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Clinical Conversations: Beyond the Article

Article Title for OBuzz

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

Guest Post—Peer Reviewers: Who Are They and Do They Agree?

Medical-Research Image for OBuzzOrthoBuzz 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 Makes Foray into Orthopaedics

VR SurgeryVirtual 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.

Nick Schepis
JBJS Social Media & Analytics Specialist

Twitter: An “Essential Tool” for Surgeons?

Twitter_Logo_BlueWhile many surgeons may not think of Twitter as a boon to professional activities, this particular social-networking platform is “an essential tool” for the academic surgeon. So claim Logghe et al. in their recent article in the Journal of Surgical Research. The authors back up their claim with pertinent, real-life examples of how Twitter can be used to practice five core values promulgated by the Association for Academic Surgery: inclusion, leadership, innovation, scholarship, and mentorship.

Inclusion—Anyone with Internet access can sign up and easily use Twitter to interact with colleagues. The service is free and facilitates the creation of “virtual communities” through the use of hashtags, making it easy to follow posts of other surgeons and organizations.

Leadership—Twitter allows users to create and expand their own professional footprint while also helping the academic and/or clinical organizations with which they are affiliated increase their reach. As the authors astutely note, “Surgeons on Twitter become respected voices with large followings not only based solely on their academic pedigree, but also on the degree to which they share interesting content and participate in timely conversations.”

Innovation—Twitter facilitates sharing among like-minded individuals in similar fields by breaking the normal constraints of time and space. This enhances the potential for multidisciplinary collaboration that may not have occurred otherwise and helps surgeons find colleagues with whom to develop and promote new ideas.

Scholarship—Multiple studies have shown that using social media can increase the dissemination and viewership of academic material. Many journals (including JBJS) are embracing social media to amplify their message and generate further scholarly discussion of their content.

Mentorship—Twitter not only increases the opportunity for younger surgeons to find potential mentors, but also helps mentors increase their pool of prospective mentees. Users of Twitter are not constrained to one-on-one conversations. Instead, using hashtags and similar strategies, they can develop or nurture a mentor/mentee relationship with multiple professionals at the same time.

As a relatively new Twitter user myself, I am nowhere close to maximizing its potential to enhance my professional life. However, the more I use it, the more I understand its possibilities. I hope other orthopaedic surgeons realize these possibilities as well, because, like all social-media platforms, Twitter is only as powerful as its users. The more of us who participate, the better we will be as physicians—and the care of our patients is bound to improve.

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

Does Residency Prepare Surgeons for Early Orthopaedic Practice?

Shoulder arthroscopy for OBuzzOne 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 Hippocratic Oath’s First Vow

WI Capture_1_12_18The 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.

Available Now: JBJS Clinical Classroom on NEJM Knowledge+

CC_watch-vid-roundedTwo 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.

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JBJS: Aiding and Abetting Orthopaedic Residents

Resident Resources CaptureNo matter how you look at it, orthopaedic residency is a relentlessly challenging five or six years. The Journal of Bone & Joint Surgery offers the following special services to make life and learning a little easier for orthopaedists in training:

Residents who connect now with JBJS establish a solid foundation for a career of lifetime orthopaedic learning. Click on the “Residents” button under “Editorial Resources” at www.jbjs.org to find out more.

JBJS Unveils Reimagined Website

Hub_Homepage-2An authoritative source for clinically useful orthopaedic information for more than 125 years, The Journal of Bone & Joint Surgery (JBJS) has launched an entirely reengineered website—jbjs.org. This superior online orthopaedic experience—fully optimized for mobile devices—speeds users to targeted content across all six JBJS journals. With a more robust search engine and subspecialty collections, the new jbjs.org delivers practice-specific research results for journal articles, videos, images, webinars, podcasts, and CME activities—all with a single click.

Complimentary access to the new jbjs.org is available until December 31, 2017.

The new website also enhances the capacity of “My JBJS,” where users can store and organize content they have bookmarked. In addition, the site offers clearly organized direct links to JBJS CME material that is related to the user’s search query.

The new jbjs.org also features Clinical Summaries, 300- to 400-word “mini-reviews” of the latest clinical findings pertaining to 100 of the most common orthopaedic conditions. Each Clinical Summary is accompanied by direct links to the most relevant, highly cited articles in JBJS and other peer-reviewed orthopaedic and general-medicine journals. “We believe that Clinical Summaries represent a uniquely useful and evidence-based contribution to orthopaedic practice and the review process in orthopaedic surgery—and that they will improve patient care and enhance professional satisfaction,” said JBJS Editor-in-Chief Marc Swiontkowski, MD.

“The new jbjs.org gives us a unique publishing platform that allows the physician to control the experience,” said Paul Sandford, Chief Executive Officer at JBJS. “All digital content resources—including articles, videos, images, and more—can now be easily located and utilized through a proprietary search feature, subspecialty collections, and Clinical Summaries. This application will open the door for new developments and expand our presence and impact with orthopaedists both in the US and globally.”

For more information about the entirely new jbjs.org, click here.

More Efficient Orthopaedic Education Needed

WI Banner for OBuzz

The October 4, 2017 issue of JBJS contains another in a series of “What’s Important” personal essays from orthopaedic clinicians. This “What’s Important” article comes from Drs. Peter Scoles and Shepard Hurwitz.

The authors suggest that integration of medical school curricula with the first year of postgraduate training is a practical approach to improving efficiency and reducing costs to both doctors in training and the academic medical centers that help train them. In explaining specific ways to change the paradigm for training orthopaedic surgeons, the authors conclude that an integrative approach would accelerate the process for qualified candidates, while lowering costs and ensuring adequate training opportunities for all.

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.