How A Solid Routine Can Help You Tackle Any Surgical Situation

William Fishco DPM FACFAS

Some people may call me boring. Some may think I am predictable. I call myself disciplined and regimented.

To illustrate, my closet is lined with identical pants and dress shirts so I wear the same clothes to work each day. If I have surgery, I wear surgical scrubs. If I am in the office all day, I wear khaki pants and a blue dress shirt. That way, I do not have to make any decisions in the morning as I know exactly what to wear.

During residency, I had a uniform to wear that included khaki pants, dress shirt and a tie. Although I currently do not wear a tie (nobody who lives in Arizona wears a tie), I still wear two-thirds of the uniform. Perhaps three years of the clothes routine stuck with me. I am fortunate that the residency uniform changed a couple of years prior to my class where pants had to be white. At least I did not have to look like the Good Humor Man.

I never go to sleep without having all of my daily charts and paperwork done. That way, I will always wake up with a clean slate and not have any pressures of work piling up. I talk to some of my friends who dedicate an entire weekend to get caught up. I need my weekends to recharge the batteries and not think about work. Moreover, my memory (even with notes) is too poor to try to make a chart note that is from a patient encounter from a week ago.

My surgical scrub techs call me “The Robot.” I do not even have to ask for instruments on cases, such as bunionectomies, that are common. I do the surgery the same way every time. Yes, there may be a few adjustments such as a more aggressive lateral release or slight modification on the osteotomy, for example, but the surgical dissection, preparation and closure is always the same. I find that the greatest compliment from my surgical tech, anesthesiologist and OR circulators is when they have my “routine” down.

I can remember when I was in residency feeling almost frustrated and jealous when I would talk to friends who were in other residencies. They would tell me that they see patients in their clinic, book the surgery and they can tell the attending what they wanted to do and pick whatever fixation method they chose. Assuming that their attending thought it was appropriate, they could “experiment” with different techniques and fixation devices. That sounded great. They could play around with different screws, plates and other devices.

I knew that my situation was different. We did not have a clinic and we did not get to “book” surgery on our own. Our surgeries came from our attendings’ private practice. Our attendings had the patient come to the hospital for preoperative labs and for us to do a history and physical the day before surgery. Then we discussed the case with our attending in the evening and it was our job to make sure we “suggested” the appropriate surgery as already planned. There was never any discussion of “let’s try this method” or “let’s try a new type of implant.” It was always the same “old” technique and same “old” fixation devices (K-wires and Synthes screws).

Now that I reflect on this, I realize my residency was all about leaning and perfecting the tenets of surgery: anatomic dissection, proper tissue handling and sound traditional fixation techniques. It sounds boring but boy do I appreciate that now. What that “routine” did for me was to give me the confidence and appreciation of how to handle any surgical situation that may arise.

I do appreciate the need for “experimentation” in all aspects of medicine and surgery. After all, without this, there would be no such thing as artificial hearts or prolonging lives with organ transplants, etc. However, the longer I am in practice, I see surgical trends go in and out of favor. For example, external fixation may be in vogue for a few years and then fade. New implants for hammertoes are the “in” thing right now but probably will not be in five years.

So until somebody can show me a better way of doing things, my professional life will continue to be machine-like. For me, it is comforting knowing that I can be consistent with patient care.


I appreciate this little peek into the life of Dr. Fishco. I would like to get a little peek into the clinical life as well. Is there a routine for each patient? Does every heel pain patient get the same routine? Do all diabetics automatically get ABIs and extra depth shoes on visit day 1?

Heel pain assuming that it is plantar fascitiis
-Stretching, icing, supportive shoes (no barefoot, sandals, slippers, or flip flops).
-NSAIDs or cortisone injection.
-I discuss orthotics as means for long-term care of their feet, and tell the patient that I will get them better without orthotics, but it is an option for long-term care.
-I do not tape/strap arches

Diabetics: I do have a PADnet device and will order that only if there is concern for PAD (ie: non-palpable pulses, history of leg pain/cramping/intermittent claudication, etc. As far as shoes, if they meet criteria per MDCR guidelines, I will order shoes and inlays. First visit is diabetic foot education and thorough neurovascular exam. Trim nails/corns/calluses if needed.

You can email me at if you would like more information on my protocols for office based care.

William D. Fishco

I enjoyed your blog once again...Joe Cione

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