Gray-Haired Consult

Don’t get me wrong.  I have a smart watch, an iPhone and an iPad, and my emails, photos and passwords are all synced.  I have more digital textbooks than I could ever read and I’m a regular Hand-e visitor.  But despite having even more technology at my fingertips, my first two years in practice have imparted a profound appreciation for one of the most “unplugged” resources: my senior partners.

In my practice, it’s called a “gray haired consult” — even when the consultant may not be gray.  It takes many forms: questions before clinic starts, reviewing X-rays, or discussing hypothetical situations or complications that bare uncanny resemblance to actual people or problems.  Sometimes, I’ll even pull a gray head into an exam room.

Why hasn’t technology filled this void?  The newest generation of surgeons thinks nothing of turning to the internet for food, clothes, transportation, housing and even spouses.  What is it then, that remains so unique about face-to-face interaction with those we trust?

First and foremost, despite all the websites and gigabytes, hand surgery is still very much an art, and while art has rules, there are broad expanses of controversy between points of certainty.  Studies have shown surgeons often disagree, even about common entities [1].  Although the number of randomized trails is mounting, there’s rarely Level 1 evidence for any decision, sometimes not even a consensus [2]. I don’t know about your practice, but many of my patients and problems don’t match the ones in the papers.

Second, there is such a thing as too much information.  Information overload or choice overload are well known psychological processes.  When there are too many treatment options, far from basking in the bliss of knowledge, we become unable to choose, and when we do, more often choose poorly [3].  Have you ever turned to academic sources for guidance, found 50 articles and 30 videos, only to become more confused and less confident than you began?

So, what is it that we provide one another through travel clubs, panel discussions and merciful gray-haired consults to junior partners?  We act as curators of information, not just repositories.  Learning how a thoughtful, successful colleague has incorporated the mass of information into his or her practice is priceless.

The technical profession of surgery also needs a collective memory of learning curves.  Every procedure looks easy when edited down to 2 minutes with an elegant voiceover, and the strongest word of caution you may get from an article might be passing acknowledgement of something being “technically demanding.”  In the end, there’s no substitute for learning your senior partner had to struggle through 10 cases before working out the kinks.  It may well be Level 5 evidence, but more than we may care to admit, “low level” evidence may have a real role in high level patient care.

So be digital and unplugged at once.  Read online journals and watch videos.  But, also attend your local and national meetings. Talk to your colleagues.  Don’t be afraid to ask questions, and please, answer questions if you’re fortunate enough to have the experience and perspective to be on the receiving end.  I look forward to seeing you in San Francisco.



[1] Bruinsma WE et al.  Interobserver Reliability of Classification and Characterization of Proximal Humeral Fractures: A Comparison of Two and Three-Dimensional CT.  JBJS 2013;95(17):1600-4.

[2] Handoll HH and Brorson S.  Interventions for Treatment Proximal Humeral Fractures in Adults.  Cochrane Database Syst Rev 2015;11.

[3] Schwartz B.  The Paradox of Choice: Why More is Less.  2014.  Harper Collins, NY.

Article written by:

Dr. Ryan Zimmerman is a Hand, Shoulder and Elbow Surgeon at Greater Chesapeake Hand to Shoulder and an Attending Surgeon at the Curtis National Hand Center in Baltimore, MD.

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