Perceptions of Preference Signaling in Orthopaedic Surgery: A Survey of Applicants and Program Directors

INTRODUCTION

To improve transparency between candidates and training programs, a preference signaling program (PSP) was implemented before the 2022 to 2023 orthopaedic surgery match. The PSP allows applicants to 'signal' up to 30 programs, informing the program of the applicant's particular interest in interviewing for their available position(s). This study reports the perspectives of orthopaedic surgery residency applicants and program directors (PDs) on the effects of preference signaling on the orthopaedic match.

METHODS

Electronic surveys were distributed to PDs and applicants.

RESULTS

Almost all programs participated in the PSP (90%), and most of the applicants (97.6%) used 25 to 30 of their allotted preference signals. Most of the applicants (67.2%) thought that their likelihood of obtaining an interview was improved at 'signaled' programs but decreased at programs without a 'signal' designation (85.3%). Both applicants and PDs considered preference signaling to be one of the three most important factors for interview selection, along with Step 2 CK score and letters of recommendation. The applicants did not think that their likelihood of matching would improve with fewer allotted signaling tokens (35.2%), and 55.2% of PDs believed 21 to 30 tokens were optimal.

CONCLUSION

Preference signaling is highly regarded by applicants and PDs. Signaling a program will likely improve an applicant's chance to interview. The optimal number of signaling tokens remains unknown, although both groups favored a larger allotment of tokens than has been seen in other specialties. Universal guidelines and recommendations for applicants and PDs would improve the utility of preference signaling.

Disparities in Gender and Diversity Representation Among Surgical Subspecialties: Are we Losing Momentum?

INTRODUCTION

Recruitment efforts have demonstrated small increases in female and under-represented applicants in recent years; however, the majority of surgical programs remain predominantly Caucasian and male. With increased national emphasis on Diversity, Equity, and Inclusion initiatives and mentoring programs, applicants to surgical specialties have continued to increase. While strategies to improve gender and racial diversity are now openly discussed, it is unclear if we have seen significant improvement. We sought to analyze the gender and diversity trends between surgical specialties.

METHODS

Publicly available data from the Association of American Medical Colleges, National Board of Medical Examiners, and Accreditation Council for Graduate Medical Education were extracted to determine total number, gender, and diversity of surgery applicants and active residents from the years 2018 to 2021. Surgical specialties within the main match were compared through an analysis completed through Microsoft Excel.

RESULTS

Between the years from 2018 to 2021, there was a rise in diversity representation among all surgical residents except for orthopedics which remained less than 30%. Orthopedics, Neurosurgery, and Thoracic Integrated training programs have the lowest rates of female representation among current residents at 16.72%, 20.37%, and 30.05%, respectively. General surgery demonstrates the greatest increase of female residents with a positive 6% change over this recent four-year time period.

CONCLUSIONS

There has been minimal positive progress in gender and diversity representation in surgical subspecialties overall in recent years. Continued advocacy through mentorship and scholarship programs is recommended to achieve greater gender and diversity representation in general surgery and surgical subspecialties.

Analysis of Academic Accomplishments and Demographics for Elected Presidents of National Orthopedic Surgery Organizations in the United States

This study analyzed the academic accomplishments and demographics of elected presidents of the American Academy of Orthopaedic Surgeons (AAOS), American Orthopaedic Association (AOA), and American Board of Orthopaedic Surgery (ABOS). Curriculum vitae and internet-based resources were reviewed to collect demographics, training characteristics, bibliometrics, and National Institutes of Health (NIH) research funding of contemporary presidents (1990-2020). Eighty presidents were included. Most presidents were men (97%), and 4% of presidents were non-White (3% Black and 1% Hispanic). Few had an additional graduate degree (4% MBA, 3% MS, 1% MPH, 1% PhD). Ten orthopedic surgery residency programs trained 47% of these presidents. Most had fellowship training (59%), and the top three were hand surgery (11%), pediatric orthopedics (11%), and adult reconstruction (10%). Twenty-nine presidents (36%) participated in a traveling fellowship. The mean age at appointment was 58±5 years, which was 27 years since residency graduation. The mean h-index was 36±23, resulting from 150±126 peer-reviewed manuscripts. Orthopedic surgery presidents had more peer-reviewed manuscripts (150±126) than chairs (73±81) and program directors (27±32) (P<.001). AOA presidents had the highest mean h-index (42±21) compared with AAOS (38±27) and ABOS (25±16) presidents (P=.035). Nineteen presidents had NIH funding (24%). More presidents had NIH funding in the AOA (39%) and AAOS (25%) than the ABOS (0%) (P=.007). Orthopedic surgery presidents possess high levels of scholarly output. AOA presidents had the highest h-index values and prevalence of NIH funding. Females and racial minorities remain underrepresented at the highest levels of leadership. [Orthopedics. 2024;47(1):e45-e51.].

Variation in Reported Learning Outcomes and Measurement Instruments in Hip Arthroscopy Simulation Training: A Systematic Review

PURPOSE

To systematically review the current literature on the effectiveness of hip arthroscopy simulation training and to determine the consistency of reporting and validation of simulation used in hip arthroscopy.

METHODS

Three databases (PubMed, EMBase, and CINAHL) were screened using PRISMA guidelines in January 2022 for published literature on virtual simulation in hip arthroscopy. Studies reporting on the use of hip arthroscopy simulation training in orthopedic surgical trainees were included and assessed for quality and risk of bias using MINORS criteria. The number of participants, participant education level, experience, simulator type, validation type, method of assessment, and simulation outcomes were extracted from included studies.

RESULTS

Of the 286 articles screened, 11 met inclusion criteria for review evaluating 323 orthopedic trainees with a mean of 29.36 participants per study published between 2012 and 2021, most commonly in the United Kingdom (55%). The four most reported surgical skills evaluated were visualization and probing tasks (82%), mean time to perform the task (73%), number of cartilage and soft tissue collisions (73%), and number of hand movements (73%). The most described measurement instruments included a simulation built-in scoring system (55%), Arthroscopic Surgical Skill Evaluation Tool (ASSET) Global Rating Scale (GRS) (27%), and motion analysis system (18%). Construct validity was the most reported overall type of validity (82%), followed by face validity (36%), transfer validity (18%) and content validity (18%). Construct validity was also the most reported validity for the simulator and measurement instrument (55% and 89%, respectively).

CONCLUSIONS

There is significant variation in reported learning outcomes and measurement instruments for evaluating the effectiveness of hip arthroscopic-based education. This study highlights that simulation training may be an effective tool for evaluation of hip arthroscopy skills.

LEVEL OF EVIDENCE

Level III, systematic review of level I to III studies.

A Cross-Sectional Study of Gender-Specific Influences of Orthopedic Subspecialty Selection

Background

Per the American Academy of Orthopaedic Surgeons, 6.5% of practicing orthopedic surgeons are female and a majority subspecialize in pediatrics, hand, and foot and ankle surgery. The study purpose is to evaluate influences of orthopedic subspecialty selection, specifically factors such as perceived strength, lifestyle, and mentorship influence on subspecialty decisions and to identify if gender plays a role in these perceptions.

Methods

An IRB approved cross-sectional study was conducted via email distribution of a REDCapTM survey to U.S. licensed orthopedic surgeons. Data regarding demographics, professional degree, training and current practice location, and perceptions regarding orthopedic surgery was obtained using Likert rating scales. Data was analyzed using descriptive statistics with two-tailed student's t-tests (α=0.05).

Results

The survey yielded 282 responses (182 females and 100 males). Overall, the distribution of residents (28%), fellows (6%), and attendings (66%) correlates well with the prevalence of each respective physician category in the field of orthopedic surgery. The study demonstrated no difference in subspecialty choice based on mentorship, work-life-balance, career advancement, subspecialty culture, salary potential, family planning, or schedule. However, a statistically significant difference exists regarding stereotypes, perceived strength required, and perception of discrimination from pursuing a specific orthopedic subspecialty. 27% of females and 10% of males reported discouragement from any subspecialty (p<0.05). Adult reconstructive and oncology were most frequently discouraged. Women reported not choosing a subspecialty because of perceived physical demands more often than men (p<0.001). Women reported an increased use of adaptive strategies in the operating room (p<0.001). Women were also more likely to report feeling discouraged from pursuing a subspecialty due to their gender (p<0.001). Both men and women reported mentorship as the most influential factor in subspecialty selection.

Conclusion

Women and men reported different factors were important in their decision of subspecialty. Women were more likely to be discouraged from a subspecialty and experience discrimination based on their perceived strength compared to male peers. Residents, fellows, and attending surgeons valued mentorship as the most influential in their subspeciality choice. This study suggests intrinsic and extrinsic influences that may differentially affect male and female orthopedic surgeons when they choose a subspecialty. Level of Evidence: III.

Feasibility of a Novel Fluoroscopic Trainer for the Orthopaedic Trainee

OBJECTIVE

We sought to create a novel method of teaching orthopedic trainees to efficiently obtain intraoperative radiographs using nonfluoroscopic digital cameras. Specifically, teaching them to make minor, uniplanar, adjustments while limiting the number of fluoroscopy images obtained during placement of a guidewire "start-point," for intramedullary nailing.

DESIGN

Prospective cohort study including medical students from 2 academic centers. Two nonfluoroscopic digital cameras simulating orthogonal fluoroscopic images were utilized. A sponge was used to simulate soft tissue resistance while navigating a guidewire to the desired starting point. Three cannulated parallel cylinders in a triangular configuration are used to simulate our "start point." Students completed 4 phases; trial and error, teaching, testing and retention.

SETTING

The protocol was completed at a single academic teaching hospital at the primary authors institution.

PARTICIPANTS

We utilized medical students from 2 GME accredited medical schools to complete the protocol. Students were selected from orthopedic surgery interest groups at their respective institutions and participation was voluntary.

RESULTS

Twenty-one medical students completed the protocol. The number of seconds to achieve each target along with the number of pictures to achieve each target were recorded and averaged. The paired t-test was used to compare the difference between phases. There is a statistically significant difference in the mean number of seconds to achieve each target between phase 1 (baseline) and phase 3 (testing) (p < 0.0001). This statistically significant difference was retained in phase 4 (retention) (p < 0.0001).

CONCLUSIONS

We were able to demonstrate a statistically significant decrease in the number of images and time to obtain the correct "start point." This could theoretically decrease operative time and morbidity while teaching students in a low-stress training environment without exposure to radiation.

Be a Lighthouse for Your Medical Students: How to Help Them Navigate During Changing Times to a Successful Match

The transition between medical school and residency is a complex, multifaceted process that is commonly a time of stress and uncertainty for medical students. Occupying most of a student's final year of medical school, the residency application includes a primary Electronic Residency Application Service application, a variable number of program-specific secondary applications, and interviews. The application process culminates with The Match. Orthopaedic surgery is among the more competitive specialties; thus, it is critical that all involved parties understand the complexity of the process and the numerous variables that play into such a critical decision point in the career trajectory of a future physician. It is important to provide a mentor with an overview of the residency application process, specifically with respect to orthopaedic surgery, so that they may be best prepared to guide their medical student mentee through the process and help them find success.

Trends in ACGME Accreditation of Orthopedic Surgery Fellowship Training

Currently, most surgeons pursue subspecialty fellowship training. This study answers the following questions: (1) How does the rate of fellowship training in orthopedic surgery compare with that in other surgical specialties? (2) To what extent did adoption of Accreditation Council for Graduate Medical Education (ACGME) accreditation change from 2013 to 2021? Orthopedic subspecialties were analyzed for total number of fellowship programs and positions in the 2013 and 2021 Match. Rates of ACGME accreditation were analyzed via chi-square tests. In 2021, orthopedic surgery had the highest rate of fellowship selection (94%) relative to general surgery (77%), ophthalmology (66%), plastic surgery (63%), and otolaryngology (55%). Across all orthopedic subspecialties, the percentage of ACGME accreditation decreased among fellowship programs (53% in 2013 to 48% in 2021, P=.166) and positions (58% in 2013 to 50% in 2021, P<.001). Orthopedic sports medicine had the highest adoption of ACGME accreditation (100%), followed by hand surgery (99%), musculoskeletal oncology (67%), and pediatric orthopedics (56%). Significant increases in the adoption of ACGME accreditation were noted for orthopedic sports medicine (93% in 2013 to 100% in 2021, P=.016) and hand surgery (81% in 2013 to 99% in 2021, P<.001). There was a significant decrease in ACGME accreditation for adult reconstructive orthopedics (40% in 2013 to 24% in 2021, P=.042), driven by the increase in unaccredited fellowship programs. Accreditation of orthopedic subspecialty fellowship training has decreased with respect to the proportion of accredited training positions. More research is needed to understand the benefits of ACGME accreditation for fellowship training in orthopedic surgery. [Orthopedics. 2024;47(1):57-63.].

Improving Applicant Satisfaction in Orthopaedic Surgery Residency Matching: The Role of Preference Signaling

Background

The orthopaedic surgery residency match is becoming increasingly more competitive with a disproportionate number of applicants to positions. As the residency application process has become more competitive, applicants have resorted to applying broadly to improve their chance of a successful match. Preference signaling was implemented for orthopaedic surgery for the 2022-2023 match cycle which allowed applicants to "signal" 30 programs of their choosing.

Methods

The purpose of this study was to assess the impact of preference signaling on orthopaedic surgery applicant experiences and outcomes in the 2023 residency application cycle and match. An anonymous electronically based survey study developed using Research Electronic Data Capture (REDCap) was send to 895 applicants to a single orthopedic residency program. 148 applicants filled out some portion of the survey for a 16.5% response rate.

Results

51% of applicants applied to 61-100 programs. Applicants received more interview offers from programs they signaled compared to programs they did not signal. 50% of applicants responded that the number of allotted signals was "just right", with more applicants responding that the number of signals allotted was "too many" rather than "too few". 62% of applicants agreed that signaling increased his/her chances of receiving an interview offer at a signaled program, 66% were satisfied with the results of the match, and 50% thought signaling had a positive impact on the application process.

Conclusion

Overall, preference signaling was well received by applicants and may help to connect applicants with residency programs they are specifically interested in. Level of Evidence: III.

Current Trends in Orthopaedics and Trauma in Germany

During the Guest Nation Symposium (cobranded with the Deutsche Gesellschaft für Orthopädie und Unfallchirurgie, Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie, and Deutsche Gesellschaft für Unfallchirurgie) at the 2023 American Academy of Orthopaedic Surgeons Congress in Las Vegas, the goal was to compile nationally important content from German orthopaedics and trauma surgery. This resulted in a mix of content on the latest developments in trauma care, knee arthroplasty, spinopelvic importance for hip arthroplasty, stemless shoulder endoprostheses, joint preservation for ankle osteoarthritis, trauma education, and research. Of course, this is only a small selection of the important issues that are being driven forward in Germany.

Training and Evaluation of Residents to Ensure Competent Physician Metrics to Recognize Struggling Residents

Assessing competency across domains of knowledge, skills, and behavior is critical to ensure that graduating orthopaedic residents possess the requisite skills and attributes to enter independent orthopaedic practice. Of the domains, knowledge is most easily assessed. In addition to the AAOS Orthopaedic In-Training Examination®, which provides a yearly gauge of residents' orthopaedic knowledge relative to their peers, there are several online platforms such as Orthobullets, the American Academy of Orthopaedic Surgeons ResStudy program, and the Journal of Bone and Joint Surgery Clinical Classroom that offer online learning resources and question banks. Clinical skills are best assessed through a combination of observation tools, including live or video assessments, 360° evaluations, and objective structured clinical examinations. Surgical skills can be evaluated in two domains: live surgical cases or simulations. The American Board of Orthopaedic Surgery is attempting to standardize live surgical evaluations through the use of the O-P tool. Although most available models feature only arthroscopic procedures, surgical simulators provide for opportunity to objectively evaluate resident performance. Behavior and professionalism has traditionally been the most challenging domain to assess. The American Board of Orthopaedic Surgery's Behavior Assessment Tool has demonstrated success in pilot testing and is being introduced as the standard for measuring behavior and professionalism in orthopaedic training. Although no single assessment tool can accurately gauge a resident's overall performance, a combination of readily available tools should be used to assess competence across domains.

The Utility of the Standardized Letter of Recommendation for Orthopedic Surgery Residency Applicants: A Systematic Review

Despite widespread adoption for evaluating residency candidates, few studies have evaluated the orthopedic standardized letter of recommendation (SLOR). A systematic review using PubMed, Embase, and Web of Science was performed in June 2022. Study design and results from SLOR investigations were compiled. Common outcomes studied were summative rank statement scores and SLOR individual domains. Applicants were rated ranked to match or in the top one-third of rank lists in non-normally distributed frequencies. The association of summative rank statement score with match outcome was rarely studied. Applicants' ratings skew positively, the utility is reportedly limited, and influence on match outcome has been inadequately studied. [Orthopedics. 2024;47(1):e1-e5.].

AOA Critical Issues: Perceptions on the State of Diversity, Equity, and Inclusion in Orthopaedic Surgery: A Survey of the AOA Membership

BACKGROUND

Orthopaedic surgery continues to trail other specialties in increasing diversity among its physician workforce. Various efforts have been and are currently being made to not only increase diversity, but also promote equity and inclusion in the field. The purpose of this study was to survey members of the American Orthopaedic Association (AOA) to determine how leaders in orthopaedics view diversity, equity, and inclusion (DEI) at the present time and to understand their perspective while moving into the future.

METHODS

An anonymous 11-question survey was disseminated online to AOA members in May 2022. These individuals were identified by the AOA membership directory and the email ListServe. The survey included free-response and multiple-choice questions. Demographic information was self-identified, and both qualitative and quantitative data were collected.

RESULTS

Of the 1,657 AOA members who were provided the survey, 262 (15.8%) responded. Approximately 29.5% (77) and 45.6% (119) of the surveyed population ranked "retention of underrepresented populations in orthopaedic residency (women, URiM)" as "very important" or "absolutely essential," respectively. The answers to the free-response questions identified multiple core themes that responders were passionate about, namely resident and attending physician recruitment and retention, as well as resident selection.

CONCLUSIONS

Leaders in the field of orthopaedic surgery desire for action to be taken in the field of DEI. The findings of this survey denote positive attitudes even though many inequalities still pervade the field of orthopaedics. Through mentorship, objective evaluation, transparency, and continued intentional action, orthopaedic surgery is well-positioned to continue to move forward with DEI.

Haitian State Hospital Orthopedic Grand Rounds Series: A Virtual Curriculum to Address Global Surgery Needs

Background

Orthopedic Relief Services International (ORSI), in partnership with the Foundation for Orthopedic Trauma and the department of Orthopedic Surgery of La Paix University Hospital in Haiti, has developed a year-round Orthopedic Grand Round series. This series is moderated by Haitian faculty, features presentations by American orthopedic surgeons, and is broadcast to major state hospitals in Haiti for residents and attendings.

Objective

To introduce clinical concepts and increase knowledge in an area that is medically underserved, especially in the field of orthopedics, through lectures that tailor to the educational needs of Haiti.

Methods

Topics for lecture series are requested by Haitian attending orthopedic surgeons and residents in collaboration with American orthopedic surgeons to meet the educational needs of the residents in Haiti. These lectures reflect the case mix typically seen at state hospitals in Haiti and consider the infrastructural capacity of participating centers. Grand rounds are held an average of twice per month for an hour each, encompassing an educational lesson followed by an open forum for questions and case discussion. Feedback is taken from Haitian residents to ensure the sessions are beneficial to their learning.

Findings and Conclusions

To date 95 sessions hosted by 32 lecturers have been completed over Zoom between the US and Haiti. The fourth year of the lecture series is currently ongoing with an expansion of topics. In an underserved medical area such as Haiti, programs that educate local surgeons are crucial to continuing the growth and development of the medical community. Programs like this have the potential to contribute to the educational infrastructure of countries in need, regardless of the specialty. The model of this program can be used to produce similar curricula in various specialties and areas around the world.

Overcoming the Barriers to Diversity in Orthopaedic Surgery: A Global Perspective

BACKGROUND

Diversity in orthopaedics continues to lag behind that in other surgical specialties. This pattern exists globally and is not unique to gender or race. This review offers a global perspective on overcoming the barriers to diversity in orthopaedics.

METHODS

A literature search of MEDLINE and Embase was conducted and a narrative review was undertaken. Publications that discussed any aspect of diversity or solutions to diversity within orthopaedics or academic orthopaedics were identified.

RESULTS

A total of 62 studies were included. Studies showed that diversity in orthopaedic training is limited by structural barriers such as long hours, requirements to relocate during training, training inflexibility, and a lack of exposure to orthopaedics. Implicit bias during the selection process for training, discrimination, and a lack of role models are additional barriers that are experienced by both minority and female surgeons. The global lack of diversity suggests that there are also inherent "cultural barriers" that are unique to orthopaedics; however, these barriers are not uniformly experienced. Perceptions of orthopaedics as promoting an unhealthy work-life balance and the existence of a "boys' club" must be addressed. Strong, committed leaders can embed cultural norms, support trainees, and act as visible role models. Targeted efforts to increase diverse recruitment and to reduce bias in selection processes for medical school and specialty training will increase diversity in the "training pipeline."

CONCLUSIONS

Diversity in orthopaedics continues to lag behind that in other specialties. Increasing diversity is important for providing a more inclusive training environment, improving patient care, and reducing health disparities. Structural and cultural barriers need to be addressed to improve diversity in orthopaedics. Promoting a culture supportive of all surgeons is essential to reframing perceptions that may prevent individuals from even considering a career as an orthopaedic surgeon. Changing attitudes require focused efforts from committed leadership in a "top-down" approach that prioritizes diversity. The efforts from national bodies seeking to tackle the lack of diversity, as well as the establishment of organizations committed to diversity, such as the International Orthopaedic Diversity Alliance, provide reasons to be optimistic for the future.