An old Japanese folktale tells the story of a warrior named Ashikaga Yoshimasa who broke his favourite tea bowl and sent it to China for repair. When he went to fetch it, the crack had been joined together with unsightly staples the size of locusts. Despite its functionality, Yoshimasa was unsatisfied and contracted Japanese craftspeople to devise a more elegant means of repair. The craftspeople replaced the staples with gold pottery glue, creating a beautiful shiny seam running through the bowl. From this, the Japanese art of kintsugi – golden repair – arose
(1).
The objective of this almost 700-year-old story is not to denounce the practice of fixing things using metal staples. Rather, kintsugi describes a strive for innovation and elegance. Perhaps autologous chondrocyte transplantation is the modern orthopaedic equivalent of kintsugi’s golden glue
(2), or perhaps it is the emergence of bioactive glass-based adhesive in situations where traditional polymethyl methacrylate cement will not suffice
(3). In the same way that Yoshimasa was unsatisfied with his stapled together bowl, the commonly used outcome measure of fracture union does not predict patient satisfaction after orthopaedic surgery
(4). What, then, does it mean to properly fix something? Modern medicine is no longer just about fixing wounds or stabilising bones – medical innovation continues to drive advancements that can increase patient satisfaction and outcomes.
In a more literal sense, the origins of kintsugi also emphasise the importance of teamwork, painting a mental image of a group of craftspeople puzzling over the broken bowl. This idea leads to the second point in this essay: collaboration in an increasingly allied health-centred surgical landscape. As stated by Bob in the eponymous television show
Bob the Builder, when asked whether he can fix something, he replies with ‘Yes we can!’ and never ‘Yes I can!’
(5). Unfortunately, the show’s title omits the contribution of Bob’s team and is solely named after Bob himself. Similarly, despite the utility of teamwork as a means of crossing professional, disciplinary and sectoral boundaries
(6), medical education greatly emphasises individual merit. Individualism may persists throughout one’s career, as illustrated by the ‘tension between professionalism and commercialism’ amongst orthopaedic surgeons described by the
Medical Journal of Australia (7). Individualism also exists amongst medical students, with a 2019 study showing that excelling in medical school exams was correlated with poorer teamworking ability
(8). In the same way that one cartoon builder cannot fix an entire city by himself, multidisciplinary team approaches have been shown to positively impact patient outcomes
(9). Therefore, such approaches should be widely employed to improve operating room efficiency, decrease errors, and save in time and cost
(10).
In a less literal sense, the field of medicine itself has areas in which amends need to be made. The Royal Australasian College of Surgeons recognises workplace issues including stress, burnout, and harassment
(11). This is illustrated by the 2015 case of a surgical trainee who won a sexual harassment case against her senior only to never work in a public hospital again
(12), and such issues also exist in the broader medical field
(13). A single lawsuit or inquiry cannot fix the problem of sexual harassment. Similarly, even though a single person may be eager to stabilise a fracture, for the bone to heal a hematoma must form, turning into a fibrocartilaginous callus, bony callus and finally bone remodelling occurs
(14). Healing must take into account all stages of assault — prelude, assault, limbo, exposure and aftermath
(13), recognising that injury occurs at every stage. The question arises; what can the next generation of surgeons do to support cultural change? At a medical student level, this means fostering an attitude of reflection and zero-tolerance towards harassment, creating a code of professional conduct that remains in place after graduation.
Since the development of kintsugi, several artists have been accused of deliberately breaking historical ceramic pieces just to mend them using kintsugi
(1). This, of course, defeats the kintsugi’s original purpose. The process of damage, repair and recovery is inherently traumatic. Within medicine and orthopaedic surgery, technological advancements have enabled more innovative, elegant techniques of repair, and multidisciplinary team approaches help to improve efficiency and patient outcomes after surgery. In cases where no quick fix can be sought, such with complex workplace issues, cultural change should start at medical student level. When single lawsuits or inquiries fall short, attitudes of zero-tolerance towards harassment must be upheld over quiet acquiescence in order to prevent further irreparable harm.
Give me a break in bones, and I’ll fix it
“Have you ever broken a bone?”
“So, what happened?”
“Since then, were you feeling vulnerable, physically, emotionally or both?”
The precise memory of the mechanism of injury, symptoms and signs could fade; however, no one would forget the sounds of cracking, popping, grinding and the excruciating pain, that is, the triggers of vulnerability.
We are good at asking questions as a clinician and proud to fix patients’ problems. As an orthopaedic surgeon the gratification of fixation could be immediate, short-term and long-term; a unique gift that draws healthcare professionals into this field. Sometimes, anatomical alignment can be achieved spontaneously or by manipulation under analgesia. Not uncommonly, open reduction and internal fixation will be required to realign the bones, with or without the repair of vulnerable nerves or vessels.
But have we thought about the impact of fixing on patients? Of course, we did. Fracture clinic for outpatient review, ongoing allied health inputs, rehabilitation program and the involvement of prosthesis institutes are all up to date to tailor patients’ needs.
“And how are you feeling now?”
The patient’s answer varies. For some, their functionality returned to the baseline prior to injury. For some, their life was not the same anymore, associated with chronic pain, reduced mobility, sensation, or social interactions. They may or may not require further interventions.
An increase in psychological resilience was reported to be positively related to physical functions after going through a fracture (1). After an uncomplicated fracture, people tend to feel stronger with the experience of injury, despite feeling vulnerable initially. This process revealed how strong we would be after appreciating how vulnerable we were in the first place.
Give me a break in training, and I’ll fix it.
In orthopaedic training, the historical stereotypes of rigid gender roles, masculinity, and the stigma of comments like ‘you don’t look like a surgeon’ from the patients or the public in general (2), acts as a break preventing female junior doctors from pursuing orthopaedics as their lifelong career. We feel vulnerable in this process. Fixation is on the way by advancing orthopaedic devices to require less physical strength, more flexible and maternity-friendly training program, social media campaigns and awareness education, such as #heforshe and #Ilooklikeasurgeon (2). The female orthopaedic group is getting stronger by recognising our vulnerability and appreciating the endless effort and support along the way, an evolving imaging of modern orthopaedic surgeon from ‘you don’t look like a surgeon’ to ‘this is my surgeon’.
A break results from a strong force that can be statically or dynamically. A break occurs at the weakest point. For fractures, it affects not only the bone but also the surroundings, such as muscles, ligaments, nerves, vessels, soft tissues, and skin. For a woman pursuing orthopaedics, it affects not only your own work and life, but also the supportive culture from our male colleagues at work and family at home, as well as a flexible orthopaedic training network.
Carolyn Ruth Bertozzi said in her interview after awarding the 2022 Nobel Laureate in Chemistry:
“I understand the gravity of being a female and now the Nobel Laureate in the sciences. There aren’t that many of us yet although there is certainly a trending in the right direction and an uptick. I think to the extent that a younger scientist and an early career scientist can look at my path and draw some inspirations from it. I would feel deep gratitude (3).”
Likewise, the blessings of being a female and an aspiring orthopaedic surgeon is that although there aren’t many of us yet, there’s certainly a rise with the ongoing support and care from orthopaedics association, mentors, and the training program. We should embrace it with deep gratitude.
Let’s fix the break, as soon as possible.