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Empathic Orthopaedists: Worth Waiting For

When I was a waiter during high school and college, I quickly learned the value of connecting with my customers. If I could fulfill whatever role they were looking me to fill (i.e., being fun and interactive, serious, acting invisible, or anything in between), I would usually be rewarded with a sizable tip or a compliment. I realized that I was not there primarily to help customers make food choices, but rather to make each customer feel as though I existed only to care for them. There is a big difference between those two roles, and I found myself thinking about those experiences while reading the article by Kortlever et al. in the February 20, 2019 issue of JBJS.

The authors aimed to determine whether an association existed between a patient’s wait time and the amount of time he or she spent with a surgeon and the patient’s perception of the surgeon’s empathy. Considering the well-established connection between the perceived empathy coming from a physician and patient satisfaction, this is an important question to examine. Interestingly, Kortlever et al. found that neither time-related variable was associated with perceived physician empathy, suggesting that decreasing wait times or spending more time with individual patients may not increase their satisfaction with the visit. However, the authors did find a direct, inverse association between surgeon stress levels and patient-perceived empathy. Specifically, for every 1-point increase in a surgeon’s self-reported stress (as measured with the Perceived Stress Scale short form), there was a 0.87 decrease in perceived empathy (as measured with the Jefferson Scale of Patient’s Perceptions of Physician Empathy).

Like most humans, patients value the quality of an interaction more than its duration. Similarly, patients are more concerned with what happens during their medical appointment than with the wait time that transpires before it. It probably does not take very long for a patient to feel that you are fully engaged with his or her concerns—or not—and increasing the length of a “bad” interaction usually will not increase its quality. Patients may not always know whether your medical advice is on target, but almost all of them can tell how much you care and whether you are “present” during their appointment.

I agree with the authors’ conclusion that the present findings indicate “that the patient-physician relationship is more built on actions and communications than on time spent.” I suspect that future studies will continue to show how powerful the perceptions of caring and empathy are when it comes to patient care.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

Editor’s Note: Kortlever et al. cite a 2005 Instructional Course Lecture by Tongue et al. that describes easy-to-learn skills for effective and empathic patient-centered interviews. Click here for full text of that article.

Coming in April: Second Saudi Tour for Miller Review Course

After a wildly successful inaugural visit to Saudi Arabia in 2018, the 5-day Miller Review Course (MRC) for orthopaedists in training will return to Riyadh from April 22-27, 2019, at the Fairmont Hotel.

The location for this intense and comprehensive orthopaedic review course—the Saudi capital and the nation’s most populous city—caters to attendees from Asia, the Middle East, and Africa, but it is open to orthopaedists-in-training from anywhere in the world. Attendees will receive not only the finest in orthopaedic review courses, but also an eye-opening introduction to Saudi life, culture, and food.

The expert Miller faculty will cover 9 orthopaedic subspecialties, plus basic science, statistics, anatomy, and musculoskeletal rehabilitation. In line with Saudi medical training, this version of the MRC is conducted exclusively in English.

The expansion of the largest orthopaedic review course in the US to the Middle East is a unique opportunity for any orthopaedic resident/registrar to prepare for the next step in their career.

Click here to register and to preview the faculty and agenda.

Education, Guidelines, Willingness: Keys to Changing Opioid-Prescribing Habits

When planning for any type of surgical procedure, the orthopaedist considers many patient and injury-specific variables. With a distal radius fracture, for example, the main goal of the surgery—anatomic reconstruction of the distal radius—remains constant. However, there are numerous other variables (fracture morphology and patient age, just to name 2) that have to be considered to achieve that goal. Yet, when it comes to postoperative pain control, I imagine that most orthopaedic surgeons prescribe the same amount of opioids to almost every patient undergoing an open reduction/internal fixation of a distal radius fracture, regardless of unique patient characteristics. Our medical mantra that “no two patients are the same” seems to fall by the wayside when it comes to postoperative pain control.

This disconnect is what I thought about while reading the article by Stepan et al. in the January 2, 2019 issue of The Journal. The authors’ institution developed and disseminated to all prescribers a 1-hour opioid education program and consensus-based postoperative opioid prescription guidelines. They then compared the number of opioid pills and total oral morphine equivalents prescribed after 9 ambulatory procedures within 3 subspecialty services (sports medicine, hand, and foot and ankle) prior to and after implementation of the guidelines. Stepan et al. found a significant decrease  in the amount of narcotics prescribed after 6 of the 9 surgery types after implementation of the guidelines. Over the course of a year, those decreases would have equaled about 30,000 fewer opioid pills!

Interestingly, there was no significant post-guideline decrease in opioid prescribing after any of the 3 foot-and-ankle procedures. The authors attribute that finding to the slow adoption of the guidelines due to adherence to previously developed pain-management recommendations in this subspecialty.

It has become apparent that we tend to overprescribe opioids postoperatively (see related OrthoBuzz post). This study supports previous data showing that prescription guidelines can be useful in decreasing the amount of postoperative narcotics prescribed to patients, while maintaining adequate pain management and good levels of patient satisfaction.  While further work in developing educational tools and procedure-specific “standards” to help surgeons guide their postoperative prescribing practices would be useful, a surgeon’s mindfulness is equally important. We need first to recognize that orthopaedic surgeons tend to overprescribe postoperative opioids—and second, we must be willing to change our habits. Without both awareness and willingness, the best guidelines and recommendations will be ignored, and an opportunity for us to help curb the opioid crisis in our country will be wasted.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

Unmasked: Predatory Publishers in Orthopaedics

It’s been more than a year since OrthoBuzz revisited the topic of predatory publishing (see related OrthoBuzz articles), but the comprehensive “Orthopaedic Forum” about this unsavory subject in the November 7, 2018 issue of JBJS warrants our attention.

In a meticulous investigation focused just on orthopaedic literature, Yan et al. found 104 suspected predatory publishers, representing 225 possible predatory journals. That’s nearly 3 times as many bogus publications as the 82 legitimate orthopaedic journals that the authors also identified. Somewhat disturbingly, 20 of the presumably predatory journals were also found to be indexed in PubMed.

The median article processing charge (APC) among predatory journals was $420, compared with $2,900 for legitimate journals. (Lower APCs tend to lure more researchers—especially younger ones—into the scams.) The most prevalent countries of origin of the predatory journals were India, the US, and the UK, while most of the authors publishing in predatory journals were from India, the US, the UK, and Japan. Predatory publishers are clearly taking advantage of the widespread pressure on researchers to publish as an avenue for career advancement.

The authors reiterate previously cited “red flags” that can tip off researchers to possibly predatory journals:

    • Very low article processing fees
    • Spelling and grammatical errors on the journal’s website
    • Overly broad scope
    • Language that targets authors more than readers
    • Promises of rapid publication
    • Dearth of information about copyright, retraction policies, or digital preservation

Yan et al. conclude that “ the scientific community needs to increase awareness of how to identify and avoid predatory journals. This is especially important for junior researchers…”

If you want more information about specific predatory journals, see Table II of the article (“List of Suspected Predatory Journals in the Field of Orthopaedics”), which includes the criteria that prompted the authors to categorize them as predatory.

Jason Miller, JBJS Executive Publisher
Lloyd Resnick, JBJS Developmental Editor

Residents in the OR—What’s the Risk?

Orthopaedic educators have long confronted the subtle implication that resident participation in surgical care can contribute to patient harm or even death. While there have been numerous changes in residency education to improve the  supervision and training of residents, the reality is that surgical trainees have to learn how to operate. This fact can leave surgical patients understandably nervous, and many of them heave heard rumors of a “July effect”—a hypothetical increase in surgery-related complications attributed to resident education at the beginning of an academic year. To provide further clarity on this quandary, in the November 21, 2018 issue of The Journal, Casp et alexamine the relationship between complication rates after lower-extremity trauma surgery (for hip fractures, predominantly), the participation and seniority of residents, and when during the academic year the surgery occurred.

The authors used the NSQIP surgical database to examine >1,800 patient outcomes after lower-extremity surgery according to academic-year quarter and the postgraduate year of the most senior resident involved in the case. The analysis revealed two major findings:

  1. Overall, there was no “July effect” at the beginning of the academic year in terms of composite complication rates.
  2. Cases involving more senior residents were associated with an increased risk of superficial surgical site infection during the first academic quarter.

While the authors were unable to provide a precise reason for the second finding, they hypothesized that it could have been related to more stringent data collection early in the academic year, senior-resident inexperience with newly increased responsibilities, or the warm-temperature time of year in which the infections occurred. Casp et al. emphasize that the database used in the study was not robust in terms of documenting case details such as complexity and the degree of resident autonomy, which makes cause-and-effect conclusions impossible to pinpoint.

Although this large database study does not answer granular questions regarding the appropriate role of residents in orthopaedic surgery, it should stimulate further research in this area. Gradually increasing responsibility is necessary within residency programs so that residents develop the skills and decision-making prowess necessary for them to succeed as attending surgeons. Studies like this help guide future research into the important topic of graduate medical education, and they provide patients with some reassurance that the surgical care they receive is not affected by the time during the academic-calendar year in which they receive it.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Webinar–Diversity in Orthopaedics: Taking Action to Drive Change

November webinar speakers updated (002)

On Wednesday, November 14, 2018 at 8:00 PM EST, the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will co-host a one-hour complimentary webinar that offers practical advice on how to achieve greater diversity in your orthopaedic workforce. The guidance comes from five orthopaedists with an impressive track record of success in meeting this challenge head-on:

  • Regis O’Keefe, MD, PhD, FAOA
  • Mary O’Connor, MD, FAOA
  • Julie Samora, MD, PhD, MPH
  • Kristy Weber, MD, FAOA
  • Lisa Lattanza, MD, FAOA

Recognizing the lack of diversity in the profession of orthopaedics as a critical issue, this webinar is one of many AOA initiatives supporting increased diversity within the profession.

Seats are limited, so REGISTER NOW.

Nov. 14 Webinar – Diversity in Orthopaedics: Taking Action to Drive Change

November webinar speakers updated (002)

On Wednesday, November 14, 2018 at 8:00 PM EST, the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will co-host a one-hour complimentary webinar that offers practical advice on how to achieve greater diversity in your orthopaedic workforce. The guidance comes from five orthopaedists with an impressive track record of success in meeting this challenge head-on:

  • Regis O’Keefe, MD, PhD, FAOA
  • Mary O’Connor, MD, FAOA
  • Julie Samora, MD, PhD, MPH
  • Kristy Weber, MD, FAOA
  • Lisa Lattanza, MD, FAOA

Recognizing the lack of diversity in the profession of orthopaedics as a critical issue, this webinar is one of many AOA initiatives supporting increased diversity within the profession.

Seats are limited, so REGISTER NOW.

Diversity in Orthopaedics: Taking Action to Drive Change – Nov. 14 Webinar

November webinar speakers updated (002)On Wednesday, November 14, 2018 at 8:00 PM EST,the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will co-host a one-hour complimentary webinar that offers practical advice on how to achieve greater diversity in your orthopaedic workforce. The guidance comes from five orthopaedists with an impressive track record of success in meeting this challenge head-on:

  • Regis O’Keefe, MD, PhD, FAOA
  • Mary O’Connor, MD, FAOA
  • Julie Samora, MD, PhD, MPH
  • Kristy Weber, MD, FAOA
  • Lisa Lattanza, MD, FAOA

For a very personal take on diversity in orthopaedics, read the “What’s Important” article by Joseph Zuckerman, MD from the August 1, 2018 issue of JBJS.

Seats are limited, so REGISTER NOW.

Nov. 14 Webinar – Diversity in Orthopaedics: Taking Action to Drive Change

November Webinar Presenters

In many areas of the US, the orthopaedic workforce does not mirror the patient population being treated. The need for workforce diversity is more than a social concern or a “good-business” practice. Diversity, or the lack of it, directly affects the quality of patient care as well as access to care.

On Wednesday, November 14, 2018 at 8:00 PM EST,the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will co-host a one-hour complimentary webinar that offers practical advice on how to achieve greater diversity in your orthopaedic workforce. The guidance comes from four orthopaedists with an impressive track record of success in meeting this challenge head-on:

  • Regis O’Keefe, MD, PhD, FAOA
  • Mary O’Connor, MD, FAOA
  • Julie Samora, MD, PhD, MPH
  • Kristy Weber, MD, FAOA

Moderated by Lisa Lattanza, MD, Professor and Vice Chair of Diversity and Professionalism and Chief of Hand, Elbow, and Upper Extremity Surgery at UCSF, this webinar will conclude with a 15-minute Q&A session during which attendees can ask questions of the panelists.

Seats are limited, so REGISTER NOW.

Journal Club Grant Brings Bhandari to UChicago

Bhandari Head ShotEditor’s Note: The Journal of Bone and Joint Surgery’s Robert Bucholz Resident Journal Club Grant provides selected orthopaedic surgery residency programs with funds that facilitate career-long skills in evaluating orthopaedic literature and its impact on clinical decision-making. The Journal is always interested in hearing how those funds have been used to enhance orthopaedic education. Here, Michael Perrone, MD describes how the University of Chicago’s Department of Orthopaedic Surgery and Rehabilitation Medicine used its grant this past academic year.

Our residency hosted Dr. Mohit Bhandari for two days. Dr. Bhandari is widely recognized as the world’s foremost authority in the translation of orthopaedic research into clinical practice. On the first day, he joined us for dinner at a local Chicago pizzeria, where we had a “Deep Dish-cussion” about several landmark articles within the orthopaedic literature. He provided his insights on the design, merits, and limitations of each paper, while also discussing each study’s clinical impact. Both residents and faculty alike found the discussion enlightening and educational.

The following morning, Dr. Bhandari delivered Grand Rounds to the entire department. His talk, “Fear Less, Do More,” gave us an inside look at the trials and tribulations of conducting large, multicenter studies and bringing them to publication. Throughout the talk, he encouraged residents and faculty to be ambitious in their pursuit of research and evidence-based practice.

There are few people with more experience or expertise within orthopaedic research than Dr. Bhandari, and his visit to our residency program was inspirational and enlightening. Such an experience would not have been possible without the generous support from JBJS.

Michael Perrone, MD
PGY-5
University of Chicago