Work-hour restrictions and orthopaedic resident education: a systematic review

The introduction of a 42 + 4 h work week for surgical residents in Switzerland - a stakeholder analysis

BACKGROUND

The Swiss national union of residents and attendings (VSAO) has voiced its desire for a transition from the current 48 h work week to a 42 + 4 h work week, in which 42 h be focused on patient care with the remaining 4 h be dedicated solely to training purposes. This could potentially result in a significant decrease in surgical education time. The current study seeks to address the issues involved in its implementation as well as possible compensatory mechanisms.

METHODS

This mixed methods study seeks to clearly underline the challenges associated with the implementation of a 42 + 4 h work week. First, the major stakeholders were identified and analysed via umbrella review. Thereafter, a classic stakeholder analysis was performed. Via morphological matrix, possible models for the implementation of a 42 + 4 h work week were developed and evaluated. Finally, representatives from the identified stakeholder groups were interviewed and given the opportunity to provide feedback.

RESULTS

A total of 26 articles were identified by the literature search and were used to identify the major stakeholders and issues involved in the implementation of the desired work hour regulation. Overall, these showed conflicting results with regard to the effect decreased working hours would have on surgical training and patient outcomes. In the end, the morphological matrix produced three feasible and desirable models for the implementation of a 42 + 4 h work week. Each included compensatory mechanisms like auxiliary staff, reduction in administrative tasks, and a switch to EPAs. In their interviews, the stakeholders generally supported these solutions.

CONCLUSION

Given the increasing emphasis on the importance of a positive work-life balance, it seems inevitable that the next few years will see the introduction of a 42 + 4 h work week in Switzerland. However, it is imperative that every effort be made to preserve the quality of training and patient care for the next generations. This will require the cooperation of all stakeholders in order to find workable solutions.

[Satisfaction with continuing education at a level 1 trauma center-Results of a survey and development of a competency-based continuing education concept]

BACKGROUND

Structured competency-based training is one of the most frequently articulated wishes of residents.

METHODS

A survey of 19 residents was conducted regarding their satisfaction with the resident education at a level 1 trauma center. In this article the development of a revised competency-based education concept was carried out.

RESULTS

The survey reflected uncertainty as to whether the current structures could meet the requirements of the residency regulations. The improved competency-based education concept consists of clinical mentoring, competency-based catalogs of learning objectives, regular theoretical and practical workshops as well as regular and structured staff evaluations.

CONCLUSION

The education concept presented reflects the attempt to establish a contemporary surgical training program which will be evaluated as it progresses.

A Curricular Model for Simulation Within Orthopaedic Residency Training

Introduction

American Board of Orthopaedic Surgery/American Council on GraduateMedical Education Residency Review Committee training requirements have necessitated the need for the adoption of simulation education into existing programmatic requirements. Current guidelines focus only on interns at a potentially significant cost to programs; both in total dollar amount and time.

Methods

The authors aim to provide a model that can maximize utility for all resident levels, manage cost by maximizing the use of cadaveric material, and allow integration of varied industry support.

Results

The Oregon Health & Science University Orthopaedic education program has developed a high-fidelity training curriculum that (1) is applicable to both junior and senior residents (2) has minimized the cost per resident with the reuse of cadaveric specimens and (3) has nurtured partnerships with industry stakeholders to reduce bias in training by collaborating with most major industry representatives.

Conclusion

The simulation curriculum outlined in this manuscript may serve as a reference for other programs and institutions to develop their own residency educational curriculum models.

[Analysis of risk factors for dropping out of residency in orthopedics and trauma surgery]

BACKGROUND

Currently, there are no data available on dropouts from residency programs and changes of clinic in orthopedics and trauma surgery (O&T). The aim of the study is to identify personal and structural risk factors leading to dropout or switching of postgraduate training in O&T in order to present solution strategies.

METHODS

A nationwide anonymous online survey was conducted among residents in O&T in summer 2020. Official mail addresses were identified via the Traumanetzwerk© of the DGU and the German Hospital Federation (n = 2090). A questionnaire (51 questions) was administered using SurveyMonkey (San Mateo, CA, USA). All residents who worked in O&T for at least 1 month in the 6 years prior to the start of the survey (from 07/2014) were eligible to participate. A binary logistic regression was calculated to identify the risk factors. The significance level was p = 0.05.

RESULTS

Of the 221 respondents, 37% switched hospital and 5% dropped out altogether. The regression revealed 3 significant risk factors for switching hospitals. Living in a partnership (p = 0.029, RR: 2.823) and less than 2 days of shadowing before the start of residency (p = 0.002, RR: 2.4) increased the risk of switching. Operating room (OR) allocation of residents according to the training plan/status (p = 0.028, RR: 0.48) reduces the risk of switching. Significant risk factors for leaving postgraduate training could not be determined (insufficient number of cases, n = 11).

DISCUSSION

Switching the hospital and residency dropouts in O&T are a relevant problem (42%). Gender has no significant influence. Tools such as longer job shadowing, as well as OR allocation according to the training plan/status can minimize the risk of switching.

Impact of the COVID-19 Pandemic on Resident Physician Clinical and Educational Work Hours at a Large Sponsoring Institution

BACKGROUND

The COVID-19 pandemic affected graduate medical education (GME) by decreasing elective procedures and disrupting didactic learning activities in 2020. Editorials have hypothesized that resident physicians worked fewer hours, therefore losing valuable experience, but we are not aware of studies that have objectively assessed changes in hours worked.

OBJECTIVE

This study aims to identify differences secondary to the COVID-19 pandemic in resident work hours across all specialties at 3 geographically dispersed, integrated academic hospitals in a large sponsoring institution.

METHODS

We obtained de-identified work hour data from all residency programs at Mayo Clinic in Arizona, Florida, and Minnesota. Resident work hours were compared between 2020 and 2019 from March to May.

RESULTS

Work hours for 1149 and 1118 residents during the pandemic and control periods respectively were compared. Decreases in resident work hours were seen, with the largest decrease demonstrated in April 2020 when 19 of 43 programs demonstrated significantly decreased work hours. Residents worked more hours from home in April 2020 compared to the previous year (Arizona: mean 1 hour in 2019 vs 5.2 hours in 2020, P<.001; Florida: mean 0.7 hour in 2019 vs 6.5 hours in 2020, P<.001; Minnesota: mean 0.8 hour in 2019 vs 10.2 hours in 2020, P<.001).

CONCLUSIONS

The COVID-19 pandemic was associated with a decrease in work hours in some, but not all, specialties. The decrease in on-site work was only partially offset by an increased number of hours worked from home.

Duty Hours Tracking - Is There an App for That?

BACKGROUND

To monitor duty hour compliance residency programs have used self-report methods which can be skewed by recall bias and data falsification. The purpose of this study was to compare the accuracy of and resident attitudes towards two duty hours tracking tools within our Orthopedic residency. We compared our institution's current self-report method of duty hours tracking via New Innovations (NI) with an automated method utilizing Hours Tracker (HT), a smartphone application which automatically logs work hours via GPS coordinates. The primary outcome measures were number of duty hour violations and survey results on resident perceptions.

METHODS

The participants were 22 residents of our 25 resident Orthopedic program. Over four weeks, residents tracked duty hours through the standard, selfreport method (NI) and simultaneously through the automated app (HT). Residents also completed an anonymous survey at the end of the study related to perceptions of the methods.

RESULTS

There was no significant difference in overall number of violations between NI and HT. HT detected more violations of the 8 hours off requirement (12 vs. 5, p = 0.03). Survey data revealed residents found HT significantly easier to use (p = .004) and less burdensome (p < .001) but in greater violation of privacy (p = .001). Residents reported they were more likely to falsify their hours when using NI (p = .002) and that the results of NI would be more likely used against them (p = .042). When analyzing by training year, junior residents indicated HT was overall easier to use than senior residents (p = .048).

CONCLUSIONS

Our study showed NI and HT are at least equivalent in accuracy with the app being overall better received, particularly by junior level residents. Until we begin accurately tracking duty hours and engaging residents with an easy to use, well-received interface to which report hours, effective developmental program changes will be difficult to achieve. An app-based approach is a starting point for re-thinking duty hours tracking within this digital age.

Does the Preferred Study Source Impact Orthopedic In-Training Examination Performance?

OBJECTIVE

This study examines the role of electronic learning platforms for medical knowledge acquisition in orthopedic surgery residency training. This study hypothesizes that all methods of medical knowledge acquisition will achieve similar levels of improvement in medical knowledge as measured by change in orthopedic in-training examination (OITE) percentile scores. Our secondary hypothesis is that residents will equally value all study resources for usefulness in acquisition of medical knowledge, preparation for the OITE, and preparation for surgical practice.

DESIGN

9 ACGME accredited orthopedic surgery programs participated with 95% survey completion rate. Survey ranked sources of medical knowledge acquisition and study habits for OITE preparation. Survey results were compared to OITE percentile rank scores.

PARTICIPANTS

386 orthopedic surgery residents SETTING: 9 ACGME accredited orthopaedic surgery residency programs RESULTS: 82% of participants were utilizing online learning resources (Orthobullets, ResStudy, or JBJS Clinical Classroom) as primary sources of learning. All primary resources showed a primary positive change in OITE score from 2018 to 2019. No specific primary source improved performance more than any other sources. JBJS clinical classroom rated highest for improved medical knowledge and becoming a better surgeon while journal reading was rated highest for OITE preparation. Orthopedic surgery residents' expectation for OITE performance on the 2019 examination was a statistically significant predictor of their change (decrease, stay the same, improve) in OITE percentile scores (p<0.001).

CONCLUSIONS

Our results showed that no specific preferred study source outperformed other sources. Significantly 82% of residents listed an online learning platform as their primary source which is a significant shift over the last decade. Further investigation into effectiveness of methodologies for electronic learning platforms in medical knowledge acquisition and in improving surgical competency is warranted.

Do Resident Surgical Volumes and Level of Training Correlate with Improved Performance on Psychomotor Skills Tasks: Construct Validity Testing of an ASSH Training Platform (STEP)?

The Surgical Training and Educational Platform (STEP) was developed by the American Society for Surgery of the Hand (ASSH) as a cost-effective set of surgical simulation modules designed to assess critical skills in hand surgery. Previous study demonstrated that STEP can differentiate between novice trainees and board-certified, certificate of added qualification hand surgeons. The purpose of this study was to assess construct validity of STEP by testing its ability to differentiate psychomotor skill level among intermediate trainees.

Global Rating Scales for the Assessment of Arthroscopic Surgical Skills: A Systematic Review

PURPOSE

To evaluate whether sufficient validity and reliability evidence exists to support the use of global rating scales (GRS) as evaluation tools in both formative assessment and competency assessment of arthroscopic procedures.

METHODS

A search of PubMed, Embase, and Scopus was conducted for articles published between 1990 and 2018. Studies reporting measures of validity and reliability of GRS relating to arthroscopic skills were included. Procedural checklists and other assessment tools were excluded.

RESULTS

A total of 39 articles met the inclusion criteria. In total, 7 de novo GRS specific for arthroscopic education and 3 pre-existing GRS repurposed 4 times for arthroscopic education were identified in the literature. The 11 GRS were used to assess 1175 surgeons 3890 times. Three GRS tools explicitly defined an arbitrary minimum competency threshold, 6 of 11 tools demonstrated construct validity-the ability to significantly discriminate between groups of differing experience-and 5 of 11 tools assessed inter-rater reliability, but only the Arthroscopic Surgical Skills Evaluation Tool demonstrated excellent inter-rater reliability. The Arthroscopic Surgical Skills Evaluation Tool was validated by 16 articles for a total of 537 surgeons for hip, knee, shoulder, and ankle arthroscopy in both simulated and clinical environments but was found to be invalid in wrist arthroscopy. The Basic Arthroscopic Knee Skill Scoring System was validated by 15 articles for a total of 497 surgeons for knee, hip, and shoulder in both clinical and simulated environments. The remaining 9 GRS were validated by 2 or fewer studies.

CONCLUSIONS

Overall, GRS have contributed to training, feedback, and formative assessment practices. The GRS reviewed demonstrate both construct and concurrent validity as well as reliability in multiple arthroscopic procedures in multiple joints. Currently, there is sufficient evidence to use GRS as a feedback tool. However, there is insufficient evidence for its use in high-stakes examinations or as a minimum competency assessment.

LEVEL OF EVIDENCE

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

Educational Resource Utilization by Current Orthopaedic Surgical Residents: A Nation-wide Survey

Background

More than 150 accredited orthopaedic residency programs exist in the United States with more than 3,300 residents. Every year, between 600 and 800 orthopaedic surgeons complete board certification. However, little is known about what residents use and prefer of the many resources available to them. The purpose of this study is to understand how orthopaedic residents across the country prioritize educational resources.

Methods

An 18-question survey with subqueries was compiled on the REDCap (Research Electronic Data Capture) platform. Residents were reached through program coordinators, program directors, and word of mouth. There were 374 total respondents. Responses were summarized for the total population and stratified separately by sex, location, and year of training. P values were adjusted for multiple comparisons using the Bonferroni method.

Results

Respondents were 83.4% male and 16.6% female. Orthobullets was the single most valued resource and general review articles were the single most valued journal resource. The average time spent studying was 10.7 hr/wk (SD = 7.6), with no notable differences by program location or sex. A significantly larger percentage of female residents placed more importance on specialty-specific journals (32.8% rated as very important versus 19.9% from males, P = 0.016) and research-related journals (P = 0.004). VuMedi use significantly increased until postgraduate year-4 (P < 0.001), whereas residents earlier in training used YouTube more often (P = 0.026). There were differences in journal prioritization by program region, with the Midwest, Northeast, and South preferring primary, focused articles and the Northeast, South, and West emphasizing systematic review articles (P = 0.032). Industry-sponsored events were used by 67.4% of residents as an educational adjunct.

Conclusions

Current residents-regardless of sex, location, and year in training-use Orthobullets and other electronic resources. There continues to be utilization of industry-sponsored resources, although they are not the primary focus for those in training.

Incidence of osteosynthesis of members in France

PURPOSE

Little data is available on the number of osteosynthesis of limbs in a country. Incidence of osteosynthesis is an essential element for the formation and organization of care. Based on the data from the work of the Hospital Information Technology Agency ( http://www.atih.sante.fr/ ) and available in open access, we wanted to know the incidence of the number of osteosynthesis performed in France and their evolution over ten years between 2006 and 2015.

METHODS

The data analyzed are derived from the website of the technical agency of information on the hospitalization (ATIH).

RESULTS AND CONCLUSIONS

In France, in 2015, 267,999 limb osteosyntheses were performed. Between 2006 and 2015, the number of osteosynthesis increased by 9.1%. The incidence of limb osteosynthesis is 403.7 per 100,000 people, rising 3.9% between 2006 and 2015. In comparison, the incidence of hip prostheses increased by 12.6%, knee prosthesis by 57.4%. The main bias of the study is of course the quality of the coding of the surgeons and the establishments, a type of fracture that can enter into one or several categories of acts. In ten years, the incidence of osteosynthesis has increased little in France. The evolution is more pronounced on fractures affecting mainly the elderly, fracture of the upper end of the femur, fracture of the distal end of the radius and fracture of the ankle. The incidence of many acts of osteosynthesis is very low and therefore responsible for a weak experience for most surgeons.

The current state of orthopaedic residency in 18 European countries

PURPOSE

The aim of this study was to compare differences in current orthopaedic and trauma training programs across Europe.

METHODS

A questionnaire was sent to the FORTE (Federation of Orthopaedic Trainees in Europe) representatives of 25 different European countries, of which 18 responded. The questionnaire included demographic information and information concerning the structure of the training programs, including duration, selection, and mandatory training requirements.

RESULTS

The number of trainees per specialist varied between countries from a ratio of 1:2 to 1:7. Residency was generally five to six years in all the countries. In more than half of the countries selection was interview-based. Nearly all countries utilized a logbook. About 80% of the participating countries had a final examination. When assessing the components of training it was found that only one country (the United Kingdom) had mandatory minimum requirements for (1) courses, (2) surgical procedures, (3) research and (4) leadership. Nearly 40% of the participating countries had only one or none of these four components as a mandatory training requirement.

CONCLUSIONS

There are many similarities in training programs, but some important differences remain in overall requirements and final qualification. The main limitation of this study was that we were unable to get data from all the European countries. FORTE will continue to serve as a forum for sharing best practices with the ultimate goal of improving and harmonizing the level of orthopaedic training across Europe. Future studies should aim to include further details about training programs as well as to include data from more countries.