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The Evolution of Orthopaedic Surgical Skills Simulation

Surgical skills education in orthopaedics has changed dramatically from the “see one, do one, teach one” process of 30 years ago. These changes have come with a greater degree of supervision and formal skills assessments, and they have been aided by the visionary leadership at the Accreditation Council for Graduate Medical Education (ACGME) and our own orthopaedic Residency Review Committee. These skill-acquisition enhancements have benefited both our trainees and the patients we collectively care for.

A decade ago, we entered a new phase of skill development and enhancement with computer-based surgical simulators. With advances in software and widespread interest across North America in goal-driven learning through simulation, great progress has been made. In the November 20, 2019 issue of JBJS, Weber et al. report on the further validation of a surgical simulator focused specifically on percutaneous, fluoroscopically guided pin placement for femoral neck fractures. The simulator was developed in partnership between the AAOS and OTA.

This study sought to determine whether novice practitioners (medical students, in this case) who completed 9 training modules before using the simulator (the “trained” group) would perform the simulated pinning task better than peers who did not complete the presimulation training (the “untrained” group). It was no surprise to me that the trained group had a significantly higher overall performance score on the simulator. In addition, relative to the untrained group, the trained students also showed improved performance on 4 specific measures—3 of which were related to the angle between the placed pins.

These findings are clearly supportive of continued development of this and additional simulation environments. But at the same time, we need to move forward with improved documentation of surgical skill acquisition among orthopaedic residents and fellows. As simulator technology continues to improve, the next decade should yield even more positive results in skills acquisition than we saw in the last decade. We are clearly on the right path with the use of advanced technology for surgical skill development among orthopaedic trainees.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Orthopaedic Interns Across Chicago Learn and Bond in Journal Club

OrthoBuzz occasionally receives posts from guest bloggers. The following contribution comes from Rob Christian, MD and Maddy Lyons, MD.

Editor’s Note: The application deadline for the 2019-2020 JBJS Robert Bucholz Resident Journal Club Grant Program has been extended to November 1, 2019.

Junior residents often hear attendings, fellows, and senior residents quote landmark studies, but few find the time to track down and read these important papers on their own. So, when the Northwestern University Orthopaedic Residency Program was awarded one of the JBJS Robert Bucholz Resident Journal Club Grants, Haley Smith, MD (PGY-2) and I used the funding to pilot an Intern Journal Club, inviting all the interns in orthopaedic surgery residency programs across Chicago to read and discuss landmark studies.

Over the last decade, several hospitals in Chicago, such as John H. Stroger, Jr. Hospital of Cook County and Ann & Robert H. Lurie Children’s Hospital of Chicago, have trained teams of orthopaedic residents from multiple programs. Working in the hospital with residents from different programs is a great educational experience, and we thought these resident teams could be even more effective if they interacted with one another prior to working together in the hospital.

Our Intern Journal Club met quarterly, and had impressive attendance, especially considering the busy intern work schedule. Each journal club session featured 4 to 5 landmark studies (suitable for PGY-1s), and discussions were led by senior residents selected across the programs.  Articles discussed came from all orthopaedic subspecialties. In addition to literature-based discussions, the get-togethers fostered collegial relationships among the different programs.

For me, the most rewarding part of the Intern Journal Club has been meeting the interns as they begin their residencies and guiding discussion to help them think critically about orthopaedic literature. With the continued support of the JBJS Robert Bucholz Resident Journal Club Grant, we look forward to continuing to host the Intern Journal Club for this year’s intern class.

Rob Christian, MD (PGY-5)
McGaw Medical Center of Northwestern University

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Initially, the JBJS Chicago Intern Journal Club felt like it was adding articles to an endless intern reading list. However, it turned out to be one of the more valuable and fun educational experiences of my intern year.

The meetings provided the unique opportunity to meet residents from the other Chicago programs. Exchanging stories of intern-year trials and tribulations quickly bonded our group. It was interesting to discover the differences and similarities in our programs, our rotations, and even in the ways in which we manage injuries. In addition to building relationships with peers across programs, the journal clubs allowed me to connect with senior residents who have similar career interests and build several new mentorships.

The articles that we read and discussed were landmark studies that shape the practice of orthopaedics on a daily basis. Through morning conferences, OITE practice questions, and clinical care, interns are exposed repeatedly to fundamentals of orthopaedics, such as open fracture management and functional bracing of humeral shaft fractures. However, without our Intern Journal Club, I may not have explored the studies on which these practice-shaping principles are built. An open, discussion-based format with senior residents helped me understand the “whys” of what we are taught.

We are fortunate to have so many great orthopaedic residency programs in Chicago, each with unique strengths. I hope that our Intern Journal Club continues in the years to come to inspire future collaboration in educational, social, and networking events among the local residency programs.

Maddy Lyons, MD (PGY-2)
Loyola University Medical Center

Seeking Trauma Section Head for JBJS Clinical Classroom

JBJS is currently seeking a Trauma Section Head for the JBJS Clinical Classroom learning system. Clinical Classroom is an interactive, adaptive learning tool featuring more than 3,500 questions and comprehensive responses across 10 orthopaedic specialties. Questions and responses are clinically relevant, peer reviewed, and authored by orthopaedic surgeons. The platform also provides substantive Learning Resources that enhance the user experience.

The Section Head is responsible for leading a team of authors and developing new trauma-related content on a yearly basis. In addition, the Section Head will address user challenges and feedback. Ideally, candidates should be fellowship trained, in orthopaedic practice for at least 5 years, and have a passion for clinical education.

Click here for more information on the Clinical Classroom product.

If you are interested in this opportunity, please contact Chris Chiodo, Editor, JBJS Clinical Classroom at cchiodo@jbjs.org.  Please include your CV and a short statement describing your interest and experience in orthopaedic education.

Patient Discharge after Knee Replacement: How Soon Is Safe?

For most patients and payers, getting out of the hospital quickly after a knee replacement is very important. For orthopaedic surgeons, excellent patient outcomes are the top priority. The latest one-hour complimentary webinar from JBJS on Tuesday, October 1, 2019 at 8:00 pm EDT will reveal clinical practices that increase the odds of achieving both of those goals.

Co-authors Nelson SooHoo, MD and Armin Arshi, MD will explore data from their JBJS study comparing complication rates after outpatient and inpatient knee-replacement, emphasizing that outpatients must receive the same attention to infection prevention, thromboprophylaxis, and rehabilitation as inpatients.

Kurt Spindler, MD and Robert Molloy, MD will then delve into their JBJS study, which suggests that hospital site, surgeon, and day of the week are more accurate predictors of length of hospital stay after knee replacement than patient age, BMI, and comorbidities.

Moderated by Daniel Berry, MD of the Mayo Clinic, the webinar will also feature expert commentaries by Joseph Moskal, MD and Ronald Delanois, MD. 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 Now!

Not Your Grandparent’s Journal Club

OrthoBuzz occasionally receives posts from guest bloggers. The following commentary comes from Matthew R. Schmitz, MD, FAOA.

Medical education is a constant need, but how it’s delivered is always changing. When my grandfather was a surgeon, medical trainees brought their dusty textbooks and print journals to “fireside chats” at an attending’s home. Today, we have online journals, tablets and smartphones, podcasts, and “virtual” discussions on social media platforms. Although the technologies evolve, the need to discuss present and past literature remains constant.

These discussions often taken place nowadays through journal clubs. Medical residents across the continent routinely get together in formal or informal settings to discuss journal articles, not only to acquire the knowledge contained in the articles themselves, but also to learn how to properly read, critique, and digest the information.

JBJS provides medical education across multiple platforms, several of which I participate in. I strongly encourage residency programs to submit an application for the 2019-2020 JBJS Robert Bucholz Resident Journal Club Grant Program before the deadline of September 30, 2019. The grant allows medical educators to support their journal clubs in many ways:

  • Investigating new and innovative alternatives to the traditional journal club.
  • Bringing an author to your institution to discuss his or her articles.
  • Hosting a virtual journal club with multiple authors via teleconference or social media.
  • Purchasing food and refreshments within the “old school” method of a fireside chat at an attending’s home.

No matter the platform or methodology, journal clubs are a vital part of orthopaedic education, not only for interpreting literature, but also for incorporating knowledge into future clinical practice and for the joy and excitement of lifelong learning.

Matthew R. Schmitz, MD, FAOA is an orthopaedic surgeon specializing in adolescent sports and young adult hip preservation at the San Antonio Military Medical Center in San Antonio, TX. He is also a member of the JBJS Social Media Advisory Board.

“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.