Speaker 1: 00:00 From Spaugh Dameron Tenny, it's White Coat Wellness, a show for doctors who are ready to improve their financial wellness. We know you work hard to help your patients, but you can't be at your best if you don't have your own finances in order. In White Coat Wellness, we highlight real-life stories from physicians and dentists to educate, encourage and inspire you to personal, professional and financial wellness. Now, from Spaugh Dameron Tenny, please welcome your host, Shane Tenny.
Shane Tenny: 00:31 Well, today we're talking global health and innovation, and I'm excited to introduce a friend and inventor, Dr. Joe Hsu. He is the Vice Chair of Quality for the Atrium Health Musculoskeletal Institute, a professor of Orthopedic Trauma Fellows program, and the director of the Limb Lengthening and Deformity service. Dr. Hsu served as a Lieutenant Colonel in the US Army, and deployed to Baghdad, Iraq in 2006. He spent the majority of his military career trying to optimize outcomes for limb reconstruction patients, and has translated that work into the civilian sector and to his work internationally.
Shane Tenny: 01:06 Dr. Hsu has also focused his research and quality efforts on opioid prescription safety, and even non-opioid strategies for pain management. He's got a really neat story. I'm excited for you to be with us today, Joe. Thanks so much for your time this morning.
Dr. Joe Hsu: 01:20 Oh, it's a honor to be here and talk about something that I think has given as much to me as I've given to it.
Shane Tenny: 01:27 Well, excellent. Why don't we maybe just ask you to start at the beginning a little bit about your early journey into medicine, and how you found your way around the world and eventually to Charlotte.
Dr. Joe Hsu: 01:36 Sure. So my journey through medicine was a little probably unconventional. I had an inkling even as early as high school that I probably wanted to do medicine, but was drawn more to join the military than anything else. And so out of high school, went to West Point. Once I got to West Point, I actually found out that those two goals could be aligned. And actually went through a pre-medical program at West Point, and was fortunate enough to be selected to go to medical school right when I graduated. Moved to new Orleans, and spent about 10 years there training in medical school and residency and fellowship there in Orthopedics and Orthopedic Trauma, and Limb Reconstruction. And went back on active duty.
Dr. Joe Hsu: 02:16 I went back on active duty, 2004, which, as we know, was a time when the war in the Middle East was accelerating. And spent most of my military career with the honor of treating our nation's wounded warriors. Through some research connections there and some other connections, I was able to find my way to Charlotte to continue a lot of that work on the civilian side. Translate some of those programs that we developed in the military for a population in need here in the greater Charlotte area.
Shane Tenny: 02:52 And how did that training and that experience create the connection that you now have with Honduras? Talk a little bit about that.
Dr. Joe Hsu: 03:01 Through some of the connections I had here, people that trained in New Orleans that I knew and other connections were for people with whom I did research on active duty in the military that helped to recruit me here. One of the things I actually found interesting about this program here in Charlotte is it actually had an international medical outreach department here, and they actually did not have a significant orthopedic presence. In my active duty time, I actually started going to Honduras as part of what's called Medical Readiness Missions, and through those Medical Readiness Missions, we take a team down to a low and middle income country, and you set up surgical capabilities and execute those surgeries with that team. What I realized, I was fortunate to go to Tegucigalpa, Honduras, a hospital called Hospital Escuela. And just to give you a little bit of information about the scope of trauma at Hospital Escuela, our busiest trauma centers in the United States see about seven to 8,000 trauma admissions a year.
Dr. Joe Hsu: 04:05 The top busiest trauma centers. They see at Tegucigalpa, Honduras, Hospital Escuela sees about 15,000 trauma admissions a year. So, so far busier than our busiest US trauma center. And as you can imagine, not well-resourced. And so when I was there, I realized that there was a significant burden of chronic disease, the sequela of trauma was a real challenge for them. Deformity and infection, especially chronic osteomyelitis. Which was a skillset that not only had I trained on both at my formal training and in New Orleans, but also some international fellowships in Russia and Italy.
Dr. Joe Hsu: 04:48 But also it was what we did every day for our combat casualties. The severe injuries of war directly correlated to severe injuries that they would see in a low and middle income country, and to the chronic nature of disease and infection, those countries. And so my work at home in the military correlated directly to that. And seeing that need there, it seemed to connect. It seemed to connect that maybe we should do something more permanent, more substantial in that environment.
Shane Tenny: 05:23 That really gave birth to the program you now have started, or had called RESTORE. Can you elaborate a little bit on that?
Dr. Joe Hsu: 05:32 Yeah, so the whole concept of RESTORE is not about what I can do as a surgeon or what my colleagues can do as surgeons. It's all about transmitting the education and resources to the local surgeons. And that was really the magic in the mix at Hospital Escuela, is they actually had orthopedic surgeons there. They have a training program there, but they just didn't have the capability to do this high end limb reconstruction. And it was just the right thing, the right time. A little bit of serendipity.
Dr. Joe Hsu: 06:05 And so what we do, what we focus on in RESTORE is there are equipment donations that we do and some other things like that, but different than a lot of other people called medical mission work, where you go and you do something for a significant number of patients. What ours is is actually mentoring the local surgeons. And so over the course of the past 10 years, I call it programmed obsolescence. So I've intentionally programmed myself to be obsolete in that surgical scenario, because the local surgeons have gotten so good and have attained and mastered the techniques that we started teaching a decade ago. And so that's the real focus of RESTORE, is to have something that is sustainable in their environment, where we're not taking a bunch of first-world technology down there and then taking it back when we leave.
Shane Tenny: 07:02 And so RESTORE really began, I think in 2010 or thereabouts, with you bringing down a team of people to train the orthopedic surgeons that were already at Hospital Escuela on just advanced techniques and things like that. Am I understanding you correctly?
Dr. Joe Hsu: 07:20 That's right. And a lot of those techniques were techniques that I learned in Russia and Italy, and refined through working almost daily on our severely wounded combat casualties. And that's the kind of techniques that they actually needed in that environment for their chronic problems that they dealt with. They really had a talented core group of surgeons there that wanted the knowledge, that wanted the ability to do those reconstructions. They just had not had that training yet.
Shane Tenny: 07:52 And what contributes to the prevalence of the high rate of deformity, or need for limb lengthening in Honduras as opposed to the US?
Dr. Joe Hsu: 08:03 Yeah, I think it's multifactorial. And the reality is if you had to boil it down, it's resources. It's the economic resources of the country, it's economic resources of the facility, because they're in a situation where you have an overwhelming number of patients. As we discussed earlier, roughly twice or more than twice that of the busiest trauma centers in our country. You have to have very limited resources, limited access to OR, limited access to implants.
Dr. Joe Hsu: 08:33 Some of the deformity is not even necessarily trauma related, but it also has to do with a situation where access to medical resources are limited. So some of the pediatric diseases become adult diseases there. Where in the United States, those are treated as children, and have less of an impact on that working age population because they're treated early on in the process. And then there are challenges around infection that are again multifactorial.
Dr. Joe Hsu: 09:04 A lot of penetrating trauma in that country, a lot of high energy trauma as well, and some issues around optimization of some of the hospital resources as well may contribute to that. To include sometimes delays in surgery, and intermittent challenges with sterility. And so I think that there's a host of factors that create a burden of disease there with limb deformity and osteomyelitis that is pretty significant.
Shane Tenny: 09:38 And I understand you typically try to go once or twice a year down to Honduras and work with the team down there. Last year, I think you were able to take a resident with you.
Dr. Joe Hsu: 09:48 Right.
Shane Tenny: 09:48 I'm imagining it must've been a pretty neat experience for her. Can you talk a little about that?
Dr. Joe Hsu: 09:52 Yeah. So I used to go more frequently, but my significant other explained to me that I needed to spend more time at home and less time in Central America. But, it actually aligned very well. As my local responsibilities here increased, as our family grew, the surgeons there became more and more advanced in their capabilities. And so now, my role is less as a surgeon and more as a mentor. And so over time, it's really actually reversed in that the surgeons there, because they have such a tremendous burden of disease, they're doing these complex reconstructions almost on a daily basis. They've become experts at this in a short 10 years, which it would take probably twice that long in a US center to gain that kind of experience. And so now I'm in the zone where I am taking down US surgeons or US trainees to learn from them.
Dr. Joe Hsu: 10:55 And I've taken down several attending orthopedic surgeons to learn a variety of techniques and advanced techniques from the local surgeons. And it's a sharing relationship, right? When you bring down an attending surgeon, one of them is a pediatric orthopedic surgeon, Brian Brighton. So Dr. Brighton can go down and teach them about a wide variety of pediatric diseases and pediatric orthopedics. But some of the really advanced limb lengthening and reconstruction techniques, they actually had more experience. And so they would share together and learn together on a lot of different things.
Dr. Joe Hsu: 11:32 And so that from my perspective was great to see. This past year, actually thanks to your organization, we were able to send down a resident here from Charlotte. She was the first resident, Dr. Sarah Peaurie was the first resident to go down and learn from the surgeons there. And everyone teases me nowadays. In the past two or three years, they're like, "Well, you barely scrub in surgery anymore. You kind of seem to be an administrator down there." That is by design, because the local surgeons are the talent now. And so to me, I knew that this was working well and this was successful when I see the local surgeons, they are training one of our residents. My role was to take pictures.
Shane Tenny: 12:21 Right. You have been promoted to the chief photographer.
Dr. Joe Hsu: 12:24 That's right.
Shane Tenny: 12:25 Yup. Yup. I'm just trying to imagine kind of the impact that your work has on the lives of the patients that receive the care for such significant disease or deformity. Is there a story in particular that maybe you can share with us that stands out to you?
Dr. Joe Hsu: 12:44 So, there are a myriad of patient stories that are inspirational. But I think the story that really sums the whole thing up for me is the story of Mirna Ochoa. And she's actually the head surgeon there in the limb reconstruction division. She was actually a senior resident the first time that I went, but her English was good. And so they assigned her to the American team to help translate for us, and it turned out that she had the skills and the desire and the intellectual bandwidth to really be the lead for this.
Dr. Joe Hsu: 13:20 And so it was a little bit unusual to identify her early. And I went to her chair and I said, "Once you graduate, I want her to run this division." Which was a little bit of an unusual conversation. And she's done it. The interesting thing to see about that is she's taught and mentor two others of her partners to do this, one pediatric and one adult. She's even in a situation where she can not only mentor and teach near peers, but some of the surgeons that are even older than her, and she's been able to shift that culture there as well.
Dr. Joe Hsu: 13:55 But really the story that I think is the most interesting, in addition to the US surgeons as you saw in the locals, so I was down there. This was probably about ... It had to have been about four years ago. And I was down, and she was doing a bone transport, which is a technique where you cut the bone and you move it to the limb where there's a defect, and the body fills in behind.
Dr. Joe Hsu: 14:19 One of the challenges if you do a bone defect with a significant gap is either the skin or the flap falls down into the gap and gets squeezed between the bone ends as you're transporting them, and then can cause some problems with wound breakdown or maybe even need a repeat surgery. And so I was down there, and she had a patient undergoing a bone transport. And this patient had sutures in the skin, in the area where the bone was being transported underneath the skin. And it was lifting up the skin, and those sutures were attached to the frame by an outrigger that she had built. And it was very elegantly lifting up the skin and transporting the bone underneath, and I started taking all kinds of pictures of it.
Dr. Joe Hsu: 15:07 I was like, "This is brilliant." I was like, "Where did you learn this? This is very similar to a technique that I saw in Russia that I've never used, and there's a new adaptation of it." And she had this awkward smile and she goes, "You taught this to me almost five years ago." So this was a technique that I guess I'd adapted on the fly in Honduras five years prior. I had completely forgotten about it because I'd only done it once there with her in Honduras. She had remembered it, put it into practice, had done it dozens of times. And so I went down, relearned the technique from her, and then brought it back and started using it in my own patients. And that's what I do now in my own patients. And so that to me, that's the beauty of doing this type of work.
Shane Tenny: 15:58 You've literally replicated yourself so well that you're now reteaching yourself practically.
Dr. Joe Hsu: 16:04 I say we figured it out together, and then she taught it to me years later.
Shane Tenny: 16:10 How does the work there in Honduras that you've been a part of, that you've seen, how does that impact your day to day in Charlotte doing surgeries here in the US? What's the perspective like?
Dr. Joe Hsu: 16:23 Well, I think think that ... The quick answer is I just gave an example of an area where a technique was reborn to me that actually improves the way we're doing the surgery here. I think more importantly, it gave me the perspective of ... I think what we don't realize and we as surgeons, we as physicians, we don't realize is how well we're doing affects everything that we do at work. And the work in Honduras ... There is a lot of things that we do in life, there's a lot of models for burnout and resilience, but the reality is there's a lot of things that empty our cup throughout the day. And there are things that can fill our cup, and this work in Honduras, you can tell the joy and the pride in my voice when I talk about the accomplishments of Dr. Ochoa there.
Dr. Joe Hsu: 17:16 It's not what I did. It's what she does. It's what her colleagues there do. That fills my cup. And I think it makes me a better clinician. It makes me a better surgeon. It makes me a better father. It makes me a better husband because it helps center me back into that. We talked about the beginning, that high school kid that had this inkling that I wanted to do medicine and make a difference.
Dr. Joe Hsu: 17:38 And sadly that gets lost in our day to day lives a lot of times because a large part of medicine has become interacting with the EHR and this technology, and do this and this regulation, and this score, and that sort of thing. But to have those experiences that are pure like that, and then to bring that back and say, "Hey. What we do is pretty cool for people." And I think that that's probably been the biggest thing that work in Honduras has done to translate back to ... To really have a positive impact on the patients that we treat here in a greater Charlotte area, and hopefully my colleagues and the residents and fellows that I work with to this day.
Shane Tenny: 18:26 Yeah, that's, neat. Now I actually want to expound on that a little bit. When we come right back from this break.
Will: 18:36 I'm Will Koster and on this episode of White Coat Wisdom, we're going to be talking about student loans again because it seems like a topic that you can't avoid. Everyday on social media or in the news, there seems to be a new headline around student loans. Student loan debt at all time high, or my favorite, less than 1% of the applicants have loans forgiven under public service loan forgiveness program.
Will: 18:57 Listeners just like you fall victim to the headache, the confusion and the anxiety that student loans can create. My experience is the best remedy for anxiety around your student loans is to remind yourself of your game plan. First off, do you even have a game plan? Are you going for public service loan forgiveness? Have you refinanced? All of these questions when left unanswered can create uncertainty. However, when you take control of your situation, it's amazing how quickly confidence is restored. If you need help creating your student loan game plan or you need a second set of eyes, I would suggest calling a professional. One that specializes in physicians or dentists, and one that has history helping people with their student loans. With today's White Coat Wisdom, I'm Will Koster.
Shane Tenny: 19:47 So, Dr. Hsu, you were just talking a little bit about the work as a physician. And perhaps for all of us, there's things in our lives that kind of make withdrawals from our energy bank, and there's things that make contributions to our energy bank. Our podcast here of course is White Coat Wellness, and I guess that's kind of almost the phrase that comes to mind when I hear you talking about the work that you've been able to do in Honduras. Really helping to ... I guess what I hear you saying is almost make you a better clinician when you're here on a day to day basis. I guess maybe pick up there a little bit. What's that concept of wellness mean, and how's that integrate with kind of what you've been doing?
Dr. Joe Hsu: 20:24 Right. So I alluded to earlier that there are a lot of theories around burnout and resilience or grit. To me, the easiest one to understand as a non psychiatrist, non psychologist is this concept of hassles versus uplifts. So there are so many hassles that we have to deal with during the day that get us into a situation where we get disconnected from our work, or disconnected from the purpose of our work. And those are the things that really kind of break us down over time.
Dr. Joe Hsu: 20:53 And that depersonalization is really one of the first signs of burnout. There are other things that are uplifts, there are these little things that we have, these little bright moments in our day that counteract the hassles. Now what does that need to be? Does it need to be a 1:1 ratio, a 10:1? It sort of depends on who you are as a person. It probably may be 100:1, is the right ...
Shane Tenny: 21:18 Depends how big the hassle is.
Dr. Joe Hsu: 21:21 And so what happens is there are things in my life that ... But part of it is being aware of when it is an uplift, and recognizing in a positive moment, say,"This is an uplift for me," and that's what RESTORE has become. RESTORE is a huge uplift for me. I'm excited to talk about it, as you can tell. I do a little bit every day. I tell people this kind of work, it's not ... You go down for a week, there's a little bit everyday that you're doing logistically on the background, and electronically mentoring the surgeons there. But that's an uplift to me. That's not like, "Oh, this is a hassle. I've got to answer this email or WhatsApp." It fulfills me to do that.
Dr. Joe Hsu: 22:05 And so as that is an uplift, it helps with what ... It helps refocus our purpose, gets us back to the why of what we do in medicine. The same thing can be said, there are some of the wounded warriors that I'm still in touch with now from the military. And I tell people that I draw resilience from my patients and I have a whole theory about how if we really recognize that one of these people has accomplished and moved on with their lives and displayed tremendous amount of grit, we can draw from that. And it gives us purpose in what we do. And I think that that's the real challenge with wellness and burnout is losing that purpose, losing that you get to where that personalization becomes a problem, and you start to withdraw from that.
Shane Tenny: 22:52 And with that said, do you have a suggestion for maybe a Doc listening to us now who says, "Yeah. Depersonalization, I deal with that every day," or they're beginning to resonate with maybe your comments there or some of the publicity around the issue of stress, exhaustion, anxiety, burnout. What suggestion, what tip would you have based on kind of your career and and spots where maybe you felt the same thing that they might do to combat that?
Dr. Joe Hsu: 23:19 I think most of the focus on it has been this concept of work/life balance. But the reality is this. The majority of the waking hours of your life are going to be at work, really no matter what your work is. And so my strategy has been to find these uplifts at work. And not only do I find them, but I'm willing to share them with other people. And that's something that is a little bit different. We're taught this tremendous humility as physicians, right? If a patient does well, it's almost considered bragging to tell someone, "Hey, look what this patient did." But the reality is the rest of the team need you to share that story as well. Because the nurses, the technicians, the same people that deal with the same struggles that we're dealing with, they don't get to know what happens to the patient.
Dr. Joe Hsu: 24:09 They don't get to know that that patient went on and got married and got to walk down the aisle because we fixed their limb. They don't get to know that. And so sharing that not only helps me, but it's going to help the rest of the team. So I think that that's one of the tips that I give people ... Is first and foremost, is recognizing you've got to find that in your work. It can't just be I'm going to take a vacation or I'm going to do more yoga. All things that I encourage people to do and I try to do myself, but finding that in your own work and sharing those stories with other people. The other thing is because of this humility barrier that we feel in medicine sometimes, if a patient thanks you, we downplay that thanks a lot of times.
Dr. Joe Hsu: 24:55 But the reality is it's important for that patient to give that thanks. That is part of their healing process, for the grateful patients to give that thanks. It's also important for us to accept it. And I think that that's a real challenge is we often ... It's downplayed for the most part. And there are strategies to doing it, there are strategies to accepting the thanks. Like I tell people, "Thank you for extending your gratitude. That means a lot to me. It's a huge team effort. We're fortunate to be able to care for people like you that are so motivated to do well and we played this part. I'm glad that we're able to work together on this." And that may be a more comfortable strategy for someone who is not willing to take that thanks or has not been taught to take that thanks.
Dr. Joe Hsu: 25:42 So it's not really something that we really do in healthcare. And in reality, when you open that conversation with a patient, you realize how meaningful you are to that patient in their lives. And that's why we got into medicine in the first place. We got into medicine for that meaning, we got into medicine for that connection. And then we lose it through all of the different processes and the requirements and the regulation, and the technology that actually doesn't seem to work. I don't know what the barrier is in medicine, but if you put medical before the word technology, it usually is not technology.
Shane Tenny: 26:20 Right, right.
Dr. Joe Hsu: 26:22 So those are things that hopefully moving forward, some of the work that we're trying to do is to help fix some of those interfaces to improve that. That's a pretty heavy lift moving forward.
Shane Tenny: 26:35 Yup. Yup. Your comment on gratitude is so profound because gratitude has healing powers, I think for the person giving and for the person receiving it.
Dr. Joe Hsu: 26:44 Absolutely.
Shane Tenny: 26:45 In some ways, I can't think of a better way to adjourn our conversation today, and the work that you've done. So thanks so much for being with us today. I really appreciate hearing just a bit of your story, and of course I'm sure folks can find you online or track you down through Twitter if they want to connect with you more.
Dr. Joe Hsu: 27:01 That sounds great. Thank you for taking the time today.
Shane Tenny: 27:04 Absolutely. Thanks.
Will: 27:09 I'm Will [inaudible 00:27:09], and on today's White Coat Achievements, a segment that highlights noteworthy achievements by your friends and colleagues, we'd like to give a shout out to two female physicians who have given women in medicine a voice, a safe space on social media to share in triumphs and victories, but also to lend a word of encouragement when faced with adversity in the workplace.
Will: 27:31 Dr. Melissa Parsons and Dr. Alexandra Mannix are the cofounders of sheMD. They launched sheMD in 2018 during their time as emergency medicine residents at the university of Florida. sheMD is a website and social media community that centers around encouraging female physicians. sheMD focuses on education to help break gender disparities in medicine, and helps mentor future female physicians.
Will: 27:59 sheMD has actually featured almost 90 different authors in under a year. They have quickly grown quite a following, and we think it is worthwhile to give them a White Coat Achievement shout out. As always, if you know someone who wears a white coat and is achieving something note worthy, please drop us a line. We'd love to hear about it. Might even feature them on a future episode, but again, this episode's White Coat Achievement goes to Dr. Melissa Parsons and Dr. Alexandra Mannix for what they're doing on sheMD.
Shane Tenny: 28:36 Thanks so much for listening to this episode of White Coat Wellness. You can stay in touch with us and other colleagues, dentists and physicians interested in financial wellness through our White Coat Wellness Facebook group. The link is in the show notes. You can follow me on Twitter at Shane_Tenny, and if you enjoyed today's conversation with Dr. Hsu, would you mind giving us a shout out or a good review on Apple iTunes or Google Play? That'd be super helpful. Also, make sure to subscribe so you won't miss any of our future doctors stories. And if you have ideas, questions, suggestions for future topics or guests, you can drop me an email directly at firstname.lastname@example.org. Thanks. We'll see you here next time.
Speaker 1: 29:15 This episode of White Coat Wellness is over, but you're not alone on your journey towards financial wellness. Spaugh Dameron Tenny has been helping physicians and dentists with their financial planning for over 60 years, and we'd love to answer any questions that would be of help to you. Visit SDTplanning.com today, and take your financial wellness to new levels. Once again, that's SDTplanning.com, and we'll see you on the next episode of White Coat Wellness.