OWL Essay 2024 Winner and runners-up

Topic: 'The nuts and bolts of what it takes to be an orthopaedic surgeon' 

Congratulations to OWL Essay 2024 winner Pooja Jeyadeva. 

We also extend congratulations to highly commended entries Olivia Freeman and Cindy Zeng. 

Winner — Pooja Jeyadeva

PGY2, Bendigo Hospital, VIC

The Forgotten Toolbox
The weather was melancholic the day I stumbled across that old toolbox.

I had found myself in my untouched study for some unknown reason when that toolbox caught my eye, its lacklustre red coating having seen better days. It was tucked away behind an old cardboard box labelled ‘dreams’, as if it had been placed there and forgotten over the years. I felt this nagging sensation in the back of my mind, like a candle being lit in the depths of a dark cavern. It seemed important.

I extracted the toolbox from its hiding spot and placed it on the desk riddled with papers, dust bunnies trailing through the air after it. I wiped the thick coating of grime from the lid and found an inscription crudely etched into the metal, ‘To be an Orthopaedic Surgeon’. The handwriting was achingly familiar. I felt a pang in the centre of my chest and that flame in the darkness started to burn brighter. An old lock held the opening latch in place. The shackle had been threaded through the latch but left unclipped, as though someone had wanted to keep the contents of the toolbox safe but accessible.

As I prised open the rusted lid, the world around me went still. I peered inside to see a mixture of well-used equipment interspersed with unscathed titanium tools that glinted in the minimal light from the windows. My eyes were drawn to a mixture of nuts and bolts in the corner of the toolbox. The candle in my mind sparked. As I laid them out on the desk, I noticed that the papers beneath them were old drafts of cover letters and résumés, research papers, training program brochures, workshop fliers, and trauma course applications. All with my name on them. Another spark.

I inspected the nuts and bolts individually, realising each of them had an inscription. Hard work. Dedication. Passion. Excellence. Talent. My heart began to race. I kept reading. Ambition. Strength. Intelligence. That candle in my mind was burning strong and steady now. These pieces were all so familiar. As I continued to scour the pieces, I noticed there were subtle differences in the scripts of the words. Whilst the previous ones were written in a generic font, some of them were written in a more cursive, almost feminine style. Courage.
Resilience. Perseverance. Compassion. Adaptability. So many words. My eyes began to water as I read them all. That candle in my mind became an inferno, illuminating the secrets I had unknowingly hidden from myself.

This was my toolbox. This was my collection of tools I had gathered over the years to carry me through my journey of becoming an Orthopaedic Surgeon. Some were shared with me from colleagues and mentors, whilst others I had picked up along the way. My mind flashed through thousands of experiences from the last few years: being part of the team even as a medical student, being invited to first assist in joint replacements, teaching others about proper fracture reductions. So many experiences. So much joy!

Yet…there were hard experiences too. Having my theatre time taken away because my male counterpart wanted more time, patients demanding to speak to the real doctor looking after them, being told that women cannot be Orthopaedic Surgeons because we are small, weak, fragile or emotional, being told that Orthopaedics requires personal sacrifice and that I should not waste my time and focus on raising a family instead. So many insults, criticisms, comments and doubts.

Yet, as I clutched those nuts and bolts with their feminine writing that were bigger than the rest, I realised that these nuts and bolts were passed on to me by the amazing women that came before me, who are blazing trails of success with their own courage, resilience, determination and perseverance. These women are not only great people, but amazing orthopaedic surgeons pioneering the way forward for female doctors everywhere.

This was my toolbox of things I needed to be a great Orthopaedic Surgeon. I had forgotten that during my constant battle of being a woman in surgery. I had almost given up. It was time to change that.

I dried my eyes and picked up my toolbox – nuts and bolts and all. It was time to get back to blazing my own trail. As I made my way to the door, I noticed that the room was now much lighter. I glanced through the window. The sun was shining. I could not stop the smile spreading over my face.

Comments from the judges

  • "Beautifully written, positive message, very relevant to the theme". 
  • "I loved the relation to the toolbox of dreams, it really made me feel engaged with the writer and it took me on their career journey. Very emotional piece and highlighted the strength women have in this very male dominated industry/practice. Loved it". 
  • "Very creative approach by way of clever reflection and brining in all the issues". 

Highly commended — Cindy Zeng

Medical student, Melbourne, VIC


To Fix a Fracture
Opening: An incision is made in the skin overlying the fracture
There is an unspoken tension when a woman reveals she wants to pursue orthopaedics. “Starting.”
The scalpel is pressed to skin. The sharp tip breaks through growing tension, and crimson drops of awkwardness wink at her; polite good for yous, not-so-subtle expressions of doubt, and well-meaning what’s your backup plan?s threaten to flood a perfectly placed incision.
Bleeding is kept at bay as each layer is carefully dissected, and eventually, the fascia of gender inequality is split wide open. As her journey continues, she delves through deeper structures, forced to navigate the male territory of the orthopaedic theatre as a lone woman.1

Reduction: The pieces of bone are moved into the right place
Layers of soft tissue are retracted to reveal a crack in the off-white dream that is orthopaedics. The extent of the fracture becomes clear, and she can see the jagged pathway of her orthopaedic journey. Each break is slightly different than the last. The longer she continues in orthopaedics, the more familiar she becomes with avulsion injuries and spiral fractures, oblique innuendoes and linear hostility. To align a fracture is to align idealistic aspirations with a comminuted reality. In the unforgiving environment of the orthopaedic ‘boy’s club’, it doesn’t matter that she is just as good – and maybe even better – when given a chance.2 For decades, her foremothers were discouraged from pursuing orthopaedics.
Years of studying, long working hours, and numerous academic accolades were discounted, reduced to a perceived lack of brute strength.3
Now, she has been given a chance. Now, it is only the fracture that is reduced.

Bolts: A plate is placed to keep the bones in alignment
The bolt of the orthopod comes in the form of a plate placed carefully along the bone to ensure fracture stability. The pieces are bolted together, guided by the metaphorical bolts of orthopaedic surgery: theoretical knowledge, technical skill, clinical experience, physical endurance, and mental tenacity. Underlying each of these skills is drive and love for the specialty itself. With each case, she succumbs to the addictive properties of re-attaching tendons, chases the exhilaration of using power tools, and finds a home in the gentle happiness of seeing her patients improve, and providing hope for their pain.
On a background of sustained excellence and years of experience in orthopaedic surgery, the plate is placed perfectly, yet there are holes still to be filled.

Nuts: Screws are inserted to fasten the plate in place
On the other side of the bolt, a nut must be fastened. Personal success is not enough; historical injury and the endorsement of ambivalent sexist attitudes caused the fracture, which must be fully stabilised. The bolts are futile without the nuts – health services recognising the value of diversity, implementation of affirmative action, policies surrounding breastfeeding and parental leave becoming available, and surgeons of all genders supporting each other. Each successful surgery by a female orthopod is a screw firmly tightened, holding together a world where women belong in orthopaedics. As each screwhole is filled, a robust framework that challenges and changes the status quo is created, reinforcing the fracture, and simultaneously reinforcing that she has what it takes.

Closing: The incision will be closed with sutures
As the case comes to a close, she repairs the layers, creating a culture that supports her. With each expert flick of the wrist, she successfully threads through the intricate hardship of what it takes to become a female orthopaedic surgeon. The gap in skin grows smaller and smaller, and with each female trailblazer that falls in love with orthopaedics, the gender gap narrows, following the suture’s lead.

Finally, she places her instruments down and looks up at her team, warm theatre lights illuminating yet another successful surgery. She knows that her work is not done yet. Tomorrow, again, she will review the nuts and bolts.

References

1. Incoll IW, Atkin J, Frank JR, Vrancic S, Khorshid O. Gender associations with selection into Australian Orthopaedic Surgical Training: 2007-2019. ANZ J Surg. 2021;91(12):2757-2766. doi:10.1111/ans.17320
2. Wallis CJD, Jerath A, Aminoltejari K, et al. Surgeon Sex and Long-Term Postoperative Outcomes Among Patients Undergoing Common Surgeries. JAMA Surg. 2023;158(11):1185– 1194. doi:10.1001/jamasurg.2023.3744
3. Ahmed M, Hamilton LC. Current challenges for women in orthopaedics. Bone Jt Open. 2021;2(10):893-899. doi:10.1302/2633-1462.210.BJO-2021-0089.R1

Highly commended — Olivia Freeman 

Medical student, Newcastle, NSW

Cambridge dictates that the essence of the metaphor of nuts and bolts is “the basic facts or practical things that need to be understood or done” (1). And yet, for orthopaedics nuts and bolts can also be taken at face value; fasteners which combine together to hold something in place; the nuts and bolts of orthopaedics are nuts and bolts. One could also argue that a more creative definition of the terms is also justified, as maybe orthopaedic surgeons are nuts, and anyone around them should bolt. In the past the pipeline from mechano and lego building as a child, to chief ikea furniture builder, to weight lifter, to orthopaedic surgeon, was a clear and accepted pathway. The nuts and the bolts of the situation, or the basic facts to be understood if you will, was that strong, tough boys who liked to build things would grow up to be bone doctors who could bang in a hip at lightning speed. And yet, as the times change, so must the nuts and bolts. The basic facts that we understand, or the axiom we accept to be true of orthopaedic surgeons and the profession, must evolve.

The Bolts
When you identify the bolt as the base, the foundation of the mechanism, then the metaphor is easily extended to the individual. You, the orthopaedic surgeon, or I, the hopeful, are the bolt. Our characteristics, ideas, skills and experiences make up the foundation of an orthopaedic career. But what features define an orthopod? A cursory search will find the “Characteristics of Highly Successful Orthopaedic Surgeons” (2), which included being highly motivated, with a desire for personal satisfaction. Yet only 5 of the 388 invited participants were female. Further exploration reveals “Demographics and Characteristics of Orthopaedic Surgery Residency Program Directors” (3), a highly respected position, and yet again only 10.5% were female. If we look to the past, then the nuts and bolts, the basic facts to be understood, is that little girls do not fit the mould of an orthopaedic surgeon. I, however, would beg to differ. The girl who grew up as a ballerina shows dedication, technical craft, strength and endurance. The girl who grew up as an artist shows creativity and dexterity. The little girl who cried at the end of Marley and Me demonstrates empathy, one of the top three characteristics of great surgeons, as identified by surgeons (5). Trawling through the literature you can also find “The Ideal Orthopaedic Surgeon” (4), where patients dictated that experience, reputation and time spent with patients were ideal features, and interestingly sex of the surgeon ranked in the lowest five characteristics. I argue that in the bolts of the matter, the characteristics which the individual contributes and that patients value, women actually excel.

The Nuts
Where in our metaphor do the nuts sit? In the past, on the bodies of the majority of orthopaedic surgeons. However by definition the nut is the part of the mechanism that holds the bolt in place, that provides support. So I posit that the nuts of orthopaedic surgery are actually our mentors, our colleagues, the surgical college and orthopaedic associations. Those that are there to support us and add to our personal foundations. AOAs commitment to increasing the proportion of female orthopaedic surgeons in leadership (6) or Women in Orthopaedics Workshops to encourage the new generation of female orthopaedic surgeons. The critical role of mentors who improve accessibility to training, perception of the career and likelihood of pursuing training (7, 8). These are the nuts, the supportive mechanisms that hold the individual in place and prevent slippage.

The Thread
In the fog of the historic imagery of hard work conjured by nuts and bolts, we often forget that the brilliance of the mechanism lies not in the individual pieces, but the thread that binds them. The precision that allows two pieces to effortlessly slide together while providing an immense amount of strength. Orthopaedics, surprisingly to some, embodies that thread. Not only because there is precision in orthopaedics, often overlooked despite the requirement for dexterity, a keen eye for angles and a sufficient amount of perfectionism. But also for the fact that the strength is derived from the combination of bolts, whether that be ballerinas or weight lifters, and nuts, associations and mentors alike, that fit together.

References

1. The nuts and bolts of something:an idiom[Internet]. Cambridge Dictionary. [cited 2024 June 29]. Available from: https://dictionary.cambridge.org/dictionary/english/nuts-and-bolts- of#
2. Klein G, Hussain N, Sprague S, Mehlman CT, Dogbey G, Bhandari M. Characteristics of highly successful orthopedic surgeons: a survey of orthopedic chairs and editors. Can J Surg. 2013 Jun;56(3):192-8. doi: 10.1503/cjs.017511. PMID: 23706848; PMCID: PMC3672433.
3. Cummings PE, Alder KD, Marigi EM, Hidden KA, Kakar S, Barlow JD. Demographics and Characteristics of Orthopaedic Surgery Residency Program Directors: A Cross-sectional Review. JB JS Open Access. 2023 Mar 22;8(1):e22.00128. doi: 10.2106/JBJS.OA.22.00128. PMID: 36969691; PMCID: PMC10032573.
4. Mirza, K., Acharya, P.U., Crasta, N. et al. The Ideal Orthopaedic Surgeon: Comparing Patient Preferences of Surgeon Attributes to Notions Held by Orthopaedic Postgraduates.JOIO 57, 1748–1756 (2023). https://doi.org/10.1007/s43465-023-00988-2
5. Luscan R, Malheiro E, Sisso F, Wartelle S, Parc Y, Fauroux B, Bégué T, Johanet H, Denoyelle F, Garabédian E-N and Simon F (2023) What defines a great surgeon? A survey study confronting perspectives. Front. Med. 10:1210915. doi: 10.3389/fmed.2023.1210915
6. DIVERSITY IN HEALTHCARE – WHY ARE WE STILL TALKING ABOUT IT?[Internet]. Australian Orthopaedic Association. [cited 2024 June 29]. Available from: https://aoa.org.au/for-patients/articles-and-galleries/articles/article-diversity-in- healthcare
7. Enson J, Malik-Tabassum K, Faria A, Faria G, Gill K, Rogers B. The impact of mentoring in trauma and orthopaedic training: a systematic review. Ann R Coll Surg Engl. 2022 Jun;104(6):400-408. doi: 10.1308/rcsann.2021.0330. Epub 2022 Apr 21. PMID: 35446153; PMCID: PMC9157945.