Editor’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
University of Chicago
Depending on which historical account you read, journal clubs have been a staple of medical education since around 1875. Still ubiquitous within medical education today, journal clubs help educators and students alike stay current on medical literature, provide a vehicle for teaching how to critically appraise medical studies, and convene a forum in which respectful debate can occur among colleagues. Journal clubs constitute a medical-education practice that almost no one questions, probably because they are so effective.
But that doesn’t mean journal clubs can’t be improved. As the September 30, 2018 deadline approaches to submit applications for the JBJS Robert Bucholz Journal Club Grant Program (click here for the application form), I encourage medical-education leaders to envision new ways in which journal clubs could further orthopaedic education. That might include various iterations of “virtual” journal clubs over the internet. For example, the Journal of Hand Surgery recently hosted a journal club on Twitter. Another intriguing possibility would be to invite authors of journal articles with conflicting conclusions about the same research question to discuss their findings in a point/counterpoint format over teleconference. (Today’s teleconferencing platforms are not hard to set up, are relatively low-cost, and could broaden journal-club participation to anyone with a suitable device and a high-speed internet connection.)
The traditional face-to-face journal club provides many unique benefits, but creating new, innovative platforms for using departmental or grant-based journal-club funds could increase their impact and help ensure the sustainability of these educational programs. It will also be important for everyone to share their experiences with alternative journal-club formats. It behooves the orthopaedic community to continually envision how to integrate the journal-club component of medical education into new technologies as they evolve.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Orthopaedic care teams can play an active role in evaluating and optimizing their patients’ bone health to help prevent primary and secondary fragility fractures and to improve postsurgical outcomes. In just about any orthopaedic scenario, helping patients optimize their bone health is an imperative for the delivery of quality care.
On Tuesday, September 11, 2018 at 8 pm EDT, the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will host a complimentary one-hour webinar that will cover the basics of a bone-health assessment by orthopaedists.
- Christopher Shuhart, MD will discuss the fundamentals of bone-related laboratory workups and bone densitometry studies.
- Joe Lane, MD, FAOA will identify bone-health “red flags” in orthopaedic patients, including common nutritional deficiencies.
- Paul Anderson, MD, FAOA will cover recent advances in bone-density measurements.
Moderated by Douglas Lundy, MD, MBA, FAOA, orthopaedic trauma surgeon at Resurgens Orthopaedics, this webinar will include a 15-minute live Q&A session during which attendees can ask questions of the panelists.
Seats are limited so REGISTER NOW.
Words are powerful. That is why it is so important for consumers of medical research to completely and thoughtfully read and evaluate the literature. Without a thorough understanding of methods, statistics, and clinical context, it is easy for a casual reader (e.g., one who scans abstracts) to make misguided conclusions based on an article’s findings—or even its title.
That concern is a large part of what Hensley et al. state in their September 21, 2017 eLetter in response to the Austin et al. study that appeared in the April 19, 2017 edition of JBJS. While many of the points made in the eLetter are valid, they itemize limitations that most readers should be able to identify during a careful reading of the article. Could the wording of the original article by Austin et al.—especially the title—have been adjusted? Sure, but all orthopaedic researchers want their results to be as impactful as possible, and they therefore will occasionally title their article to highlight the point they find most important. Sometimes (but not always) reviewers and/or editors will ask that certain phrasing be modified to avoid possible misinterpretation by readers.
The bottom line is that it is up to individual readers to critically evaluate the methods, data, and statistics to form their own conclusions from the articles they read. Hensley et al. wanted more data to review and clearly felt more context could have been placed in the paper. They read the article, looked at the data, and developed their own conclusions. I am thankful that they took the time to let the orthopaedic community be privy to their thoughts.
I am equally grateful that Austin et al. took the time to comprehensively address the eLetter by Hensley et al. Taken together, these thoughtful responses to well-conducted original research represent the best in respectful “clinical conversations” that help ensure optimal orthopaedic care for our patients.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Christopher Dy, MD, MPH, in response to a recent study in PNAS.
I am a young surgeon, but I have been submitting papers and grants for peer review for 11 years, since I was a third-year med student. I have tasted the bitterness of rejection more times than I would like to admit, several times at the hands of JBJS. But I will say, without a doubt, that the peer-review process has made my work better.
Acknowledging that our work is far from perfect at the point of submission, most of us have turned the question around: How good and reliable is the peer-review process? Several related questions arise quickly: Who are the “peers” doing the reviewing? We put weeks and months into writing a paper or submitting a grant, which then vanishes into the ether of a review process. How do we know that we are getting a “fair shake” from reviewers, who, being human, carry their own biases and have their own limitations and knowledge gaps—in addition to their expertise? And do the reviewers even agree with each other?
Many authors can answer “no” to that last question, as they have likely encountered harmony from Reviewers 1 & 3 but scathing dissent from Reviewer 2. Agreement among reviews was the question examined by Pier et al. in their recent PNAS study. Replicating what many of us consider the “highest stakes” process in scientific research, NIH peer review, the authors convened four mock study sections, each with 8 to12 expert reviewers. These groups conducted reviews for 25 R01 grant proposals in oncology that had already received National Cancer Institute funding. The R01 is the most coveted of all NIH grants; only a handful of orthopaedic surgeons have active R01 grants.
Pier et al. then evaluated the critiques provided by the reviewers assigned to each proposal, finding no agreement among reviewer assessments of the overall rating, strengths, and weaknesses of each application. The authors also analyzed how well these mock reviews paired to the original NIH reviews. The mock reviewers (all of whom are R01-funded oncology researchers) “rated unfunded applications just as positively as funded applications.” In their abstract, Pier et al. conclude that “it appeared that the outcome of the [mock] grant review depended more on the reviewer to whom the grant was assigned than the research proposal in the grant.”
From my perspective as a taxpayer, this is head-scratching. But I will leave it to the lay media to explore that point of view, as the New York Times did recently. As a young clinician-scientist, these results are a bit intimidating. But these findings also provide empirical data corroborating what I have heard at every grant-funding workshop I’ve attended—your job as a grant applicant is to communicate clearly and concisely so that intelligent people can understand the impact and validity of your proposed work, regardless of their exact area of expertise. With each rejection I get, either from a journal or a funding agency, I now think about how I could have communicated my message more crisply.
Sure, luck is part of the process. Who you get as a reviewer clearly has some influence on your success. But to paraphrase an axiom I’ve heard many times: The harder I work, the more luck I seem to have.
Christopher Dy, MD, MPH is a hand and peripheral nerve surgeon, an assistant professor at Washington University Orthopaedics, and a member of the JBJS Social Media Advisory Board.
Virtual reality (VR) is the computer-generated simulation of a three-dimensional environment that people can interact with in a seemingly real or physical way using special electronic equipment. Though I typically think of its impact on the video game world, the possibilities and applications of this technology are seemingly endless.
In fact, according to a recent article in MedCity News, VR is now being used to help train orthopaedic surgeons. Osso VR, a virtual-reality surgical training platform, hopes to change the way surgeons get trained by harnessing the possibilities of VR. The platform delivers realistic interactive surgical training environments that include the latest procedures and technology. According to pediatric orthopaedist and former game developer Justin Barad, co-founder and CEO of Osso VR, teams and individuals can practice and objectively measure their performance without needing a cadaver or putting any patients at risk while they learn. The technology also helps medical device companies help surgeons gain proficiency in a particular procedure or with a specific technology more quickly than otherwise possible.
Barad cites many problems with the way surgeons currently learn new surgical techniques. They often have to travel to remote cadaver courses for the opportunity to practice in a hands-on way. That model leaves few or no options to practice the procedure and become proficient with it. Barad claims that the model offered by Osso VR provides a new way to practice modern surgical techniques in a hands-on way and has the potential to positively impact surgical outcomes.
VR technology is still new, and orthopaedic educators are just starting to figure out how best to integrate it into orthopaedic education. But those details will likely work themselves out as the technology becomes more familiar to members of the orthopaedic community. Regardless, it is an appealing new tool that may help further bridge the gap between abstract book learning and the reality of patient care.
JBJS Social Media & Analytics Specialist
One goal of an orthopaedic surgery residency is to prepare residents for the procedures they will perform when they are attendings. Yet, until the retrospective cohort study by Kohring et al. in the April 4, 2018 issue of The Journal, it remained unclear how similar a resident’s surgical case mix was compared to the cases attendings saw in early practice. Kohring et al. used data from both the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Orthopaedic Surgery (ABOS) to compare the types of procedures residents performed between 2010 and 2012 to the cases junior attendings submitted for the ABOS Part II examination between 2013 and 2015. The authors then categorized the cases by CPT codes and split them into adult and pediatric categories to allow for further comparison.
Here are a few interesting findings from the study:
- More than half of all adult and pediatric procedures performed during residency and by early-career attendings fell within the top 10 CPT code categories.
- Knee and shoulder arthroscopy were the most commonly performed cases in adults during both residency and early practice.
- Residents take part in total knee and total hip arthroplasties much more frequently than do attendings in early practice.
- Attendings in early practice treat more than twice the number of proximal femur fractures than do residents during residency.
- Residents are exposed to a much higher rate of spinal fusion cases than are seen by early-practice attendings.
Although the authors conclude that the “similarity between residency and early practice experience is generally strong,” this study highlights some of the disparities between the two cohorts, and these findings may inform further research aimed at improving training for orthopaedic surgeons. By themselves, however, these results should not be used to change the experience residents have during their training. The authors mention the limitations inherent when comparing these two cohorts, and I can testify that my clinical practice has evolved tremendously in the 3 years since I started as an attending.
Furthermore, with more than 90% of orthopaedic residents going on to complete a subspecialty fellowship immediately after residency, it is safe to say that the degree of similarity between residency and attending case experience will vary from surgeon to surgeon.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
The January 3, 2018 issue of JBJS contains another in a series of “What’s Important” personal essays from orthopaedic clinicians.
This “What’s Important” article comes from Dr. Andrew J. Schoenfeld.
Dr. Schoenfeld reminds readers that the first vow of the Hippopcratic Oath is to “impart precept, oral instruction, and all other instructions” to help less-experienced physicians. In making a strong case for mentor-mentee relationships among today’s orthopaedists, Dr. Schoenfeld calls upon the “more seasoned clinicians among us to broadcast their ‘openness’ to serving as mentors.” He further promotes sponsorship, “the active process of engendering career opportunities for mentees.”
If you would like JBJS to consider your “What’s Important” story for publication, please submit a manuscript via Editorial Manager. When asked to select an article type, please choose Orthopaedic Forum and include “What’s Important:” at the beginning of the title.
Because they are personal in nature, “What’s Important” submissions will not be subject to the usual stringent JBJS peer-review process. Instead, they will be reviewed by the Editor-in-Chief, who will correspond with the author if revisions are necessary and make the final decision regarding acceptance.
Two of the most trusted names in medical and scientific content have joined forces to create the very best in ongoing orthopaedic education. JBJS Clinical Classroom on NEJM Knowledge+ is a state-of-the-art adaptive learning platform that helps you assess the orthopaedic material you know and identify the areas where you need reinforcement.
JBJS Clinical Classroom houses more than 2,800 questions based on learning objectives developed by experts in 10 orthopaedic subspecialties, continually tailoring the experience to your specific learning needs.
For learners—residents, fellows, or board-certified orthopaedists—JBJS Clinical Classroom reinforces clinical skills and boosts your confidence. You can even create personalized subspecialty exams and read relevant “suggested resources” from JBJS and other peer-reviewed references. You can also earn AMA PRA Category 1 Credits TM—and JBJS Clinical Classroom is approved by the ABOS to provide scored and recorded self-assessment examination (SAE) credits for maintenance of certification (MOC). JBJS Clinical Classroom is simply the most efficient and effective way to prepare for initial board certification or MOC exams.
For Residency Program Directors, JBJS Clinical Classroom reports performance data at the individual and program level. Directors can identify at-risk performers and monitor group and individual performance by learning objective and by postgraduate year.
With this special introductory offer, you can purchase a full year of JBJS Clinical Classroom on NEJM Knowledge+—all 10 subspecialty modules—for $479. That’s 20% off the $599 list price.