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“True Grit” Among Millennial Orthopaedists in Training

In a survey-based study published in the July 17, 2019 issue of The Journal of Bone & Joint Surgery, Samuelsen et al. made a hypothesis arising from a popularly held assumption about millennials: that orthopaedic residency applicants (predominantly millennials, with a mean age of 27.3) would have lower grit and self-control scores than attending orthopaedic surgeons (mean age of 51.3). The findings contradicted that hypothesis.

Surveys were completed by 655 (28%) of 2,342 attendings who received the questionnaire and by 455 (50.8%) of 895 orthopaedic residency applicants from the 2016-2017 resident match. The authors found that the residency applicants demonstrated higher mean grit scores (4.12 of 5.0) than the attending orthopaedic surgeons (4.03) (p <0.01). When compared to the general population, residency applicants and attendings scored in the 70th and 65th percentiles of grit, respectively.

The American Heritage Dictionary defines “grit” as “indomitable spirit” or “pluck.” In the medical literature, where “grit” has received a lot of attention lately, the concept is defined as “steadfast passion and perseverance for long-term goals, especially in the setting of hardship and setbacks.” However grit is defined, Samuelson et al. say it “has consistently been proven to be associated with success in…medical environments.”

Three other interesting findings:

  • There were no significant differences in self-control or conscientiousness scores between the 2 groups.
  • Both age and number of years in practice were positively correlated with self-control scores in the practicing-surgeon group.
  • Among attending surgeons, the number of publications correlated with higher grit, self-control, and conscientiousness scores.

Samuelson et al. offer a possible explanation for the impressive grit scores among residency applicants: matching into orthopaedic residency has become increasingly competitive over the past several decades and “applicants to orthopaedic surgery…tend to represent the individuals at the top of their medical school classes.” Conversely, the authors suggest that grit, self-control, and conscientiousness scores could be used to identify applicants, residents, or junior staff “who are at risk for attrition during training or burnout in their careers.”

Having postulated that, however, the authors are quick to add that “it is unclear if [these findings] will be predictive of career success in the next generation of orthopaedists.”

Click here to see a 1-minute video commentary about these findings by Chad A. Krueger, MD, JBJS Deputy Editor for Social Media.

New Minute-Commentary Video

Here’s what JBJS Deputy Editor for Social Media Chad Krueger, MD concludes after reading a survey-based study from the Department of Orthopaedic Surgery at the Mayo Clinic, comparing “grit” and self-control among orthopaedic residency applicants and practicing orthopaedists:

 

Why US Orthopaedic Residents Overprescribe Opiates

Hydrocodone Has Dark Side as Recreational DrugSeveral authors have described the medical-school experience as “socialization” into the medical field. Medical students often learn the scientific underpinnings simultaneously with the social processes of interviewing/dialoging, examining, and then developing a treatment plan with the patient. One “subspecialty” social process that orthopaedists learn is pain management. While we are certainly encouraged to understand the scientific basis of this important and complex topic, much of the learning comes in the form of mirroring: junior residents do what senior residents instruct them to do, while senior residents follow the direction of attendings. These passed-on habits are culturally ingrained and persistent.

As Young et al. show in the July 17, 2019 issue of The Journal, the pain-management habits learned in training vary greatly from country to country, which is not surprising. Specifically, these authors examined the prescribing of postprocedural opiates by residents in the Netherlands, Haiti, and United States. They found that US residents prescribe significantly more morphine milligram equivalents (MMEs) of opioids at patient discharge than residents from either of the other 2 countries. The authors also showed that residents from the United States were the only group prescribing a significantly greater amount of MMEs to patients younger than 40 years old than to those above the age of 70.

Many pundits pin the phenomenon of opioid overprescribing in the US on the American public’s wish to be free from discomfort, along with the aggressive marketing and advertising of these medications in the United States. While this may be true, I think Young et al. have further identified the major influence that a resident’s training environment may have on prescribing practices. As already mentioned, residents often imitate what they see from more experienced residents and attendings, but sometimes those lessons, especially in pain management, lack a scientific basis.

What is missing from this survey-based study is data on patient satisfaction with postprocedural opiate prescribing. Having been involved in clinical care in Haiti, my impression is that patients there accept the local practice of pain management, constrained as it might be by resource limitations. I suspect the same is true in the United States and the Netherlands. Regardless, these findings demand that emphasis be placed on teaching orthopaedic residents evidence-based pain-management protocols. This will require a concerted effort from teachers and mentors at all levels of our medical-education system. This investigation is an important reminder that developing solutions to the opioid overprescribing problem in the US might begin in residency, where “cultural formation” occurs.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Marian Frauenthal Sloane, MD: Ahead of Her Time

In 2016, only 6.5% of practicing orthopaedic surgeons in the US were women. By contrast, 49% of all medical students in the US are women. That apparent discrepancy has sparked concern, conversations, and action in the orthopaedic community.

The current gender imbalance in orthopaedics would be even more stark were it not for two trailblazing women who lived during the early part of the 20th century. One of them, Ruth  Jackson, MD, is the well-known namesake of today’s professional society of female orthopaedic surgeons. The other, New York City orthopaedist Marian Frauenthal Sloane, MD, has endured relative obscurity, until now.

The “What’s Important” essay by Hooper at al. in the June 5, 2019 issue of The Journal of Bone & Joint Surgery profiles Dr. Frauenthal Sloane’s short but influential career as orthopaedic surgeon, researcher, author (she coauthored 2 JBJS articles in the 1930s), and teacher. Despite the long way we still have to go to achieve gender diversity in orthopaedics, the authors of this fascinating sketch conclude by saying that “without [Dr. Frauenthal Sloane’s] brief but profound influence, women orthopaedists would probably be in a very different place today.”

Read related OrthoBuzz post about diversity in orthopaedic surgery.

NEJM Knowledge+ Module on Pain Management and Opioids

There is little doubt that dramatic increases in prescriptions for opioid analgesics during the 21st century have been a major contributor to the current opioid crisis. Although primary care providers are at the front line of pain management and addiction prevention and treatment, recent research indicates that orthopaedic surgeons frequently overprescribe opioids to their patients. To help support safer prescribing, NEJM Group, through an independent educational grant and with support from Boston University School of Medicine, recently launched a NEJM Knowledge+ Pain Management and Opioids module.

The course, which contains more than 60 case-based questions on this timely and important topic, is available free of charge at https://knowledgeplus.nejm.org/pain-opioids. The activity conforms to the FDA’s Opioid Analgesic REMS (Risk Evaluation and Mitigation Strategy) Education Blueprint for Health Care Providers Involved in the Treatment and Monitoring of Patients with Pain.

Many of the case-based questions in the module are geared toward primary care physicians, but approximately 50% of them deal with managing pain associated with musculoskeletal conditions. Just like JBJS Clinical Classroom, which was developed with the NEJM Knowledge+ adaptive-learning platform, this new pain management and opioid module delivers each case-based question and then uses an algorithm that identifies individual learners’ knowledge gaps, followed by targeted content that addresses those gaps after each question has been answered.

The Journal Joins You on Instagram

The Journal of Bone & Joint Surgery has been a valuable resource for the orthopedic community since 1889, when the Transactions of the American Orthopedic Association first published proceedings from the 1887 and 1888 meetings. The Journal has continued to provide gold-standard information to clinicians, researchers, and orthopaedic care teams to support the mission of improving musculoskeletal health across the globe. As new platforms and novel avenues for sharing information and ideas have taken shape, we have used these opportunities to improve global access to essential knowledge and learning resources to foster excellence in patient care.

In continuing that mission, we are pleased to join the orthopaedic community on Instagram! Our goal is to help followers stay up-to-date with the highest quality orthopaedic literature. Each post will highlight new information from a variety of sources and include links to original content. We hope that this new social media presence for The Journal will serve as yet another tool to help you stay informed about what’s new and important in orthopaedic surgery.

Follow JBJS on Instagram @the_jbjs.

#JBJS #OrthopaedicSurgery #EvidenceBasedMedicine

Changing Workplace Culture to Avoid Physician Burnout

In the February 6, 2019 issue of JBJS, David A. Rothenberger, MD contributed a thoughtful and practical “What’s Important” article about how to foster well-being among physicians and thus reduce the risk of physician burnout.

Since the article’s publication, Dr. Rothenberger has received many comments from readers. Here are several, de-identified to protect privacy, along with some responses from Dr. Rothenberger:

In my opinion, the internal culture of medicine, and specifically surgery, is to blame for poor mental health, burnout, and depression… [Surgeons are] trying to make up declining reimbursement by working harder. .. I too lived in that culture and relished being the busiest surgeon in the system, knocking out 10 to 12 operations a day,… but after the age of 50, I began noticing age catching up and increasing negativity within the profession. That is about when I decided to bail out. I have never looked back, although I miss my patients. Our profession… rewards self-punishment. Like you, I am hopeful that this will change for future physicians… My hope is that the welcome influx of women physicians will teach us misguided men a thing or two about taking care of oneself, one’s family, and understanding the limits of what we can do.

 

I believe burnout, in my case, was caused by, among other things, the destruction of our fee schedules… My brightest child wanted to follow in my footsteps, and I talked him out of it… I feel society has forsaken us.  I plan to quit this November, and it’s not soon enough.

To which Dr. Rothenberger replied as follows:
“I understand your decision to leave medicine,… but my advice is ‘do not go it alone.’ Get some support from someone you trust who understands this predicament… Plan for your future after medicine.  Re-imagine your life.”

 

I know a lot of physicians here who have problems in their practice, including a lot of my partners. I think the concept of a Chief Wellness Officer [CWO] is a great idea. I plan on forwarding [your “What’s Important” article] to our administration.

To which Dr. Rothenberger replied as follows:
“A CWO will help only if the other leaders of your system are committed to changing the culture of the workplace.  It is not an easy undertaking, but I think the return on investment justifies the multiyear approach we are taking here [at the University of Minnesota].”

 

It is really meaningful that you have emphasized that this is a bigger issue than the individual. I believe you are absolutely correct in highlighting a culture shift that prioritizes giving…factors [such as autonomy] back to physicians. [That] is probably the single most effective way to turn this around.

I am finishing my orthopedic residency… Our hospital system occasionally holds “wellness activities” that typically include massage and similar events, but these often don’t work with a busy surgeon’s schedule.  I’m interested in making burnout prevention a more recognized issue within our department and want to help bring in resources to help our residents and staff, but I am struggling with how best to practically bring this about. Do you have any advice for integrating wellness resources and burnout prevention into a busy orthopaedic department?

To which Dr. Rothenberger replied as follows:
“Wellness activities” like massage, yoga, and exercise classes are often put together by Human Resources for the workforce at large.  They are useful to individuals but do little to change the workplace culture… Our effort here at the University of Minnesota is to build a Well-Being Alliance of health care professionals who are working together as a coalition of the willing to restore well-being and joy to the practice of medicine.  We will do this by changing our workplace culture—a multiyear effort.  Features of our Alliance are that it is

  1. Interprofessional (i.e., it involves MDs, nurses, pharmacists, etc.)
  2. Longitudinal (i.e., it includes students; residents and fellows; early, mid and late-career physicians; and retired members of our community)
  3. Evidence-based as much as possible, and
  4. Financially and operationally sustainable.”

These issues of physician wellness and burnout prevention need to be highlighted locally, and local resources need to be brought to bear to address the challenge. I’m grateful to be at the University of Minnesota, where Dr. Rothenberger and the Well-Being Alliance are tackling the problem in meaningful ways.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

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