The Road to Surgery Mastery – Inside the Mind of a Modern Surgeon

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Chris Tan is a modern small animal surgeon at the University of Sydney. Ask any recent graduate from Sydney, “Who is the best veterinary mentor?” and undoubtedly Chris’s name will come up.

He is a Fellow of the Australian College of Veterinary Scientists, a Diplomate of the European College of Veterinary Surgeons and he is currently completing a PhD in Tarsal Kinematics.

At Sydney University, Chris is heavily involved in teaching veterinary students and mentoring young veterinarians.

Chris says, “I think in terms of learning, it’s something that never stops. That’s important to understand” It’s also important to remember “the profession changes, the expectations change and mentally you have to adapt with it.”

With experience in mentoring and eight years working in private practice before his residency we thought Chris would be a great veterinarian to interview on his advice for recent graduates, how to supercharge your surgery skills and his fracture repair thought process.

It is important recent graduates progress and gain experience in the first few years of practice but it is rarely smooth sailing. What are some of the big pitfalls and mistakes you see recent graduates make and what advice would you give?

“I think when you graduate sometimes your expectations can be unrealistically high and your bosses can also add to that by expecting you to do surgery in a set period of time. Never rush and never expect yourself to be proficient right at the beginning. Surgery is like sport. It takes a lot of practice. But if you try to rush that whole process, then you can learn bad habits and it slows the whole process down.”

Chris emphasises the importance of learning good technique as it creates a strong foundation on which you can improve upon.

“There’s a great saying from the movie Shooter. Slow is smooth and smooth is fast. If you’ve got good technique and smooth motions things actually happen really quickly without you actually forcing it.”

Chris also recommends never overlooking the basic physical exam.

“The physical exam is central to everything you do as a veterinarian. Often we rush into more diagnostics when actually the information is just there in front of us. I remember so many times as a new grad, the answers were right in front of me.”

To reduce the risk of this happening Chris advocates always going back to your patient when you’re not progressing and try to characterise what is actually going on. This refocuses your attention on what’s important and helps you assess the problems you are dealing with. If you still need direction Chris suggests asking a colleague to help you. In terms of getting experience, feedback is essential. “It’s extremely valuable if you can get someone else to examine the same dog as you and compare findings,” Chris says.

Many vets want to become better surgeons and some aspire to become specialist surgeons. So what makes a good surgeon?

“Surgeons have to be proficient in two areas. One is decision making, with that comes knowledge and experience. The other area is the technical aspect.”

Hence, good surgeons must have the knowledge required to make quick, intelligent decisions. Chris’s approach is to think of each surgery as an opportunity to be better than your last.

“One of the things I really like residents to do, what I always do, is reflect on how you handle each case and ask yourself, “What could I have done better?” Or look at radiographs and ask yourself, “Is that screw too long or too short?” “Should we have done anything differently?” Even if it’s a spey you might say, “I positioned those clamps too close to the ovary, I used a surgical material that was too big, my lights were in the wrong place, the dog was in the wrong position on the table. There’s always things that you can do better.””

“The more you critically appraise what you do, the more you think about ways to improve, the faster your rate of improvement will be.”

For those who are interested in specialising, Chris says, “In the intervening years between graduation and coming back to train, I spoke with a number of people about specialising and asked them what they would want in a resident and what qualifications they would like them to have. Don’t be shy about pursuing your dreams. Anything is possible at any stage of your career.”

Learning new procedures is an integral part of becoming a better surgeon. Not only does this keep things interesting but it expands the services we can offer our clients. However, this can be met with some trepidation as there is a greater risk of errors and unforeseen situations.

To increase the chances for success it is important to be prepared.
Chris recommends practising on cadavers if you have the opportunity.

It’s also important to review your anatomy before surgery. “Surgery is applied anatomy,” Chris explains. “We really go from one landmark to the next.”

It is beneficial to ask other’s advice. “If you can speak to a specialist, call and say, “I’m doing this procedure. I’ve never done it before, do you have any tips?” Even now I’ll approach more senior surgeons if they’ve got any advice about a surgery. For you, in general practice, you might ask your boss, “I’ve never done a splenectomy before, are you able to scrub in during the parts of the procedure which are new?””

Chris’s words of warning are, “it’s unwise to try to do surgery between consults.” He acknowledges you may not have a choice if it’s an emergency. However, if it’s elective it is important to give yourself adequate time so you can focus and not have the added pressure of being in two places at once.

Chris’ final tip is to support and build up your nurses. As a new graduate Chris was training his nurses in house. This had two benefits. “One, you build up a skill level in your nursing staff so you can concentrate on what you need to do, but also you’re building relationships with your nurses. It’s so important because the nurses are the key to you getting through the work. As a new graduate, the nurses are a great source of information. You really want them on side because they will help you no end.”

Fractured foot barvets

Having gleaned many great tips already, we then asked Chris to walk us through his fracture repair thought process. What is his diagnostic approach, how does he deal with open fractures, and how does he manage client cost considerations?

The first consideration when Chris sees a fracture is to make sure he does not cause any more damage.

“We look at immobilising the limb which helps with pain management but also prevents further soft tissue damage.  Then essentially we need to image [radiograph or CT] because you might palpate an instability but you need more information.”

After imaging, “The first question is always the same, can I reconstruct the bony column? If yes, then I can look at a number of different ways to fix this fracture. I can anatomically reduce it and get primary bone healing or I can take a more biological approach.”

“If you cannot reconstruct the bony column, I instantly know I am not going to try. Our aim simply becomes to stabilise the limb and restore the relationship of the joint above and below the fracture. Everything else in between we are going to leave alone.  In that way, the body will actually heal faster than it would if we tried to put the pieces of the jigsaw puzzle back together and damage the blood supply in the process.”

Open fractures bring the added complication of wound contamination and just like any wound a debridement process is required to remove the bacteria.

“Ironically, if the animal is dragged on the road and the wound looks heavily contaminated, although it may look horrible, the bacteria in there is probably less pathogenic than the ones they will pick up in your hospital.”

“The first thing I do when I see an open fracture is use sterile gloves and actually cover it.  So put a sterile dressing right over any exposed bone and then bandage it up. Next, we assess the patient for other signs of systemic disease, shock being the most common.  These are poly-trauma patients so they may have other fractures or spinal injuries.”

If it’s a low grade open fracture and there is only a very small amount of contamination Chris will generally debride, lavage and treat it like a closed fracture. If tissue is missing, he will often use a temporary immobilising device like an external fixator.

“The challenge with treating these with an external fixator is they have a tendency to loosen over time and the problem is that open fractures, particularly high grade ones with heavy contamination, take prolonged periods of time to heal.”

You may need two surgeries, one for temporary immobilisation and the other for definitive surgery.

On coaptation, Chris recognises “there is definitely a place for it but it’s all about selecting your cases correctly.” Chris emphasises the aim is not just to get the bones to meet together but to maintain function.

“We need to think about the performance of these animals particularly for young animals and very active animals. The bone might heal but if we haven’t restored function then we haven’t really done our job to the best of our ability.”

One of the biggest difficulties is discussing costs with the owner and the commitment required to deal with these fractures.

Chris says, “laying down the cards on the table early” is best. The conversation he has is, “this is going to be a challenging case. We’re all in it together and we need to prepare to ride out the bumps and accept the financial cost because this is not something that is going to be fixed with a cast and we send you home and everything will be okay.”

Some fractures are unlikely to get a good result without surgery. In these cases it’s important to not let the client dictate your treatment.

“Clients will have their own wants and desires. If you give them an easier option they will often take it. If you give them a cheaper option, they will often take that. I think it’s our responsibility to give them their options for treatment but then also the likely outcomes of each.”

If casting is not a good option he will tell them “there is probably a miniscule chance of that dog regaining good function in the limb and it’s going to be in a lot of pain for a long period of time.”

Chris says when there are significant cost concerns and surgery is required there is often no clear cut answer. This could be an opportunity for an aspiring surgeon to practice for a reduced charge but both the boss and client need to be on board.  Promoting insurance could also be a benefit in these situations.

Amputation is another option if there are very limited finances. However, Chris tries to counsel against this, preferring to fix the presenting problem.

“If owners cannot afford the optimal treatment, how far do you compromise before it becomes a welfare issue where we are not doing the right thing by the animal? I think every case is different.”

We’d like to thank Chris for taking the time to be interviewed today, his advice is invaluable for vets at any stage of their veterinary journey.

 

Interviewee

Dr Christopher Tan
BVSc BSc(Vet) FANZCVS (Small Animal Surgery) Diplomate ECVS
Small animal surgery specialist

Chris graduated from the University of Sydney in 2000 and spent the next 8 years working in general practice in Australia and the UK, before returning to Sydney to complete his residency in small animal surgery. He is both a fellow of the Australian College of veterinary scientists and a Diplomate of the European College of Veterinary Surgeons and is currently completing a PhD in tarsal bone kinematics, whilst continuing to practice and teach at the University of Sydney.

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