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Strengthening Our Residency Programs through Robust Research

Residency training is an essential pipeline to keeping the field of orthopaedics strong. As I tell the surgeons in my department, we should always be looking for our replacement. Who is going to carry the flag of orthopaedics after our time has passed?

Research related to education and training helps guide us. Continuing a collaboration between the American Orthopaedic Association’s (AOA) Council of Orthopaedic Residency Directors (CORD) and JBJS, the top abstracts from research presented at the 2019 CORD Summer Conference are now available in an article by Weistroffer and Patt on behalf of the CORD/Academics Committee.

Ten studies are featured, with a number looking at aspects of resident screening and selection. For instance, Pacana et al. evaluated use of the standardized letter of recommendation (SLOR) form; while widely adopted, it may not be a cure-all in evaluating applicants, as most applicants were “highly ranked” or “ranked to match.” Work by Secrist et al. suggests that 59 is the number of programs that medical students should target in order to obtain 12 residency interviews (with previous work showing that the average matched applicant attends 11.5 interviews). Alpha Omega Alpha status was the strongest determinant of an applicant’s interview yield. Crawford et al. surveyed residency applicants to find out which characteristics they felt were important to success in an orthopaedic residency. Hard work, compassion, and honesty made the top-10 list each year.

The importance of diversity within orthopaedics is also echoed in the included research. It is well documented that orthopaedic surgery falls far behind other specialties in this area. Among topics explored: potential differences in descriptive terms used in letters of recommendation for male and female candidates, and perceptions of pregnancy and parenthood during residency. Illustrating the importance of exposure and access to role models in orthopaedics, Samora and Cannada found that 80% of female medical students who received a scholarship to attend the Ruth Jackson Orthopaedic Society/AAOS annual meeting eventually pursued a career in orthopaedic surgery. I agree with the authors, who stated, “We must work on diversifying our field and providing opportunities for women and underrepresented minorities to consider a career in orthopaedics.”

I know we will continue to make positive change as a profession. Moreover, I am convinced that the future of orthopaedics is strong, with many with top-notch candidates ready and able to help shape our path.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Surgical-Technique Videos Focus on Pediatric Fractures

Many orthopaedic surgeons who take emergency-department or trauma call are confronted with a pediatric patient presenting with a fracture. However, very few of those orthopaedists are pediatric subspecialists. In fact, Geisinger researchers recently reported that the median number of pediatric orthopaedists per state in the US is only 23 (range 0 to 134).

To address these demographic realities, JBJS Essential Surgical Techniques has launched a video-based, point-of-care resource to help any orthopaedic surgeon manage the most common pediatric fractures with the highest level of quality, helping ensure excellent outcomes for young patients and their parents. Most of the authors of these pediatric-focused procedural videos are members of CORTICES—a collaboration of pediatric orthopedic surgeons dedicated to improving the management of emergent orthopedic conditions through education, research, and development of optimal care guidelines.

Here are links to the 5 already-published video articles in this series:

Upcoming videos in this special series will cover the following 5 topics:

  • Screw Fixation of Pediatric Proximal Tibial Tubercle Fractures
  • Reduction and Internal Screw Fixation of Transitional Ankle Fractures
  • Flexible Intramedullary Nailing of Pediatric Femur Fractures
  • Intramedullary Fixation of the Ulna for Monteggia Fracture Management
  • Open Reduction and Internal Fixation of Pediatric Medial Epicondyle Humerus Fractures

JBJS Essential Surgical Techniques is the premier online journal describing how to perform orthopaedic surgical procedures, verified by evidence-based outcomes, vetted by peer review, and utilizing video to optimize the educational experience, thereby enhancing patient care.

JBJS Clinical Classroom: A Better Path to Orthopaedic Proficiency

In 2017, JBJS partnered with NEJM Group to launch JBJS Clinical Classroom—an adaptive learning platform that meets the unique learning needs and requirements of orthopedic training programs worldwide. Clinical Classroom identifies gaps in individual users’ knowledge and assesses their self-confidence in 11 orthopaedic subspecialties. Curated by orthopaedic experts and powered by leading-edge learning technology, Clinical Classroom has quickly become a leading platform for helping orthopaedic residency programs to:

  • Identify residents’ knowledge gaps through detailed reports and monitoring
  • Improve residents’ knowledge and critical thinking skills
  • Keep residents up-to-date with the latest and highest-quality orthopaedic findings
  • Better prepare residents for OITE and board certification exams

To meet changing user needs and implement technological advancements, JBJS has improved the overall user experience in Clinical Classroom. These significant enhancements were made possible by upgrading from the original NEJM Knowledge+ platform to the new Rhapsode platform by Area9.

Highlights of JBJS Clinical Classroom on Rhapsode include the following:

  • Updated adaptive algorithm that incorporates the most advanced adaptive tools for more efficient individualized learning
  • Improved reporting and metrics providing residents and residency directors with a more comprehensive dive into individual and group performance
  • In-platform coaching delivers helpful tips tailored to resident progress and confidence as they progress through subspecialties
  • Enhanced look and feel: The clean, modern Dashboard and improved navigation allow residents to interact with and move effectively throughout the product for optimal learning
  • And so much more

To learn more about the enhanced JBJS Clinical Classroom on Rhapsode and how Clinical Classroom can best serve your program, click here.

JBJS Clinical Classroom: A Better Path to Orthopaedic Proficiency

In 2017, JBJS launched JBJS Clinical Classroom on NEJM Knowledge+, an adaptive learning platform that meets the unique learning needs and requirements of orthopedic surgeons worldwide. Clinical Classroom identifies gaps in individual users’ knowledge and assesses their self-confidence in 11 orthopaedic subspecialties. Curated by orthopaedic experts and powered by leading-edge learning technology, Clinical Classroom has quickly become a leading platform for orthopaedic surgeons who want to:

  • Improve their knowledge and critical thinking skills
  • Stay up-to-date with the latest and highest-quality orthopaedic findings
  • Earn AMA PRA Category 1 Credits™ (for US learners who successfully answer questions), and
  • Earn SAE credits for Maintenance of Certification (for US learners who successfully answer questions)

To meet changing user needs and implement technological advancements, JBJS has improved the overall user experience in Clinical Classroom. These significant changes were made possible by upgrading from the original Knowledge+ platform to the new Rhapsode platform by Area9.

Highlights of JBJS Clinical Classroom on Rhapsode include the following:

  • Enhanced look and feel: The clean, modern Dashboard and improved navigation allow you to interact with and move effectively throughout the product for optimal learning.
  • Updated adaptive algorithms that incorporate the most advanced adaptive tools for more efficient individualized learning
  • All-device access: Clinical Classroom is now user-friendly on all devices, with special enhancements for the mobile experience.
  • In-platform coaching delivers helpful tips tailored to your performance and confidence as you progress through subspecialties.
  • And so much more

To learn more about the enhanced JBJS Clinical Classroom on Rhapsode, and to stay up-to-date with ongoing developments, click here.

To explore Clinical Classroom pricing and subscription options, visit the JBJS Store today.

The Journal of Bone and Joint Surgery, Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Need for Preop Psych Evals in Orthopaedic Surgery

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Impact Science, in response to a recent ”What’s Important” article in JBJS.

In orthopaedic surgery, pre-existing psychiatric conditions in patients can have a detrimental effect on outcomes. Previous studies have shown poor improvement in postoperative self-reported pain scores among patients with psychosomatic conditions or mood disorders. Robust published evidence also suggests that psychiatric conditions can lead to complications in the treatment course, including an increased length of hospital stay and higher total systemwide costs. However, despite compelling evidence in the literature, orthopaedic surgeons—especially those early in their career—lack protocols to evaluate a patient’s current and past psychiatric history and symptom severity.

A recent “What’s Important” article in The Journal of Bone & Joint Surgery emphasizes the need for such an assessment tool. In the article, Albert T. Anastasio, MD, a resident in orthopaedic surgery at Duke University Medical Center, cites the example of bariatric surgery, where protocols have long existed for preoperative patient assessments for a history of alcohol and drug abuse. He argues convincingly that the development and use of such tools should be extended to orthopaedic procedures. For example, Dr. Anastasio questions the wisdom of a hypothetical elective spine surgery in a patient with an unaddressed psychosomatic disorder and borderline pathology on advanced imaging.

At the same time, Dr. Anastasio is quick to highlight the challenges of developing such a tool, mainly because of the subjective nature of psychiatric symptoms. But he cites existing tools that attempt to objectively evaluate psychiatric symptoms, such as the Patient Health Questionnaire-9, which is used to quantify the severity of major depressive disorder. Dr. Anastasio also cautions that any such metric should not serve as a “definitive cutoff” for surgery.

Underlying Dr. Anastasio’s call for psychiatric risk-assessment protocols is the importance of developing and enhancing collaboration between orthopaedics and psychiatry, two disciplines that he says are often “considered very far removed from each other.”

Impact Science is a team of specialized subject-area experts (Life Sciences, Physical Sciences, Medicine & Humanities) who collaborate with authors, societies, libraries, universities, and various other stakeholders for services to enhance research impact. Impact Science aims to democratize science by making research-backed content accessible to the world.

JBJS Extends Deadline for International Journal Club Grants

For the first time, JBJS is expanding its Robert Bucholz Resident Journal Club Grant Program to orthopaedic residency programs beyond North America.

The deadline for international applicants has been extended until 31 October 2020.

Grants of US$1,500 will be awarded to support selected Journal Club programs for the coming academic year. Funds can be used for subscriptions to orthopaedic journals and resources, travel grants for guest speakers, and costs associated with the monthly journal club meetings.

To apply, click here, download and fill out the form, and return it to journalclub@jbjs.org by 31 October 2020.

What I Learned at the ASSH 2020 Virtual Annual Meeting

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes Christopher Dy, MD, MPH in response to his recent participation in the virtual Annual Meeting of the American Society for Surgery of the Hand.

The year 2020 has brought with it many “firsts.” For example, due to the COVID-19 pandemic, the Annual Meeting for the American Society for Surgery of the Hand (ASSH) was moved from San Antonio to a virtual platform. Kudos to the Annual Meeting chairs (Dawn Laport, MD and Ryan Calfee, MD), ASSH president Martin Boyer, MD, and the ASSH staff for constructing an amazing experience. Here are some general take-homes from my first-ever virtual conference experience:

  • A virtual conference provides attendees with a ton of flexibility and customization. While there are often “conflicting,” concurrent sessions during an in-person meeting where I have to decide between 2 sessions, the virtual ASSH meeting format offered the ability to go back and watch prior courses and lectures. When we (hopefully) go back to in-person meetings, it would help if more sessions were recorded and made available to attendees on demand.
  • The virtual conference requires a lot more pre-meeting preparation for all parties involved, especially presenters. Because the sessions that would normally occur in the large, main halls were hosted on a professionally run platform with A/V engineers, presenters were required to attend more than a few “tech” rehearsals, as well as submit their presentation slides 4 to 6 weeks in advance. I admit that it was harder for me to present from slides that didn’t feel as fresh, since I couldn’t revise them the night before!
  • While it was convenient to view most of the meeting from my couch (or exercise bike), I really miss the in-person interactions with colleagues and friends that you get while moving between sessions. It’s also harder to pull yourself away from your family and your practice when you are “participating” in a meeting from home or office.

Here are 4 technical things I learned from the sessions I attended, largely biased toward my personal interests. I encourage readers to leave comments by clicking on the “Leave a Comment” button in the box next to the title.

  • Innovation continues for distal nerve transfers to treat peripheral nerve palsy. Professor Jayme Bertelli from Brazil gave talks demonstrating both technical aspects and his own results following transfers such as ECRL [extensor carpi radialis longus]-to-AIN [anterior interosseous nerve], distal AIN to distal PIN [posterior interosseous nerve], and opponens pollicis to adductor pollicis. I am eager to read more about these transfers and get into the cadaver lab to refine my surgical technique. (Precourse 03 and Symposium 18)
  • The debate about “supercharging” (reverse end-to-side) nerve transfers continues. There is laboratory evidence supporting the role of a supercharged nerve transfer in preserving the distal muscle unit and the distal nerve stump. However, there is controversy regarding whether it is benign and/or beneficial to have 2 “competing” sources of muscle innervation, in cases where the “native” nerve reaches the distal target after the axons coming from the supercharged transfer have been placed. While many surgeons have adopted supercharged nerve transfer into their practice, there is far more laboratory and clinical research needed to substantiate this practice and refine the indications for use. (Precourse 03 and Symposium 11)
  • Utilization of wide-awake, local-anesthesia, no-tourniquet (WALANT) hand surgery continues to grow. Surgeons are performing a growing number of different surgeries (including fracture cases and complex tendon transfers) with WALANT, and some are doing these cases in procedure rooms or offices rather than in a formal operating room. These changes are driven by both surgeon and patient preference, as well as potential cost advantages for both parties. For surgeons, there is a potential for increased revenue with WALANT, but this can come with logistical challenges such as stocking sterile trays and making sure that medications are available. The trend toward increasing utilization of WALANT in procedure rooms and in surgeons’ offices is likely to continue. (Instructional courses 24 and 56 and related OrthoBuzz post)
  • Teaching in the operating room has shifted. Many current trainees prefer to use videos for case preparation rather than focusing on book chapters, technique articles, or primary literature. Consequently, there is a growing embrace of video among hand-surgeon educators. Videos that are short, discuss indications, and provide rationale for technique-related decisions are favored. Today’s trainees are also less likely to respond well to the classic Socratic method of teaching and may need more overtly delivered feedback. (Instructional courses 10 and 36)

Christopher Dy, MD, MPH is a hand and wrist surgeon, an assistant professor of orthopaedic surgery at Washington University School of Medicine in St. Louis, and a member of the JBJS Social Media Advisory Board.

“Inflation” and Bias in Letters of Recommendation

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes Christopher Dy, MD, MPH in response to 2 recent studies in JBJS Open Access.

It’s that time of year when many of us write and review letters of recommendation (LOR) for orthopaedic residency applicants. LOR have always played a large part in the ranking and selection of applicants, and they may be weighed even more heavily during the upcoming “virtual-interview” season. Many applicants present remarkable objective measures of accomplishment, accompanied by 3 to 4 glowing LOR from colleagues. But can all these people really be that good? I am not the first to wonder whether “grade inflation” has crept into the writing of recommendation letters.

As letter writers, we fulfill two important, but potentially conflicting, roles:

  1. Mentors: We want to support the applicants who have worked with us.
  2. Colleagues: We want to be honest with our peers who are reviewing the applications.

In addition, this dynamic is now playing out in the context of our profession’s efforts to increase the racial and gender diversity of the orthopedic workforce. This begs the question as to whether there are differences in how we describe applicants based on race and gender.

To help answer that question, our research team analyzed LOR from 730 residency applications made during the 2018 match. Using text-analysis software, we examined race- and gender-based differences in the frequency of words from 5 categories:

  1. Agency (e.g., “assertive,” “confident,” “outspoken”)
  2. Communal (e.g., “careful,” “warm,” “considerate”)
  3. Grindstone (e.g., “dedicated,” “hardworking,” “persistent”)
  4. Ability (e.g., “adept,” “intelligent,” “proficient”)
  5. Standout (e.g., “amazing,” “exceptional,” “outstanding”)

We hypothesized that men and women would be described differently, expecting, for example, that agency terms would be used more often for describing men and communal terms more often for describing women.

Our hypothesis was almost entirely wrong. The agency, communal, grindstone, and ability words were used similarly for both male and female applicants. Standout words were used slightly (but significantly) more often in letters describing women. When comparing word usage in LOR for white candidates to those of applicants underrepresented in orthopedics, standout words were more commonly used in the former, and grindstone words were more commonly used in the latter. Interestingly, neither gender nor race word-usage differences were observed when LOR using the American Orthopaedic Association (AOA) standardized letter format were analyzed.

In a separate but related study, we looked at the scores given in each of the 9 domains of the AOA standardized letter of recommendation. These scores clustered far “to the right,” with 75% of applicants receiving a score of ≥85 in all domains. While I am certain that orthopaedic residency applicants are universally very talented all-around, this lopsided scoring distribution makes it very hard to differentiate among candidates. Furthermore, 48% of applicants were indicated as “ranked to guarantee match.” I suspect that the “ranked to guarantee match” recommendation is made more often than it should be. Again, this “inflation” makes it challenging for applicants to stand out – and may have especially important implications in this year’s virtual-interview environment.

What I take away from these two studies is that our natural tendency as orthopedic surgeons is to write effusively about our student mentees. Perhaps the differences in how we describe applicants based on their race and gender can be mitigated by using the AOA standardized letter format, but that format has a profound ceiling effect that makes it hard to discern the “cream of the crop.”

As a specialty, we are truly fortunate to have such excellent students vying to be orthopedic surgeons, and it is quite possible that nearly all of the applicants applying for our residency programs would make great orthopedic surgeons. However, it would help us to have a baseline measure of how we rate our students. Having some kind of benchmark against which to measure our past rankings and how they compare to those of our peers would help immensely.

Christopher Dy, MD, MPH is a hand and wrist surgeon, an assistant professor of orthopaedic surgery at Washington University School of Medicine in St. Louis, and a member of the JBJS Social Media Advisory Board.

Save Time with JBJS Clinical Summaries

Developed with the busy musculoskeletal clinician in mind, JBJS Clinical Summaries are synopses of the current State of the Science for >150 common orthopaedic conditions in 10 subspecialty areas.

Curated by recognized orthopaedic authors, JBJS Clinical Summaries deliver clinically useful “mini-reviews” of the most recent findings, with direct links to supporting original content. You can also earn CME.

To see a list of all current Clinical Summaries, click here, or click on the links below for some specific samples.

 

JBJS Webinar-Sept. 23: Opioid Use Challenges and Solutions

Amid the current backdrop of opioid misuse, overdose, and addiction, conducting robust studies to investigate management of musculoskeletal pain is uniquely challenging. Last November, a JBJS-convened symposium, supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, explored those challenges. From that meeting came a 12-article JBJS Supplement published in May 2020.

On Wednesday, September 23, 2020 at 8 PM EDT, a one-hour live JBJS webinar will focus on 2 of the most salient solutions arising from the symposium.

Jeffrey Katz, MD, MSc will examine how to overcome study-design challenges such as quantifying opioid use, confounding by indication, and distinguishing between nationwide “secular changes” in opioid prescribing and the true effects from studied interventions.

Seoyoung Kim, MD, ScD, MSCE will emphasize that careful attention to methods is crucial when designing and conducting observational studies based on claims databases and patient registries. Widely accepted definitions of many common terms, such as “persistent opioid use,” do not exist.

Moderated by James Heckman, MD, Editor Emeritus of JBJS, the webinar will feature additional expert commentaries on the two author-led presentations. Andrew Schoenfeld, MD will weigh in on Dr. Katz’s paper and Nicholas Bedard, MD will comment on Dr. Kim’s paper.

The webinar will conclude with a 15-minute live Q&A session during which attendees can ask questions of all the panelists.

Seats are limited–so Register Today!