We use our hands for so many things that we take them for granted until they’re not working anymore. It is when things go wrong like this that hand surgeons come to your aid to fix the problem at hand. Hand surgeons are can come from different specializations, but why would someone choose to focus almost exclusively on such a small part of the human body? In this two-part series, Dr. Richard Marn is joined by a med school classmate of his to pull back the curtains on this highly-specialized niche. Dr. Nathan Enoki is an experienced surgeon and US Navy veteran who works as staff surgeon for the Portland VA Healthcare system and runs his own private practice in the state of Oregon. In this episode, he shares how the daily life of a hand surgeon goes and how he is helping people and bringing satisfaction to his life through his practice.

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Fixing The Problems At Hand With Hand Surgeon/Orthopedic Surgeon, Nathan Enoki, MS, MD, Part 1

Surgery is very humbling. You can do a surgery that you think went perfectly and everything looked great and the patient can still have a problem with that. You can have something that looks incredibly difficult to do. These patients sometimes have a fantastic outcome and you think, “They’re doing a lot better than I thought that they were going to do.”

That was Dr. Nathan Enoki, a hand surgeon and also a medical school classmate of mine. He’s a great guy and I’m glad he was able to come on to this show. One thing about Dr. Enoki or Nate, as I call him, is that he took a circuitous route before he even became a hand surgeon. He was a paramedic. He got a Master’s Degree in Physiology and he was also in the Navy as well. Before I get into those details, which we’re going to talk about a little bit later, this episode and this guest interview will be a little different. I’m going to break up this guest interview into two parts. One part is going to be about what Nate does right now as a hand surgeon and how he’s helping people and bringing some satisfaction to his life. The second part, which is going to be a second episode following this episode, is going to be about how he got to where he’s at. That’s where we’ll get into that a little bit more in detail. As a reminder, if you like the content, please hit subscribe. That way, you can get the latest episodes whenever it becomes available.

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Our guest is Dr. Nathan Enoki or as I call him, Nate. He was a medical school classmate of mine and a great guy. The funny thing is he ended up marrying one of our classmates, who is also a wonderful person. Getting back to Nate, he grew up in Hawaii. He went to undergrad at the University of Hawaii at Manoa. He also went to graduate school at the University of Hawaii, where he got a Master’s of Science Degree in Physiology. He then became an EMT, Emergency Medical Technician and progressed to become a paramedic. After that, he went to medical school with yours truly and after medical school, he went into surgery but through a Navy scholarship. His internship in surgery was spent at the Naval Medical Center in San Diego, California. He also did military postgraduate training with the Naval Aerospace Medical Institute based in Pensacola, Florida.

Some of the highlights of his military service include being a US Naval flight surgeon, a squadron flight surgeon for a helicopter squadron based out of Camp Pendleton in California. He was also an assistant officer and assistant group surgeon for Operation Iraqi Freedom for a marine aircraft group. Nate was awarded many and various military awards with the United States Marine Corps and was honorably discharged as lieutenant commander with the medical corps of the United States Navy Reserve. He is board-certified in orthopedic surgery. He also has a certificate of specialty in the surgery of the hand and works for Portland Veterans Administration Hospital, where he is a hand surgeon. As I mentioned before, this interview is going to be split into two parts. Check this episode out. If it’s interesting to you, great. If you’d like to move on, skip ahead to the next episode. I hope you enjoy both. There were some technical difficulties initially so we’re going to dive right into it.

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What do you tell someone when they ask what you do and what are your responsibilities?

Professionally, I’m an orthopedic surgeon by training and my subspecialty training is in hand and wrist surgery. That’s what the branch or the subspecialty of medicine that practice hand and wrist surgery almost exclusively. I work in federal service, for the Veterans Administration where I take care of the hand and wrist needs of veterans in Portland, Oregon and Southwest Washington region up here in the Pacific Northwest.

What you do is take care of the hand and wrist and fingers. That’s all you do.

That’s my primary practice. Their hand, wrist and some elbow problems. They’re common problems and important parts of our body from a sensory standpoint. They say that when people are blind or having trouble with other sensory inputs to the brain, the most important thing that you have is your hands. You need to be able to feel what you’re holding. You need to be able to feel what you’re touching. You need to use your hands to get around your house and get around to where you need to go in your house and outside of your house. Because of that, the hands are very important. We use our hands for many things that we take for granted. We don’t realize how important they are until they’re not working anymore.

What kind of problems do you see in your practice?

In my patient population, I take care of a lot of folks who tend to be older, especially in my primary practice with Veterans Administration. Our average patient age is around 60 years old. A lot of my patients have degenerative conditions like arthritis. There’s a common type of arthritis that develops at the base of the thumb that can be painful and also debilitating. To the point where people have difficulty in pinching things and grasping things like buttoning a shirt, grabbing hold of a drinking glass, turning the key in the ignition of the car, if you have an ignition these days that the key that needs to be turned. Opening a door these days, you don’t see too many homes with the round doorknob anymore. There are handles now and the reason for that is that folks with painful hand joints find it a lot easier to open doors if it’s a lever rather than a knob.

Surgery is not always the fix for every problem that comes up. It is always the last option. Click To Tweet

A lot of degenerative conditions are things that I take care of. I also take care of traumatic injuries. When the weather starts getting nice in the Pacific Northwest, the sun comes out and people start doing activities with their table saws, their tools and power tools and they start getting injuries to their hands. We take care of those things. A lot of folks in the wintertime up here in the Pacific Northwest like to go up into the mountains and snowboard and ski and they break bones. We take a lot of care of a lot of those folks as well with hand and wrist injuries.

Do people automatically often go to surgery or most of them don’t need surgery?

Surgery is not always the fix for every problem that comes up. In fact, there’s a lot to be said about attempting non-surgical ways to treat problems that are both safer for the patient and sometimes have a lot of efficacy or are effective at taking care of these problems. For instance, for arthritis, what we typically do is we try to manage arthritis pain as non-surgically as we can for as long as we can. We go to surgical interventions and surgical options as the last option rather than the first option. In my practice, you develop a fairly longer-term relationship with your patients, perhaps as compared to other surgical subspecialties.

I tend to follow these folks for longer periods of time. We try out different types of treatments that are non-surgical in nature and we follow their progress over time. If the patient is in need of surgery at that point, then we move forward in that direction. If I can make the patient’s symptoms better without having to take them to surgery, then we stay that course and we treat them non-surgically. In my practice and in my philosophy for patient care is that surgery is done when it’s needed. It’s not necessarily something that we rush right into and do right off the bat because that’s oftentimes not the most appropriate way to manage these problems.

If you could walk us through a typical day for someone like you, and I had surgery.

In hand and wrist surgery practice, commonly, we’re fairly busy. We see a larger number of patients in a clinic a day. Going to the doctor, you’ll have an appointment set up to see the hand surgeon, to see someone like me. There are quite a few patients that are also waiting with appointments to be seen as well. The clinics tend to be busy. Their hand problems are problems that are sometimes challenging to manage and primary care doctors and many surgeons are not comfortable with managing specific problems that occur with their hands. Someone like me and in this specialty, they prefer that I take care of these problems. We get a large number of referrals of folks with hand and wrist problems in our clinic. A typical day would involve seeing a large number of patients. Patient numbers can range anywhere from 10 to 25 in a day. That can involve taking care of folks with the broken bones in the hands and wrists.

Another common diagnosis that I take care of is carpal tunnel syndrome. It’s a common problem where folks have numbness or tingling to their fingers that has gotten to the point where it’s distracting and painful for them to live with. We go through these patients and take care of them based upon what their problems are. The other issues that we run across are patients that come into the emergency room with hand injuries or painful joints or other problems at the hand, wrist or the fingers. For instance, many of them can develop an infection in the hand, in the wrist or in the fingers from a cut or an open wound and hand infections are common. It’s one of the things that we sometimes have to deal with surgically if the infection is severe enough. A typical day for me would be taking care of patients in the clinic and also seeing folks in the emergency room as well as folks who may be admitted to the hospital for other problems who have hand and wrist complaints.

What would you say is one of your favorite parts of the day, mundane parts of your day?

My typical day is a blend of all of those things. There are some benefits to being a hand surgeon. As I mentioned before, you develop a longer-term relationship with your patients, especially in my practice at the Veterans Administration. One of the nice and exciting things about it is that you get to follow these patients for a longer period of time and you can track their progress. You can develop a nice relationship with a patient, get to know them well, get to know their spouses and their children. You get to know where they’re traveling to the next summer. You have to know what their activities are, what their hobbies are. I have a lot of patients that do woodworking. I have a lot of patients who like to go hunting or fishing here in the Pacific Northwest. It’s always fun to meet up with them and find out “What big fish did you catch last season? Where were you planning to travel to next year in summertime?”

In a typical clinic day, it’s always fun to come across these folks again and you develop these long-term relationships with folks and you become a part of their family. The more mundane things that come up, that’s a difficult one. The mundane things are things for me that are difficult to fix and make better. There unfortunately are a lot of conditions where even surgery may not make them feel better. Arthritis is a common one where arthritis in certain joints can be difficult to manage in terms of pain and sometimes surgery doesn’t fix or make their pain go away. It becomes difficult and frustrating to not be able to make that problem go away for them and get them to get back to the activities that they like to do. For those folks, I would say that that’s a challenge.

 

Is there any particular moment or case or patient that you take care of that stood out?

There are a lot of folks that stand out in my practice that come to mind. In fact, I took care of a patient. I’ve been following him for various things for the last few years. You develop these relationships with these patients that become lifelong. He ends up having to go to the emergency room for various problems, but he won’t let anyone take care of him. He tells the emergency room doctor that they need to call me. I may or may not be on call at that time but he says, “You need to call Dr. Enoki about this. I’ll only let him take care of this problem.” I get a call in the middle of the night and say, “Dr. Enoki, we have patient so-and-so and he said that we needed to call you. We know you’re not on call but he asked if we could talk to you about him.”

He’s in the emergency room asking you to come in.

He has an injury that he would like me to take care of. I’m happy to do that. It’s interesting and it stands out in your mind where it’s satisfying to know that you’ve made an impact on someone’s life to the point where they trust you to that extent. If they need help, they want to get in touch with you. I find that satisfying in my practice.

What kind of problem was this gentleman suffering from that required your attention?

It was an acute injury. He had an injury to his thumb while doing some woodworking that ultimately needed surgical intervention that I did.

Nate, few of us know what it’s like to be a surgeon. Can you tell us what it’s like to be in the operating room for your patients and some of the tools that you use?

First of all, I need to say that taking folks to surgery these days in the setting of the Coronavirus is a little more challenging. There are a lot more precautions that need to be taken when patients are put under anesthesia to protect the patient and to protect the operating room staff in case anyone should have the Coronavirus. That said, one of the interesting things about hand surgery is that as compared to other specialties in orthopedic surgery where bones tend to be larger or longer or require more strength to manage or inch larger instruments or larger tools to fix, hand surgery uses a lot of things that are very small. The sutures that I use to repair wounds and tendons and nerves, for instance, are tiny. Sometimes I need to do that surgery under a microscope.

Sutures being the little threads.

That’s right, little threads that you use to repair a wound or repair a structure. Sometimes I do that surgery under a microscope. I always operate with these things called loops, you’ve probably seen them where they are magnifying lenses on the end on the glasses. I always operate with those and things tend to be smaller. To repair fractures, we still use plates and screws and drills sometimes if needed. We use some wires sometimes to put bones together to repair joints. A lot of hand surgery, the tools you use to do the job are a lot smaller. I also do some surgeries arthroscopically. A lot of folks have heard where you put a scope in the knee to look around or folks put a scope to look around in the knee. I can do that with the wrist, but the scope is a lot smaller. We do those sorts of surgeries as well. For hand and wrist surgery, it’s interesting. There are a lot of fairly complex surgeries that are done but it makes the specialty unique, challenging, and exciting all at the same time.

As doctors, we can’t get tunnel-visioned into our specialty. We need to take care of the entire patient. Click To Tweet

It sounds intricate and you have to be quite delicate because things are smaller. It’s a complex part of the body from a musculoskeletal standpoint. I would think that your surgeries are not fast and furious but much more slow and methodical.

They do tend to be slow and methodical and that’s true. Hand and wrist surgery are an interesting subspecialty because hand surgeons can come from various different disciplines. For instance, my background is in orthopedic surgery and I did subspecialty training in hand and wrist surgery. I work closely with colleagues who are plastic surgeons whose subspecialty is also hand surgery. I also work with colleagues who are general surgeons who have the same subspecialty in hand and wrist surgery as well.

Hand and wrist surgery are interesting because we draw the techniques and the abilities of at least three different major specialties into one subspecialty and use those techniques to repair various things in the hands. We do vascular surgery where we’re using tiny sutures to repair blood vessels. We do the same for nerves. My plastic surgery colleagues borrow bone management, fracture management from orthopedics. We borrow techniques from the general surgeons to repair certain things like putting skin grafts on. It comes from the general surgery service as well as the plastic surgery service. It’s an interesting subspecialty in that it’s a blending of a lot of different techniques, abilities, and knowledge.

Nate, can you describe another case that was quite satisfying for you to take care of?

There’s one patient in particular that’s satisfying and I still have a relationship with him to this day. He had arthritis at the base of both thumbs. I was following him for some time for that. We finally decided that now is the time for surgery. We scheduled him for surgery and he was ready to go and looking forward to surgery. Before surgery, the nurses in the preoperative area who were getting him ready for surgery recognized that his blood sugar was high. That’s not something that anyone noticed in the past. It was so high that we had to have a long talk about that because I needed to have that looked into.

We ended up having to cancel his surgery at that time and that was a frustrating thing for him because he had his heart set on having this surgery and getting rid of his thumb pain. That’s what he was looking forward to for months. I told him, “You may have a new onset of diabetes. We need to look into that before we undergo the surgery. One, because your blood sugar is very high. Two, because in the big picture, your health is at risk if you have diabetes that’s out of control and it might make you susceptible to other problems if we don’t address this right away.” It turns out that in the course of our referral to the primary care doctors for evaluation of his high blood sugar, not only did he have a new onset of diabetes, but he also had heart problems. Soon after we canceled his surgery, he had a heart attack. Fortunately, we had him in a position where we could fairly quickly get him to the cardiologist to evaluate that.

Long story short, his thumb surgery was delayed for several months when after undergoing management for his diabetes and after undergoing procedures for his heart attack. We did a surgery several months later when all of those problems were managed. While at the time he was frustrated about my recommendation to cancel his surgery, to this day he thanks me for catching that and for getting him in the right place to get his heart taken care of and getting his diabetes taken care of. In reality, I didn’t do any of that. The heart doctors took care of his heart and did a fantastic job with that. The endocrinology doctors helped him with his diabetes and they did a fantastic job with that.

As doctors, we can’t get tunnel-visioned into our specialty. I can’t say, “I’m here to take care of your hand and wrist. It’s up to you to take care of everything else.” We need to take care of the entire patient. We need to make sure that the entire patient is doing well, in addition to managing the specialty or the part of the body or the problem that we’re trying to manage and that we want to focus on. He was a satisfying patient for me, even though it may be a story of a delay of surgery but it was appropriately delayed. In the long run, he is far better off now than if he did not establish a relationship with me for surgery.

How would you describe your work-life balance compared to maybe other types of surgical specialties?

The work-life balance is a difficult thing to answer because it depends on how you’re practicing and what kind of practice you’re in. In general, the surgical subspecialties tend to be a little unbalanced in terms of the time spent between work and outside of work activities. Surgery is challenging. Even after the years of practice, surgery is humbling. You can do a surgery that you think went perfectly and everything looked great and the patient can still have a problem with that. You can have something that was incredibly difficult to do and these patients sometimes have a fantastic outcome. You think, “They’re doing a lot better than I thought that they were going to do.”

 

The challenging part about surgery is that one, surgery involves us getting under the skin, getting to where the things that need to be fixed and repairing those things in the best way we can sometimes. The challenge is that we have to do that involve a lot of things that are beyond our control. For instance, it’s difficult to control infection. Infection is a common problem of surgery. Even with all of the latest and greatest antibiotics available, sometimes there are infections out there that we cannot defeat with an antibiotic. All of those sorts of challenges in surgery make surgery something that you need to be dedicated to the surgeon’s job.

I would say the doctor’s job in general but the surgeon’s job in particular never ends. You are always either working at your job or you’re thinking about what’s going on with your patients that you operated on or what’s happening with the patients that you’re thinking about operating on, the patients that you operated on two years ago. They’re always on your mind and you’re always thinking about that and it’s always something that occupies at least some part of every moment of every day. That’s one of the interesting things about being a doctor in general. Rarely do you have a time or a practice where you can turn off your phone and say, “I’m not working anymore.” Nearly all doctors are always having to think about or do something with patient care or they’re worried about their patients or thinking about their patients and it’s something that becomes a part of your life. It’s not something that goes away or that you can easily turn off.

Achieving a work-life balance is especially important for surgeons because we have that tendency to be constantly involved with or concerned about the work we do and the surgeries we perform and the patients we take care of. It’s important to be able to develop some sort of skill to be able to take care of personal activities and personal life activities along with your concerns for your patients and what’s going on with your work. When people are thinking about a healthcare career, what’s important is that they think about why they’re getting into that specialty to begin with. It’s not something that you do because it’s a good job and I’m going to do it because it’s a job that I’m applying for. Just about every healthcare career involves a different level of commitment to the career and that can be both exciting and challenging. You can be exciting in that. You’re a part of something that is unique in the working world. Your job is to take care of someone who needs help.

On the other hand, you also need to develop the mechanisms within yourself and with the people you live and work with to be able to distance yourself from the work when the time is right. You need to be able to have other activities or other outside hobbies and that sort of thing to maybe get your mind off of work for a period of time. Think of something completely different. For me, personally, I like music. One way that I get away from having to think about hand surgery and wrist surgery is I play a guitar and I play a bass guitar. I play it with an entirely different group of friends who are not in the healthcare field. They don’t know anything about healthcare. We play music together. It’s things like that help you get away. Take a step back a little bit from your day-to-day activities at work to do something completely different and to work a different part of your brain. To do an activity that helps you to free your mind of things that may be concerning to you at work or things that you’re thinking about constantly during the course of a day while you’re at work.

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That was Dr. Nathan Enoki, a classmate, a good friend and a hand surgeon. The rest of his interview will feature more about his origin story in the next episode. If you like what you’ve read so far on this episode and subsequent episodes, please click on the subscribe button. When you do that, number one, it makes me feel good. Thank you very much. Number two, it helps to increase awareness to others about this show. If you’ve subscribed already, thank you very much. Thanks for reading.

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About Dr. Nathan Enoki