你金钱至上时你就会把自己的短板出卖无遗。庆幸的是，在骨科领域，我们可以享用自己的“蛋糕”。我们的专长允许我们像享受运动一样地享受我们的工作，得到个人的满足和周遭的认同，当然也可被很好的报偿。我想我们能得到这些实惠的关键在于我们对临床工作的激情和担当。世上没有多少职业能将挑战智力和体力的乐趣有机结合起来的。

  Although we are surgeons, and the job we do in the operating room is probably the most important, we also must take pride in our one-on-one skills with patients. If patients are able, the more that they understand about their problem, the better. Detailed preoperative and postoperative explanations can help the final result. I also rely on patient-information publications and my own website to inform the patient and family.
    作为外科医生，尽管我们在手术室所做的工作可能是临床实践中最为重要的环节，但是我们必须对具有与患者顺畅地沟通的能力引以为傲。如果患者具有能动性，则他们对自身所患疾病了解得越多越好。因为，术前和术后详尽的沟通可益于最终的治疗结果。除了面对面的沟通外，我还借助患者诊疗信息出版物和我自己的网站对患者及其家属进行宣教。

  The surgeon must be disciplined regarding their physical examination of the patient with acute high-energy trauma. The patient should be completely undressed and all skin areas visualized. In addition to a complete and detailed neurovascular examination, all the extremities that do not have an obvious deformity should be palpated and moved. Use x-rays liberally.
    医生必须严格自律于对急性高能量损伤患者进行细致的体格检查。检查时需要脱去患者所有衣物，检视其每一寸肌肤。除全面、细致的神经血管功能检查外，还需要触诊和活动所有无明显畸形的肢体。要不吝进行X线检查。

  For the subacute 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 that we don’t yet understand, and everyone does not fit neatly into a category. Many old trauma problems, such as malunions and nonunions, require a unique solution that you need to invent. The extra time that you spend in planning and consultation in these patients will make a difference.
    对亚急性或慢性病损，医生需要仔细的聆听患者的陈述。你每每需要假定患者是在述说实情而非疯狂不实或有所隐瞒。有很多问题我们尚不甚了解，而且也不能对每一病例简单清晰地归类。许多陈旧创伤所导致的诸如畸形愈合和不愈合之类的难题，需要你制定一个独一无二的解决方案。对这些病例进行询诊和制定方案所耗费的额外精力将会使治疗结果变得不同。

  At times we find ourselves at a loss with patients, particularly those with chronic pain problems who often will say “you’ve got to do something” or “I can’t live like this.” The justification for surgical treatment should not be based on such desperate reasoning. Surgery should always have a probability of success when undertaken. In some situations, 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 on them. 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 or terminal situations, such as neoplasm.
    有时候，我们会对一些患者，特别是那些存在慢性疼痛且时长会说“医生必须为我做些什么”或“我不能这样活着”的患者，感到迷茫。事实上，手术与否绝不可基于这样的无望的说辞。一旦实施，手术总会有成功或失败的概率。在某些情况下，你可能无法为患者提供任何帮助以改善其现状；而此时，你最好实话实说。在少数情况下，我甚至苦口婆心地跟患者说，在做手术之前，他们需要停止四处就医。这类棘手患者中的大多数都长期服用麻醉性镇痛药。而我认为我们有责任将这类药物限制应用于那些急性期或终末期患者，如肿瘤患者。

  Be an expert in the interpretation of x-rays, CT, and magnetic resonance imaging. These imaging studies combined with the clinical factors provide the main indications for surgery. Have indications for surgery; do not operate just because a fracture is present. The integrity of you and our specialty suffers with the application of faulty indications for surgery. Operating without the proper indication is not just unethical, it is an assault. 
    我们需要成为阅读和理解X线、CT和磁共振影像的专家。与临床症征相结合，这些影像资料的研读为我们提供了主要的手术指征。手术要进行得有理有据，绝不可仅依赖于有骨折的存在。因错误的指征（或无指征）而进行的手术会损害你的光明形象和我们的专业素养。无恰当指征的手术不仅仅是不合伦理的，其简直就是人身攻击（用手术刀对患者进行的强奸行为）。

  We all must aspire to perform the highest quality of orthopaedic surgery that we are capable of doing. Within your chosen niche, you should do everything you can to learn from the best. Read publications and texts. Attend courses. As we interpret medical data, large multicenter studies report the standard level of care that is present as an average across centers. Pay attention 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 that subject.
    我们必须渴望演绎我们的能力所能达到的最高质量的骨科手术。在你所选择的领域里，你需要倾尽全力向业界的最优秀的医者看齐。阅读刊物和书籍。参加培训课程。在我门所阅读的医学资料中，那些大的多中心研究成果仅代表了跨中心（普遍）适用的医疗关怀的一般水准。然而，我们需要密切注意那些有着丰富经验和学识的医者个体的系列研究成果，因为这些系列研究成果可代表全身心致力于该课题（在此研究范围内的）所能获得的（世界最高）水平。

  Visit and observe patient care and surgery with the field’s best. Most orthopaedic surgeons are open to this. A corollary to this is: learn and adopt the best existing techniques completely before attempting to modify them or develop new ones. By doing this, the maximum benefit to the patient can be obtained, and in some cases disasters can be avoided. As a resident in 1978, I attended my first Swiss AO Course. On returning home, I was delighted to be presented with a tibial plafond fracture. I operated enthusiastically; however, 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. Similarly, successful acetabular fracture surgery is achievable with the specific combinations of the operating table, patient positioning, surgical approach, reduction techniques, and implants. I have a few visitors who wish only to peer into the open wound. It bears repetition that you should 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.
    参加和观摩业界最好的医疗关怀和手术。大多数骨科医师是非常愿意这样做的。对此可以这样推理：医者需要彻底地学习和运用现有的最好的技术，然后再尝试革新旧技术或者研发新技术。这样做了，医者就能使患者最大程度上受益，并且在一些情况下能避免（给患者带来）灾难。作为一名住院医师，1978年我首次参加于瑞士举办的AO课程。回国后，我为能主刀一例胫骨平台骨折而欣喜若狂。我激情四射地做完手术。然而，数月过后，我惊诧地发现绿色的骨头自切口冒出（感染）。我学会了如何用接骨板和螺钉固定骨折，但没学会如何选择合适的入路和恰当地处理软组织。同样的道理，当一些特殊因素，如手术床、患者体位、手术入路、复位技术、内固定物等，有机结合时，髋臼骨折的手术方能成功。我发现一些参观我手术的医生仅乐于窥视切口内部所进行的操作（仅骨折的处理，而非整个手术过程）。在此有必要重申：在试图改良现有技术和发展新技术之前，你需要先将现有最好的技术进行整体的学习和运用。这一认知是技术革新的基石并能使你免于重复过去失败技术的谬误。

  Is everyone created equal as surgeons? Of course not. Surgery is a combination of intellect and motor skills. I would say that intellect is by far the most important factor. The most important factors before surgery are an understanding of the fracture and establishing a good preoperative plan, including setup, approach, reduction, and fixation strategies. 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 your familiarity with a device may be the reason to use it. 
    每一个人生来都可以成为外科医生吗？当然不！外科手术是大脑聪明才智和躯体运动协调能力的结合体，但我认为聪慧是最为重要的因素。而术前的最为重要的因素乃在对骨折透彻理解的基础上所建立起来的包括组织实施、入路、复位和固定策略在内的术前计划。术前计划需要更多地侧重于如何复位而非固定骨折。复位是个大问题，固定次之。针对一个特定的手术来说，可能有多种内固定物可以选择，而你可以根据自己的熟练度来选择其中一种。

  I think that surgeons are best judged not by a surgery in which 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 in these situations.
    我认为，评价医生的最好方式不是顺畅的手术，而是手术中出现突发意外情况时他们的应对。我曾经亲眼目睹过医生在病人情况急转直下时的颤栗。面临突发问题时的高度紧张状态理论上可以激发你的精神达到更高程度的集中以有效地进行处置。这种情况下，丰富的经验和灵活的策略可发挥作用。

  We need to critically assess the result of the surgeries that we perform. I would say that a minority of my surgeries is performed completely to my satisfaction, particularly acetabular fractures. Postoperative x-rays always should be a stimulus for thoughts regarding how things could have been done a little better.
    我们需要批判性的评估我们所做手术的效果。我敢说，只有少数我所做过的手术能完全令人满意，特别是髋臼骨折的手术。我认为，术后X线片应该被视作能激发我们有“术中如何能做得再好一点”这样思索的良品。

  How critical is speed when performing surgery? At the beginning of my career, I did not consider speed to be important; now I think it is, although admittedly not the most consequential factor. I think speed is a benefit in limiting tissue trauma and infection. It also is 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 on 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 that he is not a particularly patient person. Gus’ first words at the scrub sink were, ‘‘Joel, how long is this going to take?’’ My response, ‘‘Gus, relax and get ready for a 4-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; from that time forward, similar cases took approximately 2 hours. Conversely, you should take whatever time is necessary to achieve the desired result. Speed is not a primary goal but should increase progressively with your years of experience. Watching a good surgery go quickly means that you will not see particularly fast movements, but rather well planned and effective ones.
    手术速度有多关键？在我职业生涯的早期，我并不认为手术速度有重要。而现在，我认识到了它的重要性，尽管大家公认它不是最为关紧的因素。我想，速度有利于限制软组织损伤和感染。速度对你和你的医院来说是一个经济指标，并且也是限制你所能造福的患者数目的指标。在我早年的主刀的髋臼骨折手术中，其中一例髋臼横形加后壁骨折的手术是经Kocher-Langenbeck入路且第一次由我的主任——Gus Sarmiento——作为我的助手而完成的。假如你了解Gus Sarmiento，你会知道他不是一个特别有耐心的人。Gus在洗手池旁对我说的第一句话就是“Joel，这台手术需要多长时间？”我回答：“Gus，放松点，准备好做一台四小时的手术吧！”而他的回应却是“四小时？！我只给你两个小时！”结果，这台本来准备做四个小时的手术仅仅用了两个小时而且结果却一样地好。从那时起，类似的手术均耗时两小时左右。于此相反，为了达到你所渴望的效果，你需要用足所必需的时间。这就是说，速度虽然不是首要目标，但是它应该随着你经年的经验而逐渐加快。然而，当你看到一个手术由好变快时，这将意味着你看到的操作与其说是格外地快，不如说是计划得好和施展得高效。

  As an orthopaedic surgeon, you are the organizer and leader of the operating room team. You assume this role, regardless of whether you are inherently organized or an obvious leader type. I don’t think that personal charisma or forcefulness is a prerequisite for leading an effective operating room team. The factors that I consider most important are planning, respect, education, and encouragement for your team members and working with your team in a hands-on way. The concern that you show for the patient and the commitment that you show to achieve 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 also will rub off. Leading the team to improve performance and efficiency is a job that never stops.
    作为一个骨科医生，你是手术团队的组织者和领导者。你将自己假定为这样的角色，不管你有着什么样的内部指派或职务。我并不认为个人魅力或强势是领导一个高效手术团队的先决条件。相反，我所认为的最为重要的因素是对组员的分工、尊重、教诲和激励以及亲力亲为地与他们协作。与之相比，你对患者的关怀和对优异手术效果的承诺将变得黯然失色。尽一切所能，不要使自己成为一个行事拖沓的人，则你的迟缓和效率低下也将不复存在。领导自己的团队以改善工作表现和提高工作效率是一项永远不能停歇的事业。

  Surgical complications are inevitable, and the indication for any surgery must be judged relative 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 guilty and 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 no less involved in their care and will do everything possible to ensure a positive outcome. 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 you, the patient, and also writing it in the chart clears the way for providing effective treatment.
    手术并发症是不可避免的，任何手术的适应症都必须通过该手术相关并发症的发生率进行评判。当并发症出现时，医生有必要尽早与患者进行一次诚恳的交流。通常，医生会有愧疚感故而倾向于免却与患者及其家属进行此必要讨论。沟通过程中有两件事显得格外重要：一是开诚布公地坦然面对，二是一定要用“并发症”这个书面词语。这样做了，患者至少会因为了解到你不仅仅参与了他们的诊疗而且还将尽一切所能来保证他们能有好的预后而感到宽慰。手术切口相关并发症，诸如血肿和感染，是我们所面临的会给患者带来潜在的危害的诸多难题中的一部分。三个骨科医生检查过切口后会做出是否感染的准确判断。通常，相对于我们自己的患者而言，我们更轻易地断言某个同事的患者出现了感染并发症，原因在于我们自己怯于坦然面对。诚恳地告诉自己和患者“出现感染了”并且如实记录在案，为给患者提供有效的治疗扫清道路。

  The public often believes the myth that miracles in medicine are the norm. The truth is that we treat most problems with significant limitations with respect to our understanding and knowledge, and it is likely that we will retrospectively view many of our current treatments as primitive. Getting good results after orthopaedic trauma entails great difficulties. We, therefore, need to practice with honesty and humility.
    大众总是相信医界存在奇迹这样的神话。而事实上，我们处理多数疑难杂症时面临着理解力和学识方面的显著限制；而且，等到将来我们回过头来审视我们目前的治疗时，我们很可能会认为它们很原始。追求骨科创伤良好预后这件事本身即饱含艰辛。因此，我们需要带着诚恳和谦逊的态度投身于临床实践。

  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 database may not add a great deal of time and expense to your practice. This information can guide the evolution of your practice methods. It is important to have results to compare to improve our results. Changes to improve results are best used for groups of patients or fractures with a high level of poor results and/or complications.
    我相信，对质量控制来说，一个包括诊断、治疗、并发症和预后在内的简单的文案记录系统会有很大裨益。而且，在临床实践中，一些以前瞻性方式编辑并能输入电脑数据库的简单表格不会额外耗费多少时间和经费。这些文案信息能引导你的临床科研方法的革新，重要的是，可以通过临床效果的比较以提高疗效。由之而来的诊疗方法上的变化最适用于那些有着较差疗效和较严重并发症的病例或骨折。

  I like to give credit to my mentors. In my own career, my most important mentors have been Augusto ‘‘Gus’’ Sarmiento and Emile Letournel. I take pride in my own contributions to orthopaedic knowledge, but recognize that a huge basis of my practice is what I have learned from others.
    我由衷地钦佩我的良师益友。在我的职业生涯中，我最为重要的师友是Augusto “Gus” Sarmiento和Emile Letournel。我对自己在骨科学术领域所做的贡献感到自豪，但我清楚地知道我（卓越的）临床实践的坚强基石乃我所学。

  I consider health and lifestyle to be important in my performance as an orthopaedic surgeon. Some restraint with food and alcohol, as well as exercise, benefits you and your patients. I think a mistake that 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，在我作为骨科医生的临床工作中，健康的体格和生活方式很重要。对饮食、酒精的节制和适当的锻炼会施惠于你和你的患者。我想，我们中大多数人所犯的错误就是没有花足够的时间来休养身心。我曾问Harald Tscherne一年休假几何。他说六周。然后，我说那肯定包括他的教育（指参会授课等）旅行。“不”，他说：“纯粹的六周假期。”然而，没有任何人会质疑Tscherne教授的贡献和成就。

  You have carefully selected your career and have passed an extensive training and selection process to become an orthopaedic trauma surgeon. The evolution of your practice toward improved clinical results will make it all the more exciting and rewarding.
    经过审慎的职业规划，经历了全面的培训和严格的筛选，你成为一名创伤骨科医师。通过不懈的努力，你所做出的改善了临床疗效的实践革新将变得愈加激动人心和富于回报。

原文作者：Joel M. Matta(圣约翰医疗中心)

翻译分享：洛阳正骨医院 蔡鸿敏

校正编辑：洛阳正骨医院 田可为

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