Archive | November 2014

JBJS Reviews Editor’s Choice–Graduate Medical Education in Orthopaedics

Surgical training throughout the surgical subspecialties has typically followed a so-called apprenticeship model. Experience has been measured on the basis of case log documentation, and competency has been determined by senior mentors. Recently, a paradigm shift in medical education has led to an increasing emphasis on competence—specifically, competence with regard to operative skills, surgical knowledge, professionalism, and the use of assessment tools that can provide credible, accurate, reproducible, and transparent forms of evaluation. Indeed, medical education has become more complex, and the delivery of excellence in education has become more difficult. As an example, restrictions imposed by duty-hour limits and requirements for onsite direct supervision by teachers and mentors has changed the education experience.

Residents-in-training are now required to demonstrate proficiency and knowledge as well as performance in six core competencies: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. As of July 1, 2013, the Accreditation Council for Graduate Medical Education (ACGME), in conjunction with the American Board of Orthopaedic Surgery and the Residency Review Committee for Orthopaedic Surgery, has implemented the Orthopaedic Surgery Milestone Project, which includes new requirements for training and the assessment of motor skills during basic orthopaedic education.

The introduction to these and other measures such as simulation is rapidly improving orthopaedic medical education. The article by Samora et al. in the November 2014 issue of JBJS Reviews provides a clear window into the immediate future of graduate medical education in orthopaedics. I strongly encourage you to read this article and to be familiar with its contents. Simply stated, it is the way of the future.

Thomas A. Einhorn, MD, Editor

Vibrating Insoles, Perturbation Treadmills Could Reduce Fall Risk in Elderly

Photo credit: Harvard's Wyss Institute

Photo credit: Harvard’s Wyss Institute

The statistics about falls in the elderly are both startling and troubling:

  • Citing CDC data, The New York Times recently reported that in 2012 nearly 24,000 Americans aged 65 and older died after a fall, and more than 2.4 million elderly people presented to emergency departments for fall-related injuries.
  • Nearly one-quarter of seniors who fracture a hip during a fall die within 12 months.
  • By 2020, the US will spend more than $67 billion (in 2012 dollars) annually on direct and indirect costs of fall injuries.

Many researchers are working on ways to prevent falls among older people, and one of the most interesting recent developments is a simple shoe insole that provides imperceptible vibratory stimulation to the feet. A study in the Archives of Physical Medicine and Rehabilitation found that vibratory stimulation delivered via insoles to the medial arches of 12 elderly people improved their balance, reduced their gait variability, and boosted performance on a timed “get-up-and-go” test.

According to Lewis Lipsitz, MD, lead study author and director of the Institute for Aging Research, one root cause of falls in the elderly is the loss of sensation and proprioception in the feet, and small amounts of vibratory “noise” applied to the soles of the feet seem to address those sensory impairments. While these findings are promising, further research with more people and longer-term follow-up will be necessary to determine whether the gait and balance improvements measured in this small study actually translate into a reduction in falls.

In another approach to fall prevention, a randomized pilot study led by Dartmouth’s Jon Lurie, MD found that elders trained on a surface-perturbation treadmill as part of a regular exercise program were less likely to fall or be injured in a fall, relative to those who exercised without the special treadmill. This study was not sufficiently powered to reach statistical significance, but it helped promulgate the concept that if external perturbations such as tripping and slipping contribute to falls, then training people to respond to such perturbations would be beneficial. The authors conclude by calling for “longer-term studies involving larger and more diverse patient populations.”

Early Results from Alternative Medical-Liability Reforms

According to data published in the New England Journal of Medicine in 2011, nearly 15 percent of orthopaedic surgeons are likely to face a medical liability claim each year, and the cumulative likelihood of an orthopaedic surgeon facing such a claim by the age of 45 is 88 percent. In addition to statistics like this that suggest a flawed system, the tort-based medical malpractice system has not proven to deter substandard care or improve patient safety–and neither has the tort-reform approach to improving the existing liability environment.

Alternatives to tort reform may provide a ray of hope. A recent JAMA article summarized what it calls “a welcome influx of creative initiatives that transcend traditional reforms.” The Mello et al. article evaluates nontraditional approaches that were or are being tested during demonstration projects supported by the Agency for Healthcare Research and Quality (ARHQ). The article devotes much of its space to the so-called communication-and-resolution approach pioneered by the Lexington, Kentucky VA hospital and the University of Michigan Health System. The worth-reading article also covers mandatory presuit notification and apology laws, judge-directed negotiation programs, clinical guideline-based safe-harbor laws, and administrative compensation systems.

In a recent AAOS Now article citing possible barriers to widespread implementation of these and other no-fault approaches to medical liability reform, David Sohn, MD, JD, identifies the trial lawyer lobby as probably the biggest political hurdle that needs to be overcome.