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
Hip arthroscopy for labral pathology and cam and pincer impingement has become increasingly established as an effective procedure in the hands of experienced surgeons. However, as with all technically complex orthopaedic procedures, success entails not only sound technique, but also appropriate patient selection, meticulous pre- and intraoperative setup, and appropriate use of intraoperative fluoroscopy. Thankfully, we have a community of leaders in arthroscopy who share and teach these details.
In the December 20, 2017 issue of The Journal, Duchman et al. use the ABOS Part-II exam database to analyze who among recent graduates of orthopaedic residencies is performing hip arthroscopies. Overall, between 2006 and 2015, the authors found that 643 of 6,987 ABOS candidates (9.2%) had performed ≥1 hip arthroscopy; nearly three-quarters of those reported sports-medicine fellowship training. More than two-thirds of candidates performing hip arthroscopy performed ≤5 such procedures; conversely, only 6.5% of those candidates performed 35% of all the hip arthroscopies identified in the database.
The concerning suggestion from these findings is that the increase in hip arthroscopy utilization comes from an increased number of individuals performing the surgery, rather than from an increase in procedure volume among individual surgeons. One question this study does not address is whether there has been an increase in the prevalence of hip pathology that warrants an increased utilization of this procedure. If not, an alternative explanation, which Wennberg et al. posit in the Dartmouth Atlas, is that procedure utilization expands in relationship to the distribution of provider resources and medical opinion in the local community.
I believe that hip arthroscopy is technically challenging and that the quality of the outcome is very likely related to the per-surgeon volume of procedures performed. This makes it incumbent upon all orthopaedists who offer this procedure to actively evaluate their outcomes with validated instruments so the practitioner and her/his patients can objectively understand and discuss what the results are likely to be.
In a commentary on this study, Rupesh Tarwala, MD calls for an outcomes analysis of patients who were treated with hip arthroscopy by ABOS Part-II candidates. I concur completely, and would more specifically ask that the cohort of surgeons evaluated in this study by Duchman et al. collect and report their 1- and 2-year outcomes to The Journal.
Marc Swiontkowski, MD
The new second-quarter 2017 JBJS Quarterly CME Exam—based on articles published in April, May, and June 2017—is now available.
This course contains 100 assessment questions on topics including Shoulder, Infection, Knee, Pediatrics, Trauma, Hip, General Interest, Sports Medicine, Hand & Wrist, Basic Science, Oncology, Foot & Ankle, Elbow, and Spine.
Selected articles included in the CME Q2 Examination:
- Formal Physical Therapy After Total Hip Arthroplasty Is Not Required. A Randomized Controlled Trial
- Management of ACL Injuries in Children and Adolescents
- Modular Fluted Tapered Stems in Aseptic Revision Total Hip Arthroplasty
- The Clinical Outcome of Computer-Navigated Compared with Conventional Knee Arthroplasty in the Same Patients.
This activity is approved for 10 AMA PRA Category 1 Credits™ and by ABOS for 10 scored and recorded SAE credits
The first 2016 JBJS Quarterly CME Exam—based on articles published in January, February, and March—is now available.
Starting now and going forward, each interactive quarterly CME experience from JBJS contains 100 questions and is approved for a maximum of 10 AMA PRA Category 1 CreditsTM. Even better, the ABOS has approved the JBJS Quarterly Exams for 10 Self-Assessment Exam (SAE) credits—half of the 20 SAE credits per three-year cycle that you need for Maintenance of Certification (MOC). So you can meet several continuing-education requirements with a single JBJS-vetted learning experience.
Take JBJS Quarterly Exams online anytime, anywhere, with each exam available for one year from time of initial posting.
Cost for the quarterly CME exam is $100, and the exam may be taken multiple times for review purposes without payment.
Go to the JBJS Orthopaedic Education Center to see the whole course catalog of quarterly, subspecialty, and JBJS Reviews CME options, and start the new quarterly CME activity today.