Blog Post |  April 16, 2023

By csuvetce

Do you ever just let your mind go and journey to the wonderful world of “What if…” thinking? I sure do. These are those moments of my idealist thinking that cause me to challenge the status quo and allow me to think of what could be rather than what is.

It was exactly that sort of thinking that caused this question, “why do we have a team of people, checklists, and decision-makers involved in making commercial aviation the safest it has ever been, but we put the sole responsibility of pre- and intra-operative decision-making on a single veterinarian with no support whatsoever?”.  Is there something that we can learn from the aviation industry?  A veterinarian may be very experienced in a commonly performed procedure but, just like the experienced airline pilot, would still benefit from checklists and other so-called “defensive layers” within a systematic approach to risk mitigation that promotes patient safety.  The benefit of such a systematic approach to patient safety would be further amplified for procedures in which the veterinarian is relatively inexperienced.  Taken to an extreme, an airline would NEVER simply train a licensed pilot over a few days to fly a certain aircraft and then set them free to kick the plane’s tires, check weather.com, look both ways on the runway and then push the throttle levers forward. No … commercial aviation takes a systematic approach to maintenance of the aircraft, collaborative development a flight plan, pilot & co-pilot completing a cockpit checklist, establishing tower clearance for take-off, etc.

Now for the “what if…” thinking.

WHAT IF … we could build such a systematic approach to some of our surgical procedures veterinary medicine?   Is there a reason that we can’t?   What if, we could build a process by which the veterinarian would have colleagues and experts working alongside them to help them safely and expertly execute a surgical procedure?  Sure, we train surgical specialists through residency training programs, but we all know that barriers to referral do exist such that not all pet owners have access to these specialists. This is especially true when we open our thinking to a global / worldwide perspective.  So, what if we could train a primary care veterinarian to perform an advanced surgical procedure such as a tibial tuberosity advancement (TTA) for cranial cruciate ligament incompetence and then provide them with systematic support in the planning and execution of the procedure so that safety was optimized for each of their TTA patients?

That is exactly the sort of thinking that one orthopedic company in New Zealand (OssAbility; Canterbury, NZ) used in development of their new safety focused TTA procedure.  As a career educator and trainer in veterinary orthopedic procedures, this creative “what if thinking” intrigued me!   This exciting new approach to patient safety started by their identifying the key steps where primary care veterinarians have traditionally struggled to safely perform TTA’s in their practices. Case selection, safe positioning of the tibial crest osteotomy, and optimal implant selection were identified as key targets for improved patient safety.  They engineered instrumentation and implants and designed a decision support system that allows them to strategically target these areas of high patient risk. Now, I am thrilled that CSUVetCE will be the first CE center in North America to offer this paradigm-shifting approach to orthopedic training for the primary care veterinarian. Click here to register Practical TTA course. 

Let’s start with the challenge of supporting you with TTA case selection; in our upcoming training course, you (and your technician if you wish) will receive hands-on training in how to properly position for and submit preoperative radiographs for submission to the OssAbility Decision Support team.  There, a board-certified specialist surgeon, will review your patient’s radiographs and other pertinent information to determine, first, if TTA is indicated for your patient.  If TTA is indicated, that team provides you with a patient-specific operative plan that includes instructions on exactly how to set their adjustable cutting guide such that it will place the osteotomy in exactly the right (i.e., safest) location (comparison of this system to traditional TTA osteotomy verified this in our laboratory).  They engineered this cutting guide with adjustable offset pins that allow it to adapt to a wide variety of canine tibial shapes and sizes.  Next, the patient-specific operative plan instructs you regarding which size of advancement wedge should be used such that the tibial tuberosity is appropriately advanced (again, implants which were tested for safety and efficacy here in our CSU laboratories).  Finally, the operative plan states what size plate will best fit your patient.  All in all, it is very comprehensive approach to TTA patient safety.  Of course, our hands-on training includes multiple opportunities to perform all the above, first, on a plastic bone model and then, in combination with the surgical approach in canine cadavers.  Instructor feedback from radiographic review of those procedures will help you to refine your execution of the operative plan on your next procedure.

As the son of a military and airline pilot, I am reminded of my dad’s lessons about aeronautical safety and a few them seem germane to this discussion of patient safety. One of those sayings was “It is better to be on the ground wishing that you were in the air, than in the air wishing you were on the ground”.  There is an obvious and relevant corollary regarding the operating room. Another of his memorable sayings was about the gravity of compounded errors in which he’d bluntly remind me, “It is the third error that will kill you.”  The implication was, you’d be wise to develop a support system that will prevent you from committing errors #1 and #2.  It is the systematic approach to aviation safety that prevent pilots from committing these errors or finding themselves in the air but wishing that they were on the ground.

Just as the trained pilot is supported by a decision-making team when they are tasked with executing a flight plan, the trained veterinarian is now supported by a decision-making team as they are tasked with executing a surgical plan.  The status quo of putting all the decision-making and surgical execution burdens on the inexperienced surgeon is thrown out the window and a new systematic approach to patient safety is introduced.

Here’s to the crazy ones, the misfits, the rebels, the troublemakers, the round pegs in the square holes… the ones who see things differently — they’re not fond of rules… You can quote them, disagree with them, glorify or vilify them, but the only thing you can’t do is ignore them because they change things… they push the human race forward, and while some may see them as the crazy ones, we see genius, because the ones who are crazy enough to think that they can change the world, are the ones who do.
— Steve Jobs, 1997

So, what do you think?  Is this systematic approach to improving veterinary patient safety crazy?

Ross’ career has spanned both private practice and academia. Along the way, he has been actively engaged in orthopedic training of veterinarians for more than 30 years. Ross is a professor Orthopedics at Colorado State University, Associate Director of Education at the Translational Medicine Institute and a frequent educator at orthopedic courses held here at CSUVetCE and around the world.  If you, too, believe that “what if … thinking” is the key to innovation and advancement beyond that status quo, please get to know us at www.CSUVetCE.com because nothing fuels our passion like rubbing elbows with those who are similarly driven.


  1. Unfortunately, veterinary colleges are populated by professors who spend 4 years learning one subject and then think teaching it in 4 weeks of clinics will provide an adequate knowledge base for the “primary care veterinarian” It is simply ludicrous to think this way anymore. The systems you talk about are backed up by spending resources on training the individuals who will use them. Primary care in human medicine consists of 3 years of training. V
    My father started managing a nuclear power installation after Three Mile Island in 1979. He instituted checklists and many of the things you talk about but they were built upon having highly trained reactor operators whose training was vastly improved prior to the TMI systems failure in 1979. He also invested in non-technical training in safety, quality and team building. The training a federally licensed reactor operator or federally licensed airline pilot is decades ahead of the antiquated veterinary programs which refuses to change to meet reality.

  2. Thanks for your comment! We hope that this Community Page will be a place that we can share various vantage points and perspectives. I think that you are “spot on” with regard to the necessity for academia to respond the dramatic shifts and changes in our profession – to do otherwise supposes that veterinary industry is stagnant … and nothing could be further from the truth! I am happy to report that the CSU College of Veterinary Medicine and Biomedical Sciences is well aware of the changes happening all around us and is responding by re-thinking most everything that we do in terms of education/clinical training, clinical services and research. We don’t profess to have all of the answers, but we have utmost confidence that extraordinarily dedicated people who lead with passion and purpose will leave our profession better than we found it.

    To that end, I must say that academia is filled with amazing and dedicated people. I’ve worked half of my career in private practice and half in academia and I think that gives me a unique perspective. My private practice years were equally divided between serving as a practice associate and later as a practice founder / owner. I’ve been fortunate to have worked with amazing colleagues and friends in all sectors and that certainly included academia. I’ve worked with so many academic faculty and staff who have resisted some very financially lucrative opportunities only because they believe in investing themselves in the next generation of our remarkable profession. Have they/we done it perfectly? … certainly not, but it is not for lack of passion, purpose and dedication to our profession. Serving multiple constituencies whom often possess conflicting interests is not for the faint of heart, but it IS for the people who seek to make a difference in our profession. I marvel at these dedicated few and hold them in the highest esteem.

    In the post-graduate CE sector, CSUVetCE, like you, seeks to challenge the existing paradigm and dare to think & act differently. That is exactly what we are doing with the Practical TTA Course … we’ve embraced an approach that nobody else had dared to take. Perfect? – Probably not. Traditional thinking? – definitely not! This career called veterinary medicine is a crazy, wonderful adventure and we’re in with both feet. One thing that we won’t do, is to stay fixed and stranded where we are … together, we can dare to think and act differently.

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