Clinical Relevance vs Statistical Significance: The Good, The Bad, and The Future of Sexual Harassment in Orthopaedic Surgery
This guest post comes from Jennifer Beck, MD.
As a female, mid-career orthopaedic surgeon, I believe I bring a unique perspective to reporting on the changes that I have witnessed over the past 15 years in academic orthopaedic surgery. It is well documented that ours is an overly White, male-dominated field, often associated with the stereotype of “dumb jock” doctors bringing locker-room humor to the operating room. Stereotypes and parodies abound on various social media platforms. Additionally, it is widely known that cultural and demographic change in orthopaedics has occurred at a pace slower than in other fields in medicine.
I must clarify that the news isn’t all bad. Traiblazing individuals including female orthopaedic department chairs (Drs. Lisa Lattanza, Susan Bukata, Michelle Caird, April Armstrong, Valerae Lewis, Leesa Galatz, and Evalina Burger) and society presidents (Drs. Kristy Weber, Lori Karol, Serena Hu, Mary O’Connor, Heather Vallier, Bess Brackett, Marybeth Ezaki, Jo Hannafin, Judy Baumhauer, Lisa Cannada) and groups like the Ruth Jackson Orthopaedic Society, SpeakUp Ortho, the International Orthopaedic Diversity Alliance, and The FORUM have created pathways for positive change in support of diversity. At a time when health care is being attacked from all sides, we must band together for change and cannot lose momentum they have created.
When reviewing statistical analysis of my clinical research, the perfectionist in me wants to achieve that elusive “statistical significance” so I can say, “Yes, there was a difference.” However, when finding nonsignificant results, I am often left wondering if they are clinically relevant or useful. At the recent 2021 Annual Meeting of the American Academy of Orthopaedic Surgeons, Dr. Emily Whickers and colleagues presented a poster on sexual harassment in the field of orthopaedics. Based on a survey of members of the Ruth Jackson Orthopaedic Society, her group initiated their study “to better understand harassment in orthopedic medicine in light of ‘the stories that we had all heard,’” Whickers told MedPage Today.
They did not find a statistically significant decline in harassment during orthopaedic training, with 59% of the current residents reporting harassment vs 72% of the past residents; p = 0.10. How can orthopaedic surgery continue to make progress toward “significance”?
Encouragingly, the authors did find a trend that current residents felt more comfortable reporting harassment, a step toward defining and acknowledging the problems through a supportive culture. Now is the time to thoughtfully reflect on and openly discuss successful programs that have been instituted and their effect. We can learn from other’s successes, and failures.
As we do so, let’s discuss options to the 4 characteristics that contribute to this problem as reported by the National Academies of Sciences, Engineering, and Medicine:
- Male-dominated field
- Improve the pipeline of female/nonbinary, LGBTQ, and underrepresented minority members of our field through programs and organizations such as the J. Robert Gladden Society and The Perry Initiative
- Create and adequately resource diversity, equity, and inclusion committees and programs
- Appropriately promote and actively retain women (who are leaving medicine at record rates due to the COVID-19 pandemic)
- Organizational tolerance
- Decrease the prevalence of men who “fail up” in medicine
- Create pathways for reporting and evaluating sexual harassment in a safe and nonjudgmental fashion
- Create and support resources for victims of sexual harassment
- Create and enforce repercussions for offenders through education, behavior modification, and situational modification
- Absolve any sense of retaliation through the medical hierarchy
- Hierarchical and dependent relationships during surgical training
- Create an educational environment that is supportive and engaging of open conversations on critical issues and topics
- Identify and resource faculty mentors who can work with victims and perpetrators of sexual harassment
- Isolationist feelings of female residents
- See recommendations from Point 1
- Create programs focusing on the needs of female surgical trainees in all subspecialities
- Hire, promote, and retain female faculty and mentors
- Hire, promote, and retain male faculty and mentors who encourage and engage in open conversations
It is easy to become discouraged when efforts may not be producing the results as quickly as we want. But as numerous Peloton instructors say, “It’s progress, not perfection” that matters. Sexual harassment is not a one-time, one-solution fix. It’s not a checkbox on a to-do list. It’s the daily grind and grassroots cultural change, the need for program and policy creation and implementation, the constant evaluation of program efficacy, and the continued awareness of the struggle that will lead to the progress we desire for an inclusive and safe field of orthopaedic surgery.
Jennifer Beck, MD is a pediatric sports medicine surgeon at UCLA and a member of the JBJS Social Media Advisory Board. She thanks Jennifer Weiss, MD and Selina Poon, MD, both pediatric orthopaedic surgeons, for their help with initial editing of this post.
Cost, Value, and Maintenance of Certification: One Surgeon’s Thoughts
This guest post comes from David Vizurraga, MD in response to a recent JBJS Orthopaedic Forum article. Additional perspective on this topic is provided by JBJS Editor-in-Chief Dr. Marc Swiontkowski in a related editorial and by The American Board of Orthopaedic Surgery’s Board of Directors in a commentary.
As Sun Tzu taught, “victorious warriors win first and then go to war, while defeated warriors go to war first and then seek to win.” As orthopaedic surgeons, we are challenged with foes in the form of musculoskeletal pathology that demand our knowledge and treatment. To be victorious, we must empower ourselves with the ever-expanding knowledge of these conditions and the ever-evolving techniques used to treat them. Failure is not an option, as defeat means not only a loss for us but for our patients as well. To that end, we must prepare and assess ourselves through continuous learning and feedback.
Since 1986, the American Board of Orthopaedic Surgery (ABOS), our specialty’s branch of the American Board of Medical Specialties (ABMS), has overseen the Maintenance of Certification (MOC) program. In its current form, the ABOS MOC allows us to individually tailor our development to our own needs while simultaneously providing feedback through evaluation over a 10-year period. Recently the cost of MOC across medical specialties has drawn increasing attention.
In a recent report in JBJS, LaVigne et al. estimate the costs of each of the MOC’s potential pathways on the basis of their time costs and fees. To account for time, the authors distributed a survey asking respondents to select which pathway they chose and to provide estimates on the amount of time spent performing various components. This survey was only distributed to a single state’s orthopaedic society and yielded only 33 responses for inclusion. Leveraging previous reports, the authors then determined the average hourly rate of compensation for orthopaedic surgeons. Merging this hourly compensation and the obtained time estimates, they were able to estimate the time cost of each pathway. Although most fees were established, the Continuous Medical Education (CME) fee was calculated from the Accreditation Council for Continuing Medical Education’s (ACCME’s) total income from CME in 2010 divided by the approximately 850,000 licensed physicians in 2010.
The authors calculated the average orthopaedic surgeon’s total 10-year costs of MOC to be $71,440.61 for the oral examination pathway, $80,392.78 for the written examination pathway (with dedicated study and review course), $68,871.78 for the written examination pathway (without dedicated study and review course), and $69,721.04 for the ABOS Web-Based Longitudinal Assessment (WLA) pathway.
While cost represents one side of the coin and is that which must be paid to obtain something, worth represents the other side and is that which is obtained in return. The value of continuing education, skill development, and even camaraderie or professional networking gained through CME and professional meetings must also be considered. So too the value of board certification as determined by an assessment of potential costs imposed on surgeon, patient, and society by negative outcomes at the hands of a surgeon who is not board certified.
At the same time, while orthopaedic surgeons are among the best-compensated specialists, we must also acknowledge that some of us, military surgeons for example, are not compensated with competitivecontracts, rewarded with robust surgical volumes, or reimbursed for regular fees. Given this and basic principles of finance, this study and others like it will continue to push the ABOS to evolve and develop new strategies that maintain our professional standard, minimize cost, and provide considerable value to us, our patients, and society at large.
David Vizurraga, MD is a San Antonio-based orthopaedic surgeon specializing in adult hip and knee reconstruction and a member of the JBJS Social Media Advisory Board.
In Pursuit of Alternative Antibiotics for Use in PMMA Bone Cement
The incorporation of antibiotics within polymethylmethacrylate (PMMA) has been widely used over recent decades for managing infection following skeletal trauma. Early research helped to clarify which antibiotics in which formulations were potentially clinically effective, with a common application of managing “dead space” following debridement of bone and soft tissue, addressing established infection as well as preventing deep infection. As the microbiology involved in these infections evolves, along with the antibiotics available, we have need for continued research into this important area of orthopaedics.
In the September 15, 2021 issue of JBJS, Levack et al. report on their investigation into the suitability of alternative antibiotics (amikacin, meropenem, minocycline, and fosfomycin) for use in PMMA beads, with a particular focus on thermal stability and in vitro elution characteristics. Tobramycin was also used to validate the study methodology. Minimum inhibitory concentrations of the antibiotics were tested against S. aureus, E. coli, and Acinetobacter baumannii. Antibiotic-laden PMMA beads of different sizes were tested, with antibiotic elution determined using high-performance liquid chromatography with mass spectrometry.
The authors found that amikacin was comparable to tobramycin with respect to heat stability and elution. Meropenem showed favorable elution kinetics and thermal stability in the initial 7 days.
The investigators emphasize that “The data presented are intended to generate further study of these antibiotics to better identify potential areas of clinical utility,” and they rightly point out that their data are not intended for clinical decision-making, “as antibiotic dosages and in vivo applications, specifically with biofilms, have not been evaluated.” Nonetheless, these new data involving the characteristics of amikacin and meropenem are intriguing. Moreover, this study serves as a great reminder of the need to regularly reevaluate established therapies as research techniques, pharmacology, and clinical conditions (such as evolving microbial pathogens) continue to change.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Reducing Intraoperative Breast Radiation Exposure of Orthopaedic Surgeons
The risk of radiation exposure in the operating room (OR) is of increasing interest to orthopaedic surgeons, and the advent of lead vests and aprons, thyroid shields, and lead glasses have given surgeons wearable protection in the OR. However, recent research has demonstrated that lead vests and aprons do not adequately shield the most frequent site of breast cancer, the upper outer quadrant (UOQ) of the breast, which commonly extends into the axilla.
In the September 1, 2021 issue of JBJS, Van Nortwick et al. report on the efficacy of lead vest supplements in reducing breast radiation exposure. The researchers simulated a standard OR setting, placing an anthropomorphic torso phantom, representing a female surgeon, adjacent to an OR table. Dosimeters were employed, and scatter radiation dose equivalents were measured during continuous fluoroscopy of a pelvic phantom, representing the patient. Using 2 C-arm positions (anteroposterior and cross-table lateral projections), and with the surgeon in 2 different positions (facing the table and perpendicular to it), 5 different configurations were tested:
- No lead
- Lead vest
- Lead vest with wings
- Lead vest with sleeves
- Lead vest with axillary supplements (the wing placed on the inferior aspect of the axillary opening)
Across scenarios, the average breast UOQ radiation exposure with the use of a lead vest alone (97.4 mrem/hr) did not differ significantly from that with no lead protection (124.1 mrem/hr). However, compared with lead vest alone, significantly less exposure was seen with the use of sleeves (0.8 mrem/hr) and axillary supplements (1.3 mrem/hr). Wings (59.4 mrem/hr) decreased exposure to a lesser extent than sleeves or axillary supplements (and the difference when compared with lead vest alone was not significant). Also noted, C-arm cross-table lateral projection had higher scatter radiation than the anteroposterior projection, as has been demonstrated in previous studies.
The authors point out that, in creating the axillary supplement, a standard wing was simply attached below the axilla rather than above the shoulder, a novel approach to increasing vest protection. While comfort in using lead sleeves or axillary supplements is important to investigate further, data from this study could help inform vendor design modifications resulting in greater protection from breast radiation exposure, and ideally eliminate the need for surgeons to have to “MacGyver” a solution from existing parts.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
A downloadable JBJS infographic summarizing this study can be found here.
Press Ganey Survey in Ambulatory Upper-Extremity Care: Assessing Nonresponse Bias
Patient surveys are now being widely used by hospital systems to monitor patient satisfaction with the process of inpatient and outpatient musculoskeletal care. While data from the surveys can help guide quality-improvement efforts, many clinicians have some concerns with the survey results in that the patients who respond may not be representative of all patients, and patient-care experiences may differ between survey “responders” and “nonresponders.”
In the September 1, 2021 issue of JBJS, Weir et al. delve further into this topic in their report on the response rate and factors associated with the completion of the Press Ganey Ambulatory Surgery Survey (PGAS) among patients treated with upper-extremity procedures in their outpatient surgical center. Of the 1,489 included patients, only 13.5% (201 patients) responded to the survey. The authors found significant differences between the responder and nonresponder groups with respect to baseline characteristics, including race (72% vs 57% White in the 2 groups, respectively), education (49% vs 40% with a college degree), employment status (88% vs 79% employed), income (49% vs 34% with income ≥$70,000), and marital status (54% vs 43% currently married). The responders also had better pre-intervention PROMIS scores across multiple domains, although the authors note that these differences were not clinically meaningful.
While emphasizing that factors influencing response rates are multifactorial and complex, the authors state that “The existence of substantial differences between responders and nonresponders raises concern for potential nonresponse bias for the PGAS.” They further point out that “surgical centers may be disproportionately missing the experiences of minority groups with lower socioeconomic status, and more focused efforts may be needed to ensure that these patients have equitable care experiences.”
It seems to me that avenues toward increasing the collection of patient responses might include improved processes for following up with nonresponders using personalized phone calls or emails, or potentially other incentives to collect these data. Survey vendors themselves have a role to play, working with hospital systems to enhance the credibility of these commonly utilized tools. With more inclusive response, providers are likely to be more confident in applying survey feedback to the practice environment, thereby improving the process of care for our patients.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
A Real-World Economic Evaluation: TSA vs Hemiarthroplasty
In a new study reported in JBJS, Lapner et al. conducted a cost-utility analysis of total shoulder arthroplasty (TSA) versus hemiarthroplasty from the perspective of Canada’s publicly funded health-care system. They used a Markov model to simulate the costs and quality-adjusted life-years (QALYs) for patients undergoing either TSA or hemiarthroplasty over a lifetime horizon to account for costs and medically important events over the patient lifetime. Subgroup analyses by age groups (≤50 or >50 years) were also performed.
Discussing their findings, the authors note:
Our analysis demonstrated that TSA was more cost-effective compared with hemiarthroplasty. This study involved a large cohort of patients (5,777) who underwent TSA or hemiarthroplasty. The data demonstrate that, despite the additional initial cost of TSA implants, health-care utilization postoperatively was greater for hemiarthroplasty compared with TSA and utility scores for hemiarthroplasty were inferior. Our findings can help inform both clinical decision-making as well as health-care policy with respect to these treatments.”
Click here for the full JBJS report.
What’s New in Limb Lengthening and Deformity Correction 2021
Every month, JBJS publishes a review of the most pertinent and impactful studies reported in the orthopaedic literature during the previous year in 14 subspecialty areas. Click here for a collection of all such OrthoBuzz Guest Editorial summaries.
This month, co-author Andrew G. Georgiadis, MD selected the 5 most clinically compelling findings from among the >60 studies highlighted in the most recent “What’s New in Limb Lengthening and Deformity Correction.”
Limb Lengthening
–Investigators in one recent study used an internal extramedullary technique to achieve femoral lengthening in 11 skeletally immature patients1. Complication rates were similar to those seen with other femoral-lengthening techniques, which suggests that newer technology could be developed for all-internal lengthening in this younger age group.
Congenital Limb Deficiencies
–In an essay, a young woman who was born with congenital short limb and her mother offer their perspectives on a childhood “interrupted” by multiple limb-lengthening procedures2.
Bone Dysplasias and Tumors
–In a retrospective study of 10 patients with congenital tibial dysplasia, researchers evaluated isolated distal tibial growth modulation as the primary surgical treatment3. Mean follow-up was 5.1 years. No patient sustained a tibial fracture or developed a tibial pseudarthrosis after guided growth was initiated.
Blount Disease
–A retrospective multicenter study assessed the use of guided growth in the correction of Blount disease in 45 patients (55 limbs)4. The authors found that 64% to 88% of cases could be corrected at a mean of 24 months. The mean correction rate was 1° per month.
Trauma
–In a study involving a caprine model of tibial osteotomy, researchers evaluated animal groups treated with static fixation, dynamic fixation, and reverse dynamization. They found that reverse dynamization was superior for speed and strength of bone-healing5.
References
- Dahl MT, Morrison SG, Laine JC, Novotny SA, Georgiadis AG. Extramedullary motorized lengthening of the femur in young children. J Pediatr Orthop. 2020 Nov/Dec;40(10):e978-83.
- Hootnick D, Ellingsworth L, Mauchin R, Brown AC. “It occupied her entire childhood”: looking back on limb-lengthening. Pediatrics. 2021 Feb;147(2):e20201055. Epub 2021 Jan 5.
- Laine JC, Novotny SA, Weber EW, Georgiadis AG, Dahl MT. Distal tibial guided growth for anterolateral bowing of the tibia: fracture may be prevented. J Bone Joint Surg Am. 2020 Dec 2;102(23):2077-86.
- Danino B, Rödl R, Herzenberg JE, Shabtai L, Grill F, Narayanan U, Gigi R, Segev E, Wientroub S. The efficacy of guided growth as an initial strategy for Blount disease treatment. J Child Orthop. 2020 Aug 1;14(4):312-7.
- Glatt V, Samchukov M, Cherkashin A, Iobst C. Reverse dynamization accelerates bone-healing in a large-animal osteotomy model. J Bone Joint Surg Am. 2021 Feb 3;103(3):257-63.
Reconstruction for Chronic ACL Tears with or without Anterolateral Structure Augmentation in Patients at High Risk for Clinical Failure
Compared with isolated ACLR, combined ACLR and ALSA resulted in a reduction in persistent rotatory laxity and higher rates of return to preinjury and competitive levels of play at 2 years of follow-up in the population studied.
Read the full article here.
Rehabilitation Strategies: Fertile Ground for Prospective Randomized Trials
Approximately 18% of JBJS scientific studies published in 2020 were Level I or II investigations. The number of high-level studies has continued to grow slowly year over year. In terms of randomized controlled trial design, we have found that the facets of care that are often the focus of study are those that are most straightforward—the use of tourniquets, resurfacing the patella with total knee arthroplasty, intraoperative and postoperative drug therapies, as examples. One under-investigated area is rehabilitation, as far as both management strategies post-injury and more detailed, comprehensive post-surgical programs.
In the latest issue of JBJS, Martínez et al. evaluate the question of duration of sling use following proximal humeral fracture in patients managed nonoperatively. This is an important patient centric question that has largely been informed by “hand me down” prescriptions from residency teaching faculty. In a very well-designed Level II trial involving an adult cohort (mean age of 70; range, 42 to 94 years), they found no significant differences in pain and function between patients randomized to 1 week of immobilization versus 3 weeks of immobilization. In addition, no significant difference in the complication rate was found.
Pain was assessed using a visual analog scale at 1 week and 3 weeks after fracture and then at the 3, 6, 12, and 24-month follow-up. Functional outcome was evaluated using the Constant score, and functional disability was evaluated with the Simple Shoulder Test, a self-reported questionnaire; both of these measures were recorded at the 3, 6, 12, and 24-month evaluation. No differences in pain and function at any time point were observed.
Many readers of JBJS have had the experience of patients abandoning the sling as soon as they are comfortable, regardless of what our original instructions were, so the findings of this study are relatable. The authors concluded that, “These fractures can be successfully managed with a short immobilization period of 1 week in order not to compromise patients’ independence for an extended period.”
It strikes me that there are numerous rehabilitation prescriptions that are ripe for evaluation using a randomized design. (Wear an orthosis when sleeping? Keep it on at all times or only when walking? Etc.) Let’s get after these questions in the manner of Martinez et al. as we seek to give our patients solid evidence to back our instructions.
A downloadable JBJS infographic regarding this study can be found here.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Mental Health Phenotypes and Patient-Reported Outcomes in Upper-Extremity Care
Pain is a remarkable and, at times, poorly understood concept. There has been extensive research showing that patients with the same conditions can experience pain differently and that pain and activity intolerance simply can’t be explained by biomedical factors alone. We have all seen examples in our own clinics as surgeons, how 2 individuals with the same pathology and treatment can have different perceived outcomes.
In the current issue of JBJS, Miner et al. explore this very topic in a prospective, cross-sectional study in which they used cluster analysis to identify mental health phenotypes (combinations of various types of misconceptions—unhelpful thoughts or cognitive biases—and symptoms of anxiety or depression) that could potentially help to direct care. A total of 137 adult patients seeking upper-extremity musculoskeletal care completed a survey that included demographics and mental health questionnaires (3 regarding unhealthy thoughts about pain and 2 addressing psychological distress) along with measures of upper-extremity-specific activity tolerance, pain intensity, and pain self-efficacy.
Through a clustering algorithm, 4 mental health phenotypes were identified in the study population:
- Low misconceptions, low distress (77 patients)
- Notable misconceptions (36 patients)
- Notable depression and notable misconceptions (19 patients)
- Notable anxiety, depression, and misconceptions (5 patients)
The authors observed significant differences in activity tolerance, pain intensity, and pain self-efficacy based on mental health phenotype. Specifically, patients with low misconceptions and low distress had significantly greater activity tolerance and pain self-efficacy than those with notable misconceptions, notable symptoms of depression, and notable psychological distress. Patients with low misconceptions and low distress also had significantly lower pain intensity than those with notable symptoms of depression and notable symptoms of anxiety.
The authors did not find an association between phenotypes and socioeconomic status, as measured by participants’ zip code (used to calculate the home area deprivation index). In addition, they found no difference between phenotypes in terms of discrete traumatic conditions (35% of patients), discrete nontraumatic conditions (47%), and nonspecific diagnoses (18%), although they caution that they may not have had enough balance to detect differences based on diagnostic category.
As surgeons, we must consider psychological factors when counseling our patients. As the authors note, “musculoskeletal specialty and pre-specialty care units can benefit from strategies that anticipate mental and social-health opportunities.” As we increase our understanding of the interplay between mental and physical health, our patients stand to gain.
Co-author David Ring, MD, PhD shares his perspective on this study in the related Author Insights video, found here.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
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