My first exposure to hand surgery was in July 1958 as a straight surgical intern on the orthopedic service at the University of California Medical Center in San Francisco. Dr Donald Pratt, one of Sterling Bunnell's early trainees and a practice associate, performed several reconstructive procedures on the hand that involved soft tissue, bone, nerve, and tendon reconstruction. This master surgeon, although trained in the field of general surgery, was adept and comfortable with all tissues. He truly reflected and practiced the principles that Bunnell taught, namely, that hand surgery "is a composite problem requiring the correlation of various specialties-orthopedic, plastic and neurological surgery-the knowledge of any one of which alone is inadequate for repairing the hand."1
Bunnell further stated: "As the problem is composite, the surgeon must also be." "It is impractical for three specialists to work together in series." "There is no shortcut." "The surgeon must face the situation and equip himself to handle any and all of the tissues in the limb."
These words appear in the preface of Bunnell's classic Surgery of the Hand, published in 1944.
This early exposure prompted me to seek and obtain an orthopedic surgery residency followed by a 1-year hand surgery fellowship with Dr Robert E. Carroll.
I have never regretted this decision. Hand surgery, even in its simplest forms, is always interesting and challenging. There is always something new to learn, and the interdisciplinary approach based on plastic, orthopedic, and neurological principles as espoused by Bunnell allows the hand surgeon to treat a variety of conditions with confidence and success.
This interaction among fields of expertise has brought many advances that even Bunnell could not have predicted. Imagine his response to microsurgery in the form of free flaps, free muscle transposition, toe to hand reconstruction, and replantation as practiced by many hand surgeons today.
Hand surgeons, like all physicians, are faced with daily challenges that do not relate to the actual day-to-day practice in our field but yet have impacted us tremendously. The recent editorial by Dr Jupiter entitled, The Train Is Off the Track, certainly emphasized the "added on" stresses that are not directly related to our "hands on" experience with our patients.2
In spite of these factors, hand surgery carries with it a level of satisfaction that not many surgeons experience. Reflect on those many grateful patients that have recognized your high level of dedication and expertise in your management of their condition or injury. Easier said than done, yes of course, but such reflection may represent an antidote to the troubling issues so well portrayed by Dr Jupiter.
James R. Doyle, MD
Emeritus Professor of Surgery (Orthopaedics)
John A. Burns School of Medicine
University of Hawaii
1. Bunnell SB. Surgery of the Hand (preface vii). Philadelphia, PA: JB Lippincott; 1944.
2. Jupiter JB. The train is off the track. Tech Hand Upper Extremity Surg. 2008;12:1.