Introduction

The social system in Asia has been largely influenced by capitalism, which has greatly affected the medical field. Physicians in Asia are now considered mere service providers by a government that heavily subsidizes [12] a crowded medical system [2]. It is my perception, however, that the general public in Asian-Pacific regions still view physicians, including orthopaedic surgeons, as bearers of an altruistic responsibility who provide paternalistic and honorable medical services. I would argue that Asian physicians are more revered than physicians in other regions.

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Tae Kyun Kim MD, PhD

However, with high public expectations comes intense pressure to meet those expectations. It is not surprising to learn that Asian physicians are easily prone to stress. Some reasons may be universal and others may be unique to Asian culture. I would like to share my thoughts on how orthopaedic surgeons in the Asia-Pacific region can maintain a healthy and happy life [10].

Patients Who Challenge Us

The tasks of an orthopaedic surgeon fall into three categories: (1) Seeing patients at outpatient clinics, (2) performing surgery, and (3) caring for hospitalized patients. Personally, I find the most difficult task to be treating patients in clinic. For example, I sometimes encounter patients who are not satisfied with their knee replacement. Patient dissatisfaction is typically associated with a multitude of factors, some of which are beyond a surgeon’s control, such as low pain thresholds, unrealistic preoperative expectations, and psychological disorders [1, 4]. Recent studies [10, 13] reveal that orthopaedic surgeons in China have experienced psychological and even physical threats by patients or family members, suggesting perhaps that it is more challenging to establish a healthy doctor-patient relationship in Asia than in other countries.

It was only until recently that I began to accept the challenges associated with a large outpatient clinic. Physicians in the Asia-Pacific region often see many more patients in a given day compared to other regions [3]. I rarely finish my day with a peaceful mind after seeing a series of challenging patients, often spending my nights recalling (and even regretting) some encounters. But just as perfecting a surgical technique takes countless hours of practice, so does learning how to work with challenging patients.

The ability to work with challenging patients is essential to finding happiness. In talking with my peers and from my own experiences, I have learned that a physician should not feel offended by a patient who complains or questions his or her treatment outcomes. These complaints and questions are another way for the patient to convey that the current treatment is not working. It is up to the physician to decide whether it is worth changing course or sticking with the original treatment.

In my experience, frustrated patients who have visited multiple physicians with no definitive diagnosis or solution often are skeptical of physicians and are more likely to remain unsatisfied of any suggested solution. It is often the case that the ultimate cause of patient dissatisfaction is not directly related to their medical condition, but associated with a financial issue, conflict among family members, and/or personal agony. It is prudent to ask a direct question: “What are you concerned about?” Some patients do not know why they are in distress. As the conversation goes on, the patient may come to a realization. Maybe the patient waited several months before seeing the physician. Maybe the patient waited 60 minutes for a consultation with the physician that may last only 5 minutes. For these patients, the physician can start with an apology for keeping them waiting.

Finally, the physician is advised to keep three key questions in mind during a patient consultation: (1) What is the cause of the disease or problem? (2) What is the cause of symptoms or complaints that brought the patient to the clinic? (3) Are there any nonmedical issues bothering the patient? With these three questions in mind, the physician can remain calm to guide a challenging patient to reach reasonable solutions.

Unexpected Adverse Events During Surgery—Guiding Principles

The goal of every surgeon is to perfectly plan and execute each surgical procedure. But the reality is that surgeons sometimes encounter unexpected adverse events during surgery. These can cause harm to the patient, and distress to the physician. When we face unexpected events, it is easy to get frustrated or blame others, which is more likely in the Asia-Pacific region because surgeons work in a more hierarchical culture. One should be cognizant of the fact that responding emotionally only intensifies or worsens the situation.

Whenever I encounter an unexpected event during surgery, I try to remember four guiding principles that help keep me calm: (1) Determine the best surgical remedies to minimize the adverse effects of unexpected events, and execute them. (2) Decide what modifications should be made in postoperative rehabilitation protocols to accommodate the unexpected events during surgery. For example, vigorous medial ligament release, which is often required in TKA for Asian knees with severe varus deformity, sometimes end up with complete release of superficial MCL, subsequently causing medial instability [5, 7]. This type of medial instability originating from complete release of superficial MCL, arguably can be treated by surgical repair without using constrained types of prostheses [9] or even bracing without additional surgical remedy [6]. (3) Consider explicit or implicit practical compensation for patients. It has been my experience that despite increasingly litigious trends in the West, where physicians are hesitant to apologize for an adverse event for fear of being sued [8], most patients and family members in the Asia-Pacific region are inclined to accept what the physician explains or offers, particularly when delivered in a warm and compassionate way. (4) Learn from the experience. We all learn from mistakes, not from success. We must at least convert the immediate harm into a benefit for our future patients by learning from what occurred, so as to be able to offer better care to our future patients.

Develop Relationships With Peers

I like to refer to the following quote by Muhammad Ali: “Often it isn’t the mountains ahead that wear you out, it’s the little pebble in your shoe.”

This quote conveys the difficult nature of the human relationship, one of the most challenging and agonizing realities that we all face. I firmly believe, and a recent study [11] even shows, that good human relationships are the most important factor for a happy life. However, maintaining a good relationship is not easy because the working environment for orthopaedic surgeons in the Asia-Pacific region can be quite competitive. Like the West, a large number of orthopaedic surgeons often compete for few jobs and even fewer resources. Because of the highly competitive nature of the workplace, it is natural to perceive your colleagues as enemies rather than as friends. Do not give in to this way of thinking. There are three approaches, which I believe are effective for building good relationships with peers in Asian culture. (1) Change your perspective. If you are in a conflict with a peer, slow down and examine the argument from his or her point of view. (2) Turn a competitive relationship into a mutually beneficial one. Determine a solution that maximizes the synergy while minimizing collateral damage. For example, we can offer peers opportunities to collaborate together instead of seeking to dominate them. (3) Be compassionate. Physicians are naturally competitive people. It is in our nature to try to win the debate, and gain recognition among our peers. But we do not have to be the smartest person in the room. One can be more accepted and favored when performing the role of an assistant instead of playing the role of the main actor.

Although medicine is one of the most-favored professions in the Asia-Pacific region, not all physicians lead a happy life. Human nature may be universal, but the ways in which one appreciates or responds to a situation, which I believe is more crucial to happiness than the situation itself, vary within the region and culture. It has been my observation that Asians tend to be more modest in expressing themselves. The truth is, we are more sensitive and sometimes, much more emotional. This is quite a contrast to the cool approach that I have observed during my fellowship in the United States. Therefore, we Asian surgeons can live a better, or at least less distressful life, when considering these unique approaches.