It is hard to ignore the disparities between the daily practices of orthopaedic surgeons in the Asia-Pacific region and those in the West. Some elements of practice just do not “export” very well; we know that some clinical research findings in European populations do not apply in Asian patients, and vice versa. Differences in culture, as well as varied economic and political systems mean that healthcare research done in the United States may not apply at all in Asia. Certain surgical techniques may be more applicable in Asia than in the West. For Asian patients with TKA, additional surgical steps are more frequently required to address severe coronal or torsional deformity, which left untreated, can result in unbalanced asymmetrical gaps [3-6]. While “traditional medicine” may be a fad in the West, the “traditions” come from the East, and those traditions run long and deep in some parts of Asia. I frequently encounter patients with joint pain who still seek acupuncture. Modern medicine is a relative novelty in Asia; some patients still prefer what they grew up with.
Another issue is access. Economic restrictions in the Asia-Pacific region can limit patients’ access to healthcare. Vast geographic distances and sometimes-dire economic disparities can limit patients’ access to timely care in specialties as diverse as trauma and arthroplasty. This can result in patients presenting with deformities uncommon or unheard-of in the West. Furthermore, timely and appropriate support from the healthcare industry, which conveys treatment options to patients in some orthopaedic specialties such as arthroplasty and trauma, are not readily available compared to Western countries. Practical knowledge, surgical skills, and clinical experience can be limited and are not always easily accessible. The sometimes-suboptimal quality of the operating theatre and inaccessibility of contemporary devices may even discourage young, passionate surgeons in training.
Young surgeons in transition from training to practice commonly face a number of the challenges summarized above. But the situation in Asia—where senior surgeons often are well-resourced, the mentors revered, and new practices often begin in outlying areas with little infrastructure—is more challenging than in other regions of the world. I experienced this myself. When I began my practice, I had not realized the many issues that were ahead of me. In retrospect, my limited knowledge allowed me to focus and find solutions to the urgent matters at hand. The lessons that came from those painful experiences laid the foundation for the approaches I now use in my practice. I would like to share some of my ideas and experiences with our young Asian orthopaedic surgeons, who may perceive the problems they face as insurmountable. They are not.
View Challenges as Opportunities
I believe that disparities, whether pragmatic or psychological, can become opportunities if surgeons address them strategically. The first strategic approach is recognizing that one's perspective needs to change. When a young surgeon tries to set up his or her own clinic after spending a year with a master surgeon, the new surgeon soon realizes that everything is more difficult compared to the earlier experience with a master surgeon. One is typically of the lowest rank in a large staff. Patients do not know the new surgeon's name. The hospital either does not have the resources to help the new hire, or it prefers to share those resources with more-established surgeons (it only makes sense that hospitals will bet on horses that have already won races over those that have not). There is no infrastructure, and the new surgeon may not be given time, fluoroscopy machines, or experienced nursing help. However, while one struggles to solve these issues one by one, one inevitably gains an in-depth understanding and knowledge of the issues in the real world, which will equip the now-developing surgeon with the qualities of a leader, such as tolerance and wisdom.
Maximize Your Limited Resources
The second strategic imperative is to convert the limited resources that may be available—whether because one is in a resource-poor environment or because one is just beginning in practice—to a patient-care approach that will still deliver consistently excellent results. To young surgeons who have seen top-class patient care systems at home or abroad, the gap between where they begin their practice and the established systems they have observed in big cities and referral centers may seem too broad to bridge. Do not get discouraged. No matter how tough the situation is, there should be the best or at least most reasonable solution for the disease or the patient. Although there will be constraints on hardware (buildings, devices, and technologies) and software (knowledge, skills, and experience), thoughtful teamwork with the available partners in the environment can lead to protocols or approaches that can work even in the most-austere environments. Even though the instruments or equipment used in your protocol may not be the best ones in the global sense, it is possible to make one's approach successful locally, or at least to make the best of what is available. It is the surgeon's mindset that plays the most important role in orchestrating all hardware and software resources to provide the best care for patients. The goal is not necessarily to reproduce the pace, throughput, efficiency, and clinical productivity of a busy, well-resourced tertiary-care system when one is in a new practice in an outlying area; attempting that is a recipe for complications and harm. Rather, the goal is to take care of those patients one can accommodate safely and effectively given the available resources. When one shows oneself capable of this, opportunities to do more—and the support needed to do so safely—will appear. Let the volume and tempo build as the support and setting allow.
Build Your Reputation
One of the serious challenges of young surgeon's career is determining how to build a good reputation among his or her patients. If a surgeon has a good reputation, patients will line up to see the surgeon, and the physician will develop a better standing among the clinical staff. Although there is a strong trend toward shared-decision making in North America [1, 2], it is typically a more-paternal role that patients seek from orthopaedic surgeons in Asian countries. Despite some newer litigious social trends here in Asian cultures, patients still tend to endorse most important decisions to the surgeon once they trust the surgeon. Therefore, the professional and ethical responsibilities of orthopaedic surgeons in the Asia Pacific region may be greater than those in other regions.
A physician's reputation stands on two essential qualities: Treatment outcomes and compassion. It appears to be the global trend that competition among healthcare providers is fierce and treatment options offered to patients are not always the most beneficial. Some surgeons will recommend unreasonably aggressive treatment options. A physician's fundamental mission is to guide the patient to the most-reasonable treatment option in a particular setting, taking into account the clinical picture, the available options, and the patient's goals and values. Efficacy, safety, and cost-benefit ratio should be considered as part of this decision. While surgeons’ outcomes probably do improve as they become more experienced, even new surgeons can display compassion, and it is so important that they not allow their sometimes-difficult surroundings to cause them to forget to do so. Attitude and intention are critical here. One doesn't have to be an established surgeon and professor to display it. Anyone - everyone - can and should do so, but it takes practice and intention to make it a part of one's routine. One good way may be to capture and mention the most critical concern to the particular patient. Sometimes, the issue is not necessarily medical. Sometimes the patient has psychological or financial concerns. Listen to what your patient has to say. While patients may forget details they were told about their conditions and the finer points of their treatment options, they never forget the joy and gratitude they feel from the doctor's warmth.
In fact, I believe that it is compassion—which is as available to younger surgeons in resource-strained environments as it is to professors at large hospitals—that will do more to influence a surgeon's developing reputation than any other quality or trait. Take the time to express it, to patients and to their families.
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3. Kim YH, Matsuda S, Kim TK. Clinical Faceoff: Do we need special strategies for Asian patients with TKA? Clin Orthop Relat Res.
4. Lasam MP, Lee KJ, Chang CB, Kang YG, Kim TK. Femoral lateral bowing and varus condylar orientation are prevalent and affect axial alignment of TKA in Koreans. Clin Orthop Relat Res.
5. Mullaji AB, Marawar SV, Mittal V. A comparison of coronal plane axial femoral relationships in Asian patients with varus osteoarthritic knees and healthy knees. J Arthroplasty.
6. Nagamine R, Miyanishi K, Miura H, Urabe K, Matsuda S, Iwamoto Y. Medial torsion of the tibia in Japanese patients with osteoarthritis of the knee. Clin Orthop Relat Res.