Orthopaedic resident and program director opinions of resident duty hours: a national survey

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.

Can a Computer-based Force Feedback Hip Fracture Skills Simulator Improve Clinical Task Performance? A Cadaveric Validation Study

BACKGROUND

This cadaveric study seeks to determine whether skills acquired on the simulator translate to improved performance of the clinical task. We hypothesized that completion of simulator training modules would improve performance of percutaneous hip pinning.

METHODS

Eighteen right-handed medical students from two academic institutions were randomized: trained (n = 9) and untrained (n = 9). The trained group completed nine simulator-based modules of increasing difficulty, designed to teach techniques of placing wires in an inverted triangle construct in a valgus-impacted femoral neck fracture. The untrained group had a brief simulator introduction but did not complete the modules. Both groups received a hip fracture lecture, an explanation and pictorial reference of an inverted triangle construct, and instruction on using the wire driver. Participants then placed three 3.2 mm guidewires in cadaveric hips in an inverted triangle construct under fluoroscopy. Wire placement was evaluated with CT at 0.5 mm sections.

RESULTS

The trained group significantly outperformed the untrained group in most parameters (P ≤ 0.05).

CONCLUSIONS

The results suggest that a force feedback simulation platform with simulated fluoroscopic imaging using an established, increasingly difficult series of motor skills training modules has potential to improve clinical performance and might offer an important adjunct to traditional orthopaedic training.

Explicit teaching in the operating room: Adding the why to the what

CONTEXT

Residents need their supervisors in the operating room to inform them on how to use expertise in present and future occasions. A few studies hint at such explicit teaching behaviour, however without explaining its underlying mechanisms. Understanding and improving explicit teaching becomes more salient nowadays, as access of residents to relevant procedures is decreasing, while end-terms of training programs remain unchanged: high quality patient care.

OBJECTIVES

A structured analysis of (1) the practices supervisors use for explicit teaching and (2) how supervisors introduce explicit teaching in real time during surgical procedures.

METHODS

An observational qualitative collection study in which all actions of nine supervisor-resident dyads during a total hip replacement procedure were videotaped. Interactions in which supervisors explicitly or implicitly inform residents how to use their expertise now and in future occasions were included for further analysis, using the iterative inductive process of conversation analysis.

RESULTS

1. Supervisors used a basic template of if/then rules for explicit teaching, which they regularly customised by adding metaphors, motivations, and information about preference, prevalence and consequence. 2. If/then rules are introduced by supervisors to solve a (potential) problem in outcome for the present patient in reaction to local circumstances, for example, what residents said, did or were about to do.

CONCLUSIONS

If/then rules add the why to the what. Supervisors upgrade residents' insights in surgical procedures (professional vision) and teach the degree of individual freedom and variation of their expert standards for future occasions. These insights can be beneficial in improving supervisors' teaching skills.

The relationship between the orthopedic job market and sports medicine fellowship applications between 2010 and 2017

Objectives: More than 90% of graduating orthopedic residents pursue at least one year of fellowship training. There are no studies to date that examine the trends for sports medicine positions in the orthopedic job market. The purpose of this study was to evaluate trends in orthopedic sports medicine positions using postings from four orthopedic journals. Methods: Print advertisements for job positions in three American orthopedic journals (Journal of Bone and Joint Surgery, Journal of the American Academy of Orthopaedic Surgeons, and American Journal of Sports Medicine) between 2010 and 2017 were reviewed. The results were compared to sports medicine fellowship match trends. Results: Between 2010 and 2017, there were a total of 403 postings for orthopedic sports medicine positions, 186 in Journal of Bone and Joint Surgery, 113 in Journal of the American Academy of Orthopaedic Surgeons, and 52 in American Journal of Sports Medicine. There was a 43% decline in print sports medicine advertisements from 2010 to 2015. The number of job advertisements for sports medicine positions remained consistent (approximately 10%) from 2010 to 2015, then dropped to 2.1% (57/2698) and 1.4% (66/4735) in 2016 and 2017, respectively. Conclusion: There is no direct correlation between job positions advertised in orthopedic journals and sports medicine fellowship positions offered. Additionally, there has been an increase in job advertisements requiring fellowship training, indicating an increased demand for sub-specialty trained orthopedic surgeons. Lastly, the drop in total orthopedic advertisements in the years proceedi ng 2015 may serve as a harbinger for the transition to largely online content, and job postings in journals may not be the most reliable source of job opportunities, but further investigation should be done in relation to this topic.

Evaluation of Sports Medicine Fellowships in the United States Based on Academic Productivity

Institutional academic productivity remains an influential factor in an applicant's selection of fellowship training. This study aimed to determine the quality and quantity of research in the United States orthopaedic sports medicine fellowship programs and identify those with highest productivity.

Training Surgeons to Perform Arthroscopic All-Inside Meniscal Repair: A Randomized Controlled Trial Evaluating the Effectiveness of a Novel Cognitive Task Analysis Teaching Tool, Imperial College London/University College London Meniscus Repair Cognitive Task Analysis (IUMeRCTA)

BACKGROUND

All-inside meniscal repair is an increasingly common technique for the surgical treatment of meniscal tears. There are currently no standardized techniques for training residents in this procedure. Cognitive task analysis (CTA) is a method of analyzing and standardizing key steps in a procedure that allows training to be conducted in a validated and reproducible manner.

PURPOSE

(1) To design a digital CTA teaching tool for a standardized all-inside meniscal repair. (2) To evaluate whether CTA-trained residents would perform better in a meniscal repair task compared with a control group who underwent traditional apprenticeship methods of training.

STUDY DESIGN

Controlled laboratory study.

METHODS

Three expert knee surgeons were interviewed using a modified Delphi method to generate a consensus among the ideal technical steps, cognitive decision points, and common errors and solutions for an all-inside meniscal repair. This written information was then combined with visual and audio components and integrated onto a digital platform to create the Imperial College London/University College London Meniscus Repair Cognitive Task Analysis (IUMeRCTA) tool. Eighteen novice residents were randomized into an intervention group (digital CTA tool) and control group (equipment instruction manual). Both groups performed an all-inside meniscal repair on high-fidelity, phantom knee models and were assessed by expert surgeons, blinded to the interventions, using a validated global rating scale (GRS). After a power calculation, median GRS scores were compared between groups using the Mann-Whitney U test; significance was set at P < .05.

RESULTS

For the IUMeRCTA tool design, the procedure was divided into 55 steps across 9 phases: (1) preoperative planning, (2) theater and patient setup, (3) portal placement, (4) meniscal examination, (5) tear reduction, (6) suture planning, (7) suture insertion, (8) repair completion, and (9) postoperative care and rehabilitation. For the trial, the intervention group (mean ± SD GRS, 32 ± 2.9) performed significantly better than did the control group (GRS, 24 ± 3.3; P < .001).

CONCLUSION

This is the first CTA tool to demonstrate objective benefits in training novices to perform an arthroscopic all-inside meniscal repair.

CLINICAL RELEVANCE

The IUMeRCTA tool is an easily accessible and effective adjunct to traditional teaching that enhances learning the all-inside meniscal repair for novice surgeons.

The Current State of Orthopaedic Educational Leadership

INTRODUCTION

It is important to understand the current characteristics of orthopaedic surgery program leadership, especially in the current climate of modern medicine. The purpose of this report was to describe the demographic, academic, and geographic characteristics of current orthopaedic chairs and program directors (PDs).

METHODS

Orthopaedic surgery residency programs were obtained from the Accreditation Council for Graduate Medical Education website and cross-referenced with the Electronic Residency Application Service, identifying 161 residency programs for the 2018 to 2019 cycle. All data were collected in January 2020 to best control for changes in leadership. Demographic and academic information were collected from public websites. For geographic analysis, the United States was divided into five regions, and training locations were categorized as appropriate.

RESULTS

A total of 153 chairs and 161 PDs were identified. 98.0% of chairs were men versus 88.8% of PDs (P = 0.001). Chairs had been in practice and in their current position for longer than PDs (26.4 vs 16.8 years [P < 0.005] and 9.1 vs 7.1 years [P = 0.014], respectively). Chairs had more publications and were more likely to be professors than PDs. PDs were more likely to remain at both the same region and institution that they trained in residency. The most common subspecialty was sports among chairs and trauma among PDs, although when compared with national averages orthopaedic trauma and orthopaedic oncology were the most overrepresented subspecialties.

CONCLUSION

Orthopaedic chairs are more likely to be men, have had longer careers, and have more academic accomplishments than their PD counterparts. Geography appears to have an association with where our leaders end up, especially for PDs. Subspecialization does not notably influence leadership positions, although orthopaedic trauma and orthopaedic oncology surgeons are more commonly represented than expected. This report serves to identify the current state of orthopaedic leadership and may provide guidance for those who seek these leadership positions.

Residents Think in the "Now" and Supervisors Think Ahead in the Operating Room. A Survey Study About Task Perception of Residents and Supervising Surgeons

OBJECTIVE

Progressive autonomous task performance is the cornerstone of teaching residents in the operating room, where they are entrusted with autonomy when they meet their supervisors' preferences. To optimize the teaching, supervisors need to be aware of how residents experience parts of the procedure. This study provides insight into how supervisors and residents perceive different tasks of a single surgical procedure.

DESIGN

In this qualitative survey study a cognitive task analysis (CTA) of supervisors and residents for the 47 tasks of an uncemented total hip arthroplasty was executed. Both groups rated the level of attention they would assign to each task and were asked to explain attention scores of 4 or 5.

SETTING

University Medical Centre Groningen (the Netherlands) and its 5 affiliated teaching hospitals.

PARTICIPANTS

Seventeen supervising surgeons and 21 residents.

RESULTS

Normal attention (median attention score 3) was assigned by supervisors to 34 tasks (72.3%) and by residents to 35 tasks (74.5 %). Supervisors rated 12 tasks (25.6%) and residents 9 tasks (19.1%) with a median attention score of 4. In general, supervisors associated high attention with patient outcome and prevention of complications, while residents associated high attention with "effort."

CONCLUSIONS

Supervisors and residents assigned attention to tasks for different reasons. Supervisors think ahead and emphasize patient outcome and prevention of complications when they indicate high attention, while residents think in the "now" and raise attention to execute the tasks themselves. The results of this study allow residents and supervisors to anticipate preferences: residents are able to appreciate why supervisors increase attention to specific tasks, and supervisors obtain information on which tasks require individual guidance of residents. This information can contribute to improve the learning climate in the operating room and task-specific procedural training.

Does Increased Schedule Flexibility Lead to Change? A National Survey of Program Directors on 2017 Work Hours Requirements

BACKGROUND

The learning and working environment for resident physicians shifted dramatically over the past two decades, with increased focus on work hours, resident wellness, and patient safety. Following two multi-center randomized trials comparing 16-h work limits for PGY-1 trainees to more flexible rules, the ACGME implemented new flexible work hours standards in 2017.

OBJECTIVE

We sought to determine program directors' (PDs) support for the work hour changes and programmatic response.

DESIGN

In 2017, US Internal Medicine PDs were surveyed about their degree of support for extension of PGY-1 work hour limits, whether they adopted the new maximum continuous work hours permitted, and reasons for their decisions.

KEY RESULTS

The response rate was 70% (266/379). Fifty-seven percent of PDs (n = 151) somewhat/strongly support the new work hour rules for PGY-1 residents, while only 25% of programs (N = 66) introduced work periods greater than 16-h on any rotation. Higher rates of adopting change were seen in PDs who strongly/somewhat supported the change (56/151 [37%], P < 0.001), had tenure of 6+ years (33/93 [35%], P = 0.005), were of non-general internal medicine subspecialty (30/80 [38%], P = 0.003), at university-based programs (35/101 [35%], P = 0.009), and with increasing number of approved positions (< 38, 10/63 [16%]; 38-58, 13/69 [19%]; 59-100, 15/64 [23%]; > 100, 28/68 [41%], P = 0.005). Areas with the greatest influence for PDs not extending work hours were the 16-h rule working well (56%) and risk to PGY1 well-being (47%).

CONCLUSIONS

Although the majority of PDs support the ACGME 2017 work hours rules, only 25% of programs made immediate changes to extend hours. These data reveal that complex, often competing, forces influence PDs' decisions to change trainee schedules.

The Role of High School Football Coverage in Resident Education

Athletic team coverage experience varies widely across orthopedic surgery residency programs in the United States. There is a paucity of literature regarding whether serving as a team physician contributes to resident education and whether it can be performed within the bounds of current work-hour restrictions. Residents consider coverage of high school football games a valuable educational experience that does not adversely affect their 80-hour work week. Sixty-one orthopedic residents who served as high school football team physicians as part of their residency curriculum completed an 11-question survey. Responses ranged from strongly agree (1) to strongly disagree (5) on a Likert scale. The majority of residents agreed that serving as a team physician was an overall valuable experience (85%), that it enhanced their orthopedic sports medicine education (89%), and that it increased their awareness of the role played by athletic trainers (97%). The majority of respondents disagreed only with the statement that serving as a team physician had negatively affected their 80-hour work week (54%), and an additional 26% neither agreed nor disagreed. The vast majority of participating orthopedic residents consider high school football team coverage a valuable experience that enhances education and can be performed within work-hour limitations. [Orthopedics. 2020;43(6):e574-e578.].

Duty Hour Reform and the Outcomes of Patients Treated by New Surgeons

OBJECTIVE

The aim of the study was to address the controversy surrounding the effects of duty hour reform on new surgeon performance, we analyzed patients treated by new surgeons following the transition to independent practice.

SUMMARY BACKGROUND DATA

In 2003, duty hour reform affected all US surgical training programs. Its impact on the performance of new surgeons remains unstudied.

METHODS

We studied 30-day mortality among 1,483,074 Medicare beneficiaries undergoing general and orthopedic operations between 1999 and 2003 ("traditional" era) and 2009 and 2013 ("modern" era). The operations were performed by 2762 new surgeons trained before the reform, 2119 new surgeons trained following reform and 15,041 experienced surgeons. We used a difference-in-differences analysis comparing outcomes in matched patients treated by new versus experienced surgeons within each era, controlling for the hospital, operation, and patient risk factors.

RESULTS

Traditional era odds of 30-day mortality among matched patients treated by new versus experienced surgeons were significantly elevated [odds ratio (OR) 1.13; 95% confidence interval (CI) (1.05, 1.22), P < 0.001). The modern era elevated odds of mortality were not significant [OR 1.06; 95% CI (0.97-1.16), P = 0.239]. Relative performance of new and experienced surgeons with respect to 30-day mortality did not appear to change from the traditional era to the modern era [OR 0.93; 95% CI (0.83-1.05), P = 0.233]. There were statistically significant adverse changes over time in relative performance to experienced surgeons in prolonged length of stay [OR 1.08; 95% CI (1.02-1.15), P = 0.015], anesthesia time [9 min; 95% CI (8-10), P < 0.001], and costs [255USD; 95% CI (2-508), P = 0.049].

CONCLUSIONS

Duty hour reform showed no significant effect on 30-day mortality achieved by new surgeons compared to their more experienced colleagues. Patients of new surgeons, however, trained after duty hour reform displayed some increases in the resources needed for their care.

Validation of a novel hip arthroscopy simulator: establishing construct validity

Hip arthroscopy (HA) is technically demanding and associated with a prolonged learning curve. Recently, arthroscopic simulators have been developed to anatomically model various joints including the knee, shoulder and hip. The purpose of this study is to validate a novel HA simulator. Twenty trainees and one sports medicine fellowship-trained orthopaedic surgeon at a single academic institution were recruited to perform a diagnostic HA procedure using the VirtaMed ArthroS hip simulator. Trainee characteristics, including level of training, general arthroscopy experience and hip specific arthroscopy experience, were gathered via questionnaire. For the purpose of this study, participants were categorized as novice (<25), intermediate (25–74) or experienced (≥75) based on the number of prior arthroscopies performed. Various performance metrics, including composite score, time and camera path length were recorded for each attempt. Metrics were analyzed categorically using ANOVA tests with significance set to P < 0.05. Composite performance score in the novice cohort was 114.5 compared with 146.4 and 151.5 in the intermediate and experienced cohorts (P = 0.0019), respectively. Novice arthroscopists performed the simulated diagnostic arthroscopy procedure in an average time of 321 s compared with 202 s and 181 s in the intermediate and experienced cohorts (P < 0.002), respectively. Cartilage damage and simulator safety score did not differ significantly between groups (P = 0.775). Simulator composite score and procedure time showed strong correlation with year of training (r = 0.65 and −0.70, respectively) and number of arthroscopies performed (r = 0.65 and −0.72). The ArthroS hip simulator shows good construct validity and performance correlates highly with total number of arthroscopic cases reported during training.

Early Practice Patterns of Hand Surgeons: An American Board of Orthopaedic Surgery Database Study

PURPOSE

To investigate the variety of cases that are performed by newly graduated fellowship-trained orthopedic hand surgeons.

METHODS

All cases submitted by board-eligible orthopedic surgeons taking part II of their board examination between 2004 and 2013 were obtained from the database of the American Board of Orthopaedic Surgery (ABOS). Each case was then categorized based on the fellowship training of the treating surgeon and whether it was a hand surgery case. Each hand surgery case was then further categorized into 1 of the 8 surgical categories used by the ABOS to determine eligibility for the Subspecialty Certificate in Orthopaedic Surgery of the Hand (SCOSH).

RESULTS

During our study period, 6,854 orthopedic surgeons submitted 858,146 cases to the ABOS. Fellowship-trained hand surgeons made up 13% of all surgeons, and 24% of all submitted cases were hand surgery cases. Based on the cases submitted, 44% of hand surgeons were not on track to become eligible for the SCOSH. The most common reason for not reaching eligibility was failure to meet the minimum requirements in 1 of either the congenital, the skin and wound problems, the contracture and joint stiffness, the microvascular, or the tumor categories.

CONCLUSIONS

A large proportion of fellowship-trained orthopedic hand surgeons are not on track to meet the minimum eligibility requirements for the ABOS SCOSH during their part II case collections. Their case profile is not sufficiently diverse to be considered an active hand surgery practice for the purpose of SCOSH eligibility.

CLINICAL RELEVANCE

This study highlights 1 possible reason why over one-third of young hand surgeons do not obtain their subspecialty certification.

Generational Differences in Grit, Self-Control, and Conscientiousness Among Orthopaedic Surgeons: From Millennials to Baby Boomers

BACKGROUND

The training process and practice of orthopaedic surgery is demanding and arduous. Accordingly, grit, self-control, and conscientiousness are desirable qualities in orthopaedic surgeons. Some established orthopaedists have expressed concern that the future generation of surgeons may not possess the same level of grit as their predecessors. The purpose of this study was to evaluate levels of grit among attending orthopaedic surgeons, identify predictors of grit in orthopaedic surgeons, and compare grit scores between attending surgeons and orthopaedic residency applicants. We hypothesized that applicants would demonstrate lower grit and self-control scores but greater conscientiousness scores than attending surgeons.

METHODS

A total of 2,342 attending orthopaedic surgeons and 895 orthopaedic residency applicants from the 2016-2017 National Resident Matching Program (NRMP) were given surveys that quantified their grit, self-control, and conscientiousness. Demographic and career information also was collected.

RESULTS

Assessments were completed by 655 (28%) of 2,342 practicing orthopaedic surgeons and 455 (50.8%) of 895 orthopaedic residency applicants. The residency applicants demonstrated higher mean grit scores (4.12 of 5.0) than the attending orthopaedic surgeons (4.03) (p < 0.01). These average scores placed applicants and attending surgeons at the 70th and 65th percentile, respectively, when compared with the general population. There were no differences in self-control (p = 0.68) or conscientiousness (p = 0.93) between the 2 groups. Attending surgeons with more publications had increased grit (p < 0.01), self-control (p = 0.04), and conscientiousness (p = 0.01) scores. Attending surgeons who had been inducted into the Alpha Omega Alpha honor society as medical students demonstrated greater conscientiousness scores than those who were not members (p = 0.04).

CONCLUSIONS

Orthopaedic residency applicants were at least as gritty, consistent in their interest, persevering in their efforts, and ambitious as currently practicing orthopaedic surgeons. Although these results may be encouraging and diverge from some preconceived perceptions of "millennials," it is unclear if they will be predictive of career success in the next generation of orthopaedists.

Recruiting expertise: how surgical trainees engage supervisors for learning in the operating room

CONTEXT

For centuries now, the operating room (OR) has been the environment in which surgical trainees come to master procedures. Restricted working hours and insufficient levels of autonomy at the end of their training necessitate a shift towards alternative effective learning strategies. Self-regulated learning is a promising strategy by which surgical trainees can learn more with fewer exposures. However, the challenge is to understand how surgical trainees regulate their learning in the clinical context of the OR.

OBJECTIVES

The purpose of this study is to identify and understand the strategies of surgical trainees in engaging their supervisors for learning purposes and how these strategies contribute to effective learning.

METHODS

Total hip replacement procedures performed by four surgical trainees and their supervisors were videotaped. Using the iterative inductive process of conversation analysis, each verbal initiative to engage the supervisor was identified, analysed ('why that now') and categorised.

RESULTS

Surgical trainees used a range of practices to engage supervisors and recruit expertise, ranging from explicit recruitment to implicit hints. We identified four major categories. Surgical trainees: (i) invite the supervisor to provide an evaluation of the ongoing task; (ii) express an evaluation of the ongoing task and then explicitly invite the supervisor to provide an evaluation; (iii) express an evaluation of the ongoing task and then invite the supervisor to provide confirmation, and (iv) express an evaluation of the ongoing task without engaging the supervisor.

CONCLUSIONS

Surgical trainees recruit expertise from supervisors using practices of four different categories. Trainees' actions are provoked by the moment at which they experience insufficient expertise and are focused on the task at hand in the immediate present. Supervisors can and do elaborate on these requests to provide explicit teaching. Insight into these practices provides tools for reflection on OR learning, proficiency assessment and deliberation to adapt guidance in the real time of the procedure.

The Role of Athletic Event Coverage in Orthopaedic Residency Training: A National Survey of Residency Program Directors

INTRODUCTION

No Accreditation Council for Graduate Medical Education guidelines exist regarding athletic event coverage by orthopaedic residents. This study assesses the availability and characteristics of event coverage opportunities in residency programs.

METHODS

An anonymous web-based survey assessing resident athletic event coverage opportunities was distributed to members (n = 158) of the American Orthopaedic Association's Council of Orthopaedic Residency Directors.

RESULTS

The survey response rate was 39% (n = 62). Most of the programs (76%) offer athletic event coverage opportunities for residents, most (54%) of which are optional. Of the programs with coverage opportunities, 34 (74%) have a teaching curriculum and 10 (22%) report that residents are always under the direct supervision of an attending orthopaedic surgeon. Thirty programs (64%) count the time spent at athletic events toward duty hours.

DISCUSSION

A comprehensive and uniform resident experience for athletic event coverage does not exist. This finding may represent an area of deficiency in orthopaedic training requiring enhanced national standards.

Efficacy of a Virtual Arthroscopic Simulator for Orthopaedic Surgery Residents by Year in Training

BACKGROUND

Virtual reality arthroscopic simulators are an attractive option for resident training and are increasingly used across training programs. However, no study has analyzed the utility of simulators for trainees based on their level of training/postgraduate year (PGY).

PURPOSE/HYPOTHESIS

The primary aim of this study was to determine the utility of the ArthroS arthroscopic simulator for orthopaedic trainees based on their level of training. We hypothesized that residents at all levels would show similar improvements in performance after completion of the training modules.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Eighteen orthopaedic surgery residents performed diagnostic knee and shoulder tasks on the ArthroS simulator. Participants completed a series of training modules and then repeated the diagnostic tasks. Correlation coefficients (r 2) were calculated for improvements in the mean composite score (based on the Imperial Global Arthroscopy Rating Scale [IGARS]) as a function of PGY.

RESULTS

The mean improvement in the composite score for participants as a whole was 11.2 ± 10.0 points (P = .0003) for the knee simulator and 14.9 ± 10.9 points (P = .0352) for the shoulder simulator. When broken down by PGY, all groups showed improvement, with greater improvements seen for junior-level residents in the knee simulator and greater improvements seen for senior-level residents in the shoulder simulator. Analysis of variance for the score improvement variable among the different PGY groups yielded an f value of 1.640 (P = .2258) for the knee simulator data and an f value of 0.2292 (P = .917) for the shoulder simulator data. The correlation coefficient (r 2) was -0.866 for the knee score improvement and 0.887 for the shoulder score improvement.

CONCLUSION

Residents training on a virtual arthroscopic simulator made significant improvements in both knee and shoulder arthroscopic surgery skills.

CLINICAL RELEVANCE

The current study adds to mounting evidence supporting virtual arthroscopic simulator-based training for orthopaedic residents. Most significantly, this study also provides a baseline for evidence-based targeted use of arthroscopic simulators based on resident training level.

Progressive Autonomy in the Era of Increased Supervision: AOA Critical Issues

The observation of decreased resident autonomy, ultimately influencing the readiness of a new graduate to practice, has been supported with a number of recent surveys. This perceived lack of autonomy is felt to be due, in part, to many reasons, including duty-hour regulations, increased supervision requirements, patient safety measures, concern for complication rates, and other performance measures. Pressure on faculty members to have increased clinical productivity may not allow for more resident autonomy.Increased clinical exposure to improve resident independence may come from several suggested areas. First, restructuring the residency program to allow for more clinical time may be one way to improve education. Second, increased use of surgical simulation will allow for more experience to develop technical skills within a controlled environment. Surgical simulators can be used to acquire new skills and also as a means of assessing competence. Third, competency-based education (CBE) has been offered as a way to improve resident education. At its core, CBE offers criterion-based assessments for residents and faculty that allow for more frequent feedback.

An Analysis of Orthopaedic Job Trends in the United States Over the Past 30 years

Introduction:

Orthopaedic surgery residency training requires 5 clinical years; fellowship subspecialty training requires an additional year. Orthopaedic surgery fellowship training has financial implications regarding potential career earnings and opportunity cost. To evaluate the effect of fellowship training on employment, 30 years of orthopaedic job advertisements were analyzed to determine fellowship requirements for academic centers, private practices, urban areas, and rural areas. It was hypothesized that subspecialty training is an important prerequisite for orthopaedic employment.

Methods:

Job advertisements in the Journal of Bone and Joint Surgery (JBJS Am) and Orthopedics were analyzed to determine whether fellowship training versus “generalist” (no subspecialty fellowship) positions were advertised for the years 1984, 1989, 1994, 1999, 2004, 2009, and 2014. Jobs were categorized as academic (defined by the requirement to teach medical students, residents, or fellows); private practice; rural (defined as population under 200,000); and urban. “General” orthopaedic surgery job postings were defined as job advertisements that did not require fellowship training.

Results:

A total of 4,720 job advertisements were analyzed. From 1984 to 2014, the percentage of advertised jobs requiring fellowship training increased from 5% to 68% (P < 0.05). Conversely, from 1984 to 2014, the percentage of advertised jobs targeting general orthopaedic surgeons decreased from 95% to 32% (P < 0.05). Between 2009 and 2014, advertised jobs requiring fellowship surpassed general orthopaedic surgery jobs.

Conclusions:

Over the past 30 years, there was a trend toward fellowship being required as part of the advertised orthopaedic jobs available to graduates of orthopaedic training programs. The reasons for increased orthopaedic training are likely multifactorial, including limited clinical duty hours during orthopaedic residency, advertisement and marketing forces emphasizing super-sub-specialty care in multispecialty orthopaedic groups, and the greater complexity of orthopaedic procedures being performed.

Outcomes in the Orthopaedic Sports Medicine Fellowship Match, 2010-2017

Background:

Sports medicine is one of the most competitive fellowships in orthopaedic surgery. Despite its popularity, fellowship applicants have limited understanding of the orthopaedic sports medicine fellowship match process.

Purpose:

To define key outcomes in the orthopaedic sports medicine fellowship match, including the overall match rate, number of programs filled, and number of applicants ranked by programs that filled between 2010 and 2017.

Study Design:

Cross-sectional study.

Methods:

This study utilized data regarding the orthopaedic sports medicine fellowship match collected by the American Orthopaedic Society for Sports Medicine (AOSSM) from 2010 through 2017. Applicant data included number of applicants, number of matched and unmatched applicants, and percentage of applicants matching into their top choices. Fellowship program data included number of programs participating in the match and number of applicants ranked by filled and unfilled programs.

Results:

Between 2010 and 2017, the mean number of orthopaedic sports medicine fellowship applicants was 244.8. On average, 92.0% of applicants matched into a fellowship program. The mean number of programs participating in the fellowship match was 92.9, with a mean of 219.9 accredited positions and 5.4 nonaccredited positions. Over the time period studied, a mean of 75.8% of programs matched all available positions. Programs that matched fully ranked 9.0 applicants per position, on average, compared with a mean of 6.5 applicants ranked per position among programs that did not fully match (P = .0016).

Conclusion:

From 2010 to 2017, the number of applicants, positions available, overall match rate, and number of programs participating in the orthopaedic sports medicine fellowship match have remained consistent. The mean number of applicants per position ranked by fully matched fellowship programs was 9.0 compared with a mean of 6.5 applicants per position ranked by programs that did not fully match. These data may be helpful as we look to the future of orthopaedic sports medicine fellowship positions and the match process. In addition, this study reveals characteristics that divide sports medicine fellowship programs that fully match from those that do not. Applicants and/or fellowship program directors may utilize this information to modify their approach to the match process going forward.

Progressive Surgical Autonomy Observed in a Hand Surgery Resident Clinic Model

OBJECTIVE

Resident clinics (RCs) are intended to catalyze the achievement of educational milestones through progressively autonomous patient care. However, few studies quantify their effect on competency-based surgical education, and no previous publications focus on hand surgery RCs (HRCs). We demonstrate the achievement of progressive surgical autonomy in an HRC model.

DESIGN

A retrospective review of all patients seen in a weekly half-day HRC from October 2010 to October 2015 was conducted. Investigators compiled data on patient demographics, provider encounters, operational statistics, operative details, and dictated surgical autonomy on an ascending 5 point scoring system.

SETTING

A tertiary hand surgery referral center.

RESULTS

A total of 2295 HRC patients were evaluated during the study period in 5173 clinic visits. There was an average of 22.6 patients per clinic, including 9.0 new patients with 6.5 emergency room referrals. Totally, 825 operations were performed by 39 residents. Trainee autonomy averaged 2.1/5 (standard deviation [SD] = 1.2), 3.4/5 (SD = 1.3), 2.1/5 (SD = 1.3), 3.4/5 (SD = 1.2), 3.2/5 (SD = 1.5), 3.5/5 (SD = 1.5), 4.0/5 (SD = 1.2), 4.1/5 (SD = 1.2), in postgraduate years 1 to 8, respectively. Linear mixed model analysis demonstrated training level significantly effected operative autonomy (p = 0.0001). Continuity of care was maintained in 79.3% of cases, and patients were followed an average of 3.9 clinic encounters over 12.4 weeks.

CONCLUSIONS

Our HRC appears to enable surgical trainees to practice supervised autonomous surgical care and provide a forum in which to observe progressive operative competency achievement during hand surgery training. Future studies comparing HRC models to non-RC models will be required to further define quality-of-care delivery within RCs.

Canadian Plastic Surgery Resident Work Hour Restrictions: Practices and Perceptions of Residents and Program Directors

Background

The impact of resident work hour restrictions on training and patient care remains a highly controversial topic, and to date, there lacks a formal assessment as it pertains to Canadian plastic surgery residents.

Objective

To characterize the work hour profile of Canadian plastic surgery residents and assess the perspectives of residents and program directors regarding work hour restrictions related to surgical competency, resident wellness, and patient safety.

Methods

An anonymous online survey developed by the authors was sent to all Canadian plastic surgery residents and program directors. Basic summary statistics were calculated.

Results

Eighty (53%) residents and 10 (77%) program directors responded. Residents reported working an average of 73 hours in hospital per week with 8 call shifts per month and sleep 4.7 hours/night while on call. Most residents (88%) reported averaging 0 post-call days off per month and 61% will work post-call without any sleep. The majority want the option of working post-call (63%) and oppose an 80-hour weekly maximum (77%). Surgical and medical errors attributed to post-call fatigue were self-reported by 26% and 49% of residents, respectively. Residents and program directors expressed concern about the ability to master surgical skills without working post-call.

Conclusions

The majority of respondents oppose duty hour restrictions. The reason is likely multifactorial, including the desire of residents to meet perceived expectations and to master their surgical skills while supervised. If duty hour restrictions are aggressively implemented, many respondents feel that an increased duration of training may be necessary.

Residents and Program Director Perspectives Often Differ on Optimal Preparation Strategies and the Value of the Orthopedic In-Training Examination

OBJECTIVES

The purpose of this work was to compare resident and program director (PD) perspectives on the value of the Orthopaedic In-Training Examination (OITE), resident study habits, and best resources for optimal performance.

DESIGN

A national survey of orthopedic surgery residents and PDs.

SETTING

Mayo Clinic, Rochester, MN PARTICIPANTS: The survey was completed by 445 (41.5%) eligible orthopedic surgery residents and 37 (77.1%) PDs.

RESULTS

Although residents and PDs agreed on when (p = 0.896) and how much (p = 0.171) residents currently study, residents felt that the OITE was not as valuable of an assessment of their knowledge, and also felt their individual scores were less likely to remain confidential compared to PDs (p < 0.001). The mean OITE score below which residents were concerned about their ability to pass American Board of Orthopaedic Surgeons Part 1 was 9.7 percentile points higher than PDs threshold (42.3% vs. 32.6%, respectively, p = 0.003). Both groups agreed that it is important to dedicate focused study time to the OITE (p = 0.680) and to perform well (p = 0.099). Regarding the best resources and preparation strategies, both residents and PDs tended to agree on the value of most (6 of 10) study methods. Residents ranked practice question websites (mean ranking of 2.6 vs. 3.8 of 10, respectively; p < 0.001) and formal rotations in a subspecialty (6.0 vs. 7.7 respectively, p < 0.001) higher than PDs. In contrast, PDs tended to value their program's formal OITE prep program (4.1. vs. 5.3, respectively, p = 0.012) and reading primary literature (5.6 vs. 6.6, respectively, p = 0.012) more than residents.

CONCLUSION

Residents and PDs agreed on many critical components of this process; however, a number of key differences in perspectives exist.

Orthopedic In-Training Examination: A Performance Review Based on Program- and Resident-Specific Characteristics

OBJECTIVES

The orthopedic in-training examination (OITE) is the most common and objective method used to assess resident knowledge in the United States. As such, residents and programs use a number of strategies to maximize OITE performance. The purpose of this work was to better understand what strategies were being implemented and to determine which program-specific and resident-specific characteristics best correlate with improved scores.

DESIGN

A national survey of orthopedic residents and program directors (PDs) was performed to better understand OITE performance and correlate scores with various test preparation strategies.

SETTING

Mayo Clinic, Rochester, MN.

PARTICIPANTS

The survey was completed by 33 of 48 (68.8%) PDs and 341 of 878 (38.8%) eligible residents.

RESULTS

The most commonly used program-wide strategies were as follows: negative consequences for poor performance (72.7%), formal OITE prep program (54.5%), and purchase of OITE test prep material for residents (51.5%). The program-specific characteristics that had the strongest correlation with increased scores were negative consequences for poor performance (p < 0.001), high value placed on the OITE by PD and residents (p < 0.001), excusing residents from clinical duties the evening prior (p < 0.001), having residents take the examination on different days (p = 0.012), and allowing residents to lead a review course (p = 0.047). The resident-specific characteristics that correlated most with score were increased study time leading up to the test (p = 0.031) and attendance at their program's OITE prep program (p = 0.062).

CONCLUSIONS

Although programs and residents looking to improve knowledge acquisition and OITE scores use a number of techniques, a few distinct strategies correlate with the greatest increases in OITE performance. These may be appropriate methods to consider for those looking to improve their performance in coming years.

Resident Physician Duty-hour Requirements: What Does the Public Think?

INTRODUCTION

To date, no study has reported on the public's opinion of orthopaedic resident duty-hour requirements (DHR).

METHODS

A survey was administered to people in orthopaedic waiting rooms and at three senior centers. Responses were analyzed to evaluate seven domains: knowledge of duty hours; opinions about duty hours; attitudes regarding shift work; patient safety concerns; and the effects of DHRs on continuity of care, on resident training, and on resident professionalism.

RESULTS

Respondents felt that fatigue was unsafe and duty hours were beneficial in preventing resident physician fatigue. They supported the idea of residents working in shifts but did not support shifts for attending physicians. However, respondents wanted the same resident to provide continuity of care, even if that violated DHRs. They were supportive of increasing the length of residency to complete training. DHRs were not believed to affect professionalism. Half of the respondents believed that patient opinion should influence policy on this topic.

DISCUSSION

Orthopaedic patients and those likely to require orthopaedic care have inconsistent opinions regarding DHRs, making it potentially difficult to incorporate their preferences into policy.

The Cost of Getting Into Orthopedic Residency: Analysis of Applicant Demographics, Expenditures, and the Value of Away Rotations

OBJECTIVES

Little is known about the demographics and expenditures of applicants attempting to match into the competitive field of orthopedic surgery. In attempt to better inform potential applicants, the purposes of this work are to (1) better understand the demographics of successfully matched applicants, (2) determine the monetary cost of applying, and (3) assess the value of away rotations for improving chances of a successful match.

DESIGN

Prospective comparative survey.

SETTING

Mayo Clinic Department of Orthopedic Surgery, Rochester, MN.

PARTICIPANTS

A week following the 2015 Orthopedic Surgery Residency Match, a survey was sent to 1,091. The survey focused on applicant demographics, number of programs applied to, cost of applying, and the value of away rotations.

RESULTS

A total of 408 applicants completed the survey (response rate = 37%). Of these, 312 (76%) matched and 96 (24%) did not match into a US Orthopedic Surgery Residency. Of the matched applicants, 300 (96%) were from US allopathic medical schools, 9 (3%) US Osteopathic Schools, and 3 (1%) were international graduates. Males comprised 84% of these applicants whereas 16% were female. The mean number of programs applied to was 71 (range: 20-140). On average, applicants were offered 16 interviews (range: 1-53) and they attended 11 (range: 0-12). Completing a rotation at a program increased an applicant׳s chances of matching into that program by a factor of 1.5 (60% vs 40%). Of the applicants who matched, most applicants matched to an orthopedic residency in the same region where the applicant attended medical school (58%). The average cost of the application was $1,664 (range: $100-$5,000) whereas the cost of interviews (travel, food, etc.) was $3,656 (range: $15-$20,000). Total expenditures ranged from $450 to $25,000 (mean = $5,415). Over 8% of matched applicants spent >$10,000.

CONCLUSIONS

Gaining acceptance into orthopedic surgery residency remains a very competitive process. Away rotations appear to correlate strongly with match status; however, the process remains quite expensive for applicants.

Unprofessional Behaviors Among Tomorrow's Physicians: Review of the Literature With a Focus on Risk Factors, Temporal Trends, and Future Directions

PURPOSE

Recent reports have identified concerning patterns of unprofessional and dishonest behavior by physician trainees. Despite this publicity, the prevalence and impact of these behaviors is not well described; thus, the authors aimed to review and analyze the various studies on unprofessional behavior among U.S. medical trainees.

METHOD

The authors performed a literature review. They sought all reports on unprofessional and dishonest behavior among U.S. medical school students or resident physicians published in English and indexed in PubMed between January 1980 and May 2014.

RESULTS

A total of 51 publications met criteria for inclusion in the study. The data in these reports suggest that plagiarism, cheating on examinations, and listing fraudulent publications on residency/fellowship applications were reported in 5% to 15% of the student and resident populations that were studied. Other behaviors, such as inaccurately reporting that a medical examination was performed on a patient or falsifying duty hours, appear to be even more common (reportedly occurring among 40% to 50% of students and residents).

CONCLUSIONS

"Unprofessional behavior" lacks a unified definition. The data on the prevalence of unprofessional behavior in medical students and residents are limited. Unprofessional behaviors are common and appear to be occurring in various demographic groups within the medical trainee population. The relationship between unprofessional behaviors in training and future disciplinary action is poorly understood. Going forward, defining "unprofessional behavior"; developing validated instruments to evaluate such behaviors scientifically; and studying their incidence, motivations, and consequences are critical.

Orthopaedic Surgery Residents and Program Directors Agree on How Time Is Currently Spent in Training and Targets for Improvement

BACKGROUND

Although much attention has been paid to the role of deliberate practice as a means of achieving expert levels of performance in other medical specialties, little has been published regarding its role in maximizing orthopaedic surgery resident potential. As an initial step in this process, this study seeks to determine how residents and program directors (PDs) feel current time spent in training is allocated compared with a theoretical ideal distribution of time.

QUESTIONS/PURPOSES

According to residents and PDs, (1) how do resident responsibilities change by level of training as perceived and idealized by residents and PDs? (2) How do resident and PD perceptions of current and ideal time distributions compare with one another? (3) Do the current training structures described by residents and PDs differ from what they feel represents an ideal time allocation construct that maximizes the educational value of residency training?

METHODS

A survey was sent to orthopaedic surgery resident and PD members of the Midwest Orthopedic Surgical Skills Consortium asking how they felt residents' time spent in training was distributed across 10 domains and four operating room (OR) roles and what they felt would be an ideal distribution of that time. Responses were compared between residents and PDs and between current schedules and ideal schedules.

RESULTS

Both residents and PDs agreed that time currently spent in training differs by postgraduate year with senior-level residents spending more time in the OR (33.7% ± 8.3% versus 17.9% ± 6.2% [interns] and 27.4% ± 10.2% [juniors] according to residents, p < 0.001; and 38.6% ± 8.1% versus 11.8% ± 6.4% [interns] and 26.1% ± 5.7% [juniors] according to PD, p < 0.001). The same holds true for their theoretical ideals. Residents and PDs agree on current resident time allocation across the 10 domains; however, they disagree on multiple components of the ideal program with residents desiring more time spent in the OR than what PDs prefer (residents 40.3% ± 10.3% versus PD 32.6% ± 14.6% [mean difference {MD}, 7.7; 95% confidence interval {CI}, 4.4, 11.0], p < 0.001). Residents would also prefer to have more time spent deliberately practicing surgical skills outside of the OR (current 1.8% ± 2.1% versus ideal 3.7% ± 3.2% [MD, -1.9; 95% CI, -.2.4 to -1.4], p < 0.001). Both residents and PDs want residents to spend less time completing paperwork (current 4.4% ± 4.1% versus ideal 0.8% ± 1.6% [MD, 3.6; 95% CI, 3.0-4.2], p < 0.001 for residents; and current 3.6% ± 4.1% versus ideal 1.5% ± 1.9% [MD, 2.1; 95% CI, 0.9-3.3], p < 0.001 for PDs).

CONCLUSIONS

Residents and PDs seem to agree on how time is currently spent in residency training. Some differences of opinions continue to exist regarding how an ideal program should be structured; however, this work identifies a few potential targets for improvement that are agreed on by both residents and PDs. These areas include increasing OR time, finding opportunities for deliberate practice of surgical skills outside of the OR, and decreased clerical burden. This study may serve as a template to allow programs to continue to refine their educational models in an effort to achieve curricula that meet the desired goals of both learners and educators. Additionally, it is an initial step toward more objective identification of the optimal educational structure of an orthopaedic residency program.

Orthopedic Residency: Are Duty Hours Predictive of Performance?

OBJECTIVE

This study examines the relationship between self-recorded resident work hours and Orthopedic In-training Examination (OITE) scores, resident clinical performance, and American Board of Orthopedic Surgery pass rates. The hypothesis of this study is that increasing duty hours would have a positive correlation with clinical and OITE performance.

DESIGN

Total duty hours and recorded operating room hours from a single orthopedic residency program were extracted from 2006 to 2012. During the same time span, OITE scores, resident clinical scores from the E-Valuation system, and American Board of Orthopedic Surgery pass rates were collected. The correlation between the variables was assessed using the Pearson correlation coefficient's precision statistic.

SETTING

A large public tertiary academic center in the upper Midwestern United States.

PARTICIPANTS

A total of 82 orthopedic surgery residents over 7 years.

RESULTS

A total of 82 residents were matriculated between 2006 and 2012. The average weekly recorded duty hours were as follows: postgraduate year 2 (PGY2) = 60 hours/week (Standard Deviation (SD) ± 4), PGY3 = 59 hours/week (SD ± 5), PGY4 = 51 hours/week (SD ± 4), PGY5 = 49 hours/week (SD ± 3). There was significant variability in the average number of hours worked among residents (range: 2128-3753h/y) for the full academic year. The OITE scores and the work hours were found to be independent of each other (ρ = 0.017, p = 0.825), and no correlation was found between OITE scores and the resident E-value scores (ρ = 0.071, p = 0.34). Residents spent 36% to 48% of their time in the operating room. Second year residents logging more hours scored higher on faculty evaluation of overall competency (ρ = 0.31, p = 0.035). Faculty assessment of technical skills had a positive correlation with operating room duty hours for PGY5 class (ρ = 0.346, p = 0.025).

CONCLUSIONS

A large variation in duty hours exists between resident-logged duty hours. No correlation exists between in-training scores and duty hours. There is a positive correlation between senior resident operating room hours and technical skill scores.

Evidence-based surgical training in orthopaedics: how many arthroscopies of the knee are needed to achieve consultant level performance?

Despite being one of the most common orthopaedic operations, it is still not known how many arthroscopies of the knee must be performed during training in order to develop the skills required to become a Consultant. A total of 54 subjects were divided into five groups according to clinical experience: Novices (n = 10), Junior trainees (n = 10), Registrars (n = 18), Fellows (n = 10) and Consultants (n = 6). After viewing an instructional presentation, each subject performed a simple diagnostic arthroscopy of the knee on a simulator with visualisation and probing of ten anatomical landmarks. Performance was assessed using a validated global rating scale (GRS). Comparisons were made against clinical experience measured by the number of arthroscopies which had been undertaken, and ROC curve analysis was used to determine the number of procedures needed to perform at the level of the Consultants. There were marked differences between the groups. There was significant improvement in performance with increasing experience (p < 0.05). ROC curve analysis identified that approximately 170 procedures were required to achieve the level of skills of a Consultant. We suggest that this approach to identify what represents the level of surgical skills of a Consultant should be used more widely so that standards of training are maintained through the development of an evidenced-based curriculum.

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

PURPOSE

The ACGME (US) and The European Working Time Directive (UK) placed work-hour restrictions on medical trainees with the goal of improved patient safety. However, there has been concern over a potential decrease in medical education. Orthopaedic training is the focus of this study. We examined previously published subjective and objective data regarding education and work-hour restrictions and developed the questions: Do specific perceptions emerge within the subjective studies examined? Are there objective differences in educational measures before and after work-hour restrictions? Is there a difference between the subjective and objective data?

METHODS

A systematic review was conducted via MedLine, regarding orthopaedic studies in the USA and UK, with reference to work-hour restrictions and education.

RESULTS

Subjective survey studies demonstrate that residents and attending physicians have a negative response to work-hour restrictions because of the perceived impact on their overall education and operating room experience. Conversely, limited objective studies demonstrated no change in operative volume before or after implementation of restrictions.

CONCLUSIONS

This review highlights the need for more objective studies on the educational implications of work-hour restrictions. Studies to date have not demonstrated a measurable difference based on case logs or training scores. Opinion-based surveys demonstrate an overall negative perception by both residents and attending physicians, on the impact of work-hour restrictions on orthopaedic education. Current published data is limited and stronger evidence-based data are needed before definitive conclusions can be reached.

What effects have resident work-hour changes had on education, quality of life, and safety? A systematic review

BACKGROUND

More than 15 years ago, the Institute of Medicine (IOM) identified medical error as a problem worthy of greater attention; in the wake of the IOM report, numerous changes were made to regulations to limit residents' duty hours. However, the effect of resident work-hour changes remains controversial within the field of orthopaedics.

QUESTIONS/PURPOSES

We performed a systematic review to determine whether work-hour restrictions have measurably influenced quality-of-life measures, operative and technical skill development, resident surgical education, patient care outcomes (including mortality, morbidity, adverse events, sentinel events, complications), and surgeon and resident attitudes (such as perceived effect on learning and training experiences, personal benefit, direct clinical experience, clinical preparedness).

METHODS

We performed a systematic review of PubMed, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Google Scholar using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were any English language peer-reviewed articles that analyzed the effect(s) of orthopaedic surgery resident work-hour restrictions on patient safety, resident education, resident/surgeon quality of life, resident technical operative skill development, and resident surgeon attitudes toward work-hour restrictions. Eleven studies met study inclusion criteria. One study was a prospective analysis, whereas 10 studies were of level IV evidence (review of surgical case logs) or survey results.

RESULTS

Within our identified studies, there was some support for improved resident quality of life, improved resident sleep and less fatigue, a perceived negative impact on surgical operative and technical skill, and conflicting evidence on the topic of resident education, patient outcomes, and variable attitudes toward the work-hour changes.

CONCLUSIONS

There is a paucity of high-level or clear evidence evaluating the effect of the changes to resident work hours. Future research in this area should focus on objective measures that include patient safety as a primary outcome.

Preparedness of Ob/Gyn residents for fellowship training in gynecologic oncology

Residency training in obstetrics and gynecology is being challenged by increasingly stringent regulations and decreased operative experience. We sought to determine the perception of preparedness of incoming gynecologic oncology fellows for advanced surgical training in gynecologic oncology. An online survey was sent to gynecologic oncologists involved in fellowship training in the United States. They were asked to evaluate their most recent incoming clinical fellows in the domains of professionalism, level of independence/graduated responsibility, psychomotor ability, clinical evaluation and management, and academia and scholarship using a standard Likert-style scale. The response rate among attending physicians was 40% (n = 105/260) and 61% (n = 28/46) for program directors. Of those who participated, 49% reported that their incoming fellows could not independently perform a hysterectomy, 59% reported that they could not independently perform 30 min of a major procedure, 40% reported that they could not control bleeding, 40% reported that they could not recognize anatomy and tissue planes, and 58% reported that they could not dissect tissue planes. Fellows lacked an understanding of pathophysiology, treatment recommendations, and the ability to identify and treat critically ill patients. In the academic domain, respondents agreed that fellows were deficient in the areas of protocol design (54%), statistical analysis (54%), and manuscript writing (65%). These results suggest that general Ob/Gyn residency is ineffective in preparing fellows for advanced training in gynecologic oncology and should prompt a revision of the goals and objectives of resident education to correct these deficiencies.

Impact of fellowship training on clinical practice of orthopaedic sports medicine

BACKGROUND

Approximately 90% of current orthopaedic graduates are engaging in fellowship training, with sports medicine being the most commonly chosen specialty. The purpose of this study was to evaluate the impact of fellowship training on clinical decision-making by fellowship-trained sports medicine surgeons.

METHODS

A survey was designed to assess the importance of fellowship on common clinical decisions made in the nonoperative and surgical treatment of knee, shoulder, and elbow disorders. The survey also included questions for the respondents on their comfort level with a variety of routine and complex surgical procedures. The survey was sent to alumni of 113 orthopaedic sports medicine programs across the United States.

RESULTS

Completed surveys were returned by 310 surgeons who had been in practice for an average of 9.0 years. They represented alumni of twenty-nine orthopaedic sports medicine fellowship programs across sixteen states. Fellowship was considered very important for surgical decision-making in the knee and shoulder. For nonoperative treatment, fellowship had a greater impact on shoulder disorders than on knee or elbow disorders. Fellowship was significantly more important than residency (p < 0.001) for determining preferred surgical equipment, implants, and braces. Among the surgical procedures assessed, respondents were least comfortable with the treatment of multi-ligamentous knee injuries, posterior cruciate ligament injuries, and shoulder instability with bone loss.

CONCLUSIONS

Fellowship has a significantly higher impact than residency on industry-related decision-making. Fellowship-trained sports surgeons should consider seeking additional training in the treatment of multi-ligamentous knee injuries, posterior cruciate ligament injuries, shoulder instability with bone loss, and elbow disorders. The current findings were limited by the relatively small respondent pool, which represented only 26% of sports medicine fellowship programs in the United States.

Medical school handoff education improves postgraduate trainee performance and confidence

OBJECTIVES

Determine postgraduate first-year (PGY-1) trainees ability to perform patient care handoffs and associated medical school training.

METHODS

About 173 incoming PGY-1 trainees completed an OSCE handoff station and a survey eliciting their training and confidence in conducting handoffs. Independent t-tests compared OSCE performance of trainees who reported receiving handoff training to those who had not. Analysis of variance examined differences in performance based on prior handoff instruction and across levels of self-assessed abilities, with significance set at p<0.05.

RESULTS

About 35% of trainees reported receiving instruction and 51% reported receiving feedback about their handoff performance in medical school. Mean handoff performance score was 69.5%. Trainees who received instruction or feedback during medical school had higher total and component handoff performance scores (p<0.05); they were also more confident in their handoff abilities (p<0.001). Trainees with higher self-assessed skills and preparedness performed better on the OSCE (p<0.05).

CONCLUSIONS

This study provides evidence that incoming trainees are not well prepared to perform handoffs. However, those who received instruction during medical school perform better and are more confident on standardized performance assessments. Given communication failures lead to uncertainty in patient care and increases in medical errors, medical schools should incorporate handoff training as required instruction.

The effect of resident duty-hours restrictions on internal medicine clerkship experiences: surveys of medical students and clerkship directors

PHENOMENON: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students' and clerkship directors' perceptions of the effects of the 2011 DHR on internal medicine clerkship students' experiences with teaching, feedback and evaluation, and patient care.

APPROACH

Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation.

FINDINGS

Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. INSIGHTS: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student-patient relationship and students' clinical skills acquisition.

Surgical training using three-dimensional simulation in placement of cervical lateral mass screws: a blinded randomized control trial

BACKGROUND CONTEXT

The skills and knowledge that residents have to master has increased, yet the amount of hours that the residents are allowed to work has been reduced. There is a strong need to improve training techniques to compensate for these changes. One approach is to use simulation-training methods to shorten the learning curve for surgeons in training.

PURPOSE

To analyze the effect of surgical training using three-dimensional (3D) simulation on the placement of lateral mass screws in the cervical spine on either cadavers or sawbones.

STUDY DESIGN

A blinded randomized control study.

METHODS

Fifteen orthopedic residents, postgraduate year (PGY) 1 to 6, were asked to simulate Magerl lateral mass screw trajectories from C3-C7 on cadavers using a navigated drill guide, but with no feedback as to the actual trajectory within the bone (Baseline 1). This was repeated to determine baseline accuracy (Baseline 2). They were then randomized into three groups: Group 1, control, did not receive any training, whereas Groups 2 and 3 received 3D navigational feedback as to the intended drill trajectory on sawbones and cadavers, respectively. All three groups then performed final simulated drilling (final test). All 3D images were deidentified and reviewed by a blinded single fellowship-trained orthopedic spine surgeon. Each image/screw was measured for the starting site, caudad/cephalad angle, and medial/lateral angle to determine trajectory accuracy.

RESULTS

The aggregate mean difference from a perfect screw was compiled for each session for each group. A negative difference shows improvement, whereas a positive difference shows regression. The difference between final test and Baseline 1 in the control group was 2.4°, suggesting regression. In contrast, the differences for groups sawbone and cadaver were -8.2° and -7.2°, respectively, suggesting improvement. When comparing the difference in aggregate sum angle for the sawbones and cadaver groups with the control group, the difference was statistically significant (p<.0001).

CONCLUSIONS

Training with 3D navigation significantly improved the ability of orthopedic residents to properly drill simulated lateral mass screws. As such, training with 3D navigation may be a useful adjunct in resident surgical education.

Resident duty hours: a survey of internal medicine program directors

INTRODUCTION

In 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented new Common Program Requirements to regulate duty hours of resident physicians, with three goals: improved patient safety, quality of resident education and quality of life for trainees. We sought to assess Internal Medicine program director (IMPD) perceptions of the 2011 Common Program Requirements in July 2012, one year following implementation of the new standards.

METHODS

A cross-sectional study of all IMPDs at ACGME-accredited programs in the United States (N = 381) was performed using a 32-question, self-administered survey. Contact information was identified for 323 IMPDs. Three individualized emails were sent to each director over a 6-week period, requesting participation in the survey. Outcomes measured included approval of duty hours regulations, as well as perceptions of changes in graduate medical education and patient care resulting from the revised ACGME standards.

RESULTS

A total of 237 surveys were returned (73% response rate). More than half of the IMPDs (52%) reported "overall" approval of the 2011 duty hour regulations, with greater than 70% approval of all individual regulations except senior resident daily duty periods (49% approval) and 16-hour intern shifts (17% approval). Although a majority feel resident quality of life has improved (55%), most IMPDs believe that resident education (60%) is worse. A minority report that quality (8%) or safety (11%) of patient care has improved.

CONCLUSION

One year after implementation of new ACGME duty hour requirements, IMPDs report overall approval of the standards, but strong disapproval of 16-hour shift limits for interns. Few program directors perceive that the duty hour restrictions have resulted in better care for patients or education of residents. Although resident quality of life seems improved, most IMPDs report that their own workload has increased. Based on these results, the intended benefits of duty hour regulations may not yet have been realized.

Developments and innovations in resident and fellowship education: review article

BACKGROUND

Medical trainee education has drastically changed over the past 30 years significantly since the inception of the Accreditation Council for Graduate Medical Education (ACGME) in 1981. With an emphasis on patient safety, regulations and oversight from the ACGME have drastically changed the way many programs function with respect to trainee responsibilities, duty hours, and resident supervision.

QUESTIONS/PURPOSES

The purpose of this review is to summarize significant changes and innovations implemented by the ACGME and their proposed effects on trainee education. While there is an emphasis on musculoskeletal radiology fellowship training, the majority of the regulations and guidelines are applicable to all training programs.

METHODS

Articles, commentaries, and policies focusing on ACGME requirements were reviewed, with a focus on musculoskeletal radiology.

RESULTS

Changes in ACGME policies have resulted in significant structural modifications in how training programs are designed, specifically with respect to curriculum standardization, measuring outcomes of trainee performance, and integration of residents and fellows into hospital-based quality improvement and patient safety initiatives.

CONCLUSION

With an eye to continued training program advancement and improvement, the goal of universal oversight and standardization in medical training remains to produce forward-thinking physicians with an emphasis on lifelong learning, patient care, and quality improvement.

ACGME Duty Hour Requirements: Perceptions and Impact on Resident Training and Patient Care

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) created national guidelines for resident work hours to promote safe care and high-quality learning. However, some reports suggested that the 2003 rules did not reduce resident fatigue or improve patient care. Since July 2011, further restrictions have been in effect. The changes have been the source of much controversy regarding their impact on resident education and patient safety. We reviewed existing literature on the effects of the new and old rules, with a focus on the field of orthopaedics. In addition, we conducted a national survey of orthopaedic residents and residency directors to assess the general opinions of the orthopaedic community. Overall, only 19.7% of all respondents were satisfied with the new 2011 regulations, whereas 58.9% believe the 80-hour work week averaged over 4 weeks is appropriate. The results will inform discussions and decisions related to changing residency education in the future.

ACGME Accreditation of Orthopaedic Surgery Subspecialty Fellowship Training Programs

BACKGROUND

Orthopaedic surgery training in the United States consists of a five-year-minimum orthopaedic surgery residency program, followed by optional subspecialty fellowship training. There is an increasing trend for trainees to complete at least one fellowship program following residency training, with approximately 90% of current trainees planning to complete a fellowship. The purpose of this investigation was to assess the overall variability of orthopaedic subspecialty fellowships in terms of characteristics, match process, and the tendency to be accredited by the Accreditation Council for Graduate Medical Education.

METHODS

Nine orthopaedic surgery subspecialties were assessed for their fellowship match program, their number of fellowship programs and positions in the match, and the number of programs and positions accredited by the Accreditation Council for Graduate Medical Education. Programs with a Subspecialty Certificate offered by the American Board of Orthopaedic Surgery were compared with programs without a Subspecialty Certificate. Comparative statistics utilizing an unpaired t test with a statistical cutoff of p < 0.05 were performed.

RESULTS

Three separate matching programs are used by the nine subspecialties. Hand surgery utilizes the National Residents Matching Program, shoulder and elbow surgery utilizes the American Shoulder and Elbow Surgeons Fellowship Match, and the other seven subspecialties utilize the San Francisco Matching Program. In total, 478 fellowship programs were identified, representing 897 fellowship positions. The highest percentage of fellowship programs that are accredited by the Accreditation Council for Graduate Medical Education was in orthopaedic sports medicine (93.1%), compared with the lowest percentage in foot and ankle orthopaedics (16.3%). A significantly higher percentage (p < 0.05) of fellowship programs accredited by the Accreditation Council for Graduate Medical Education were found for subspecialties with American Board of Orthopaedic Surgery Subspecialty Certificates (hand and sports) (87.9%) compared with subspecialties without Subspecialty Certificates (34.3%).

CONCLUSIONS

There are more orthopaedic subspecialty fellowship positions available annually than there are graduating orthopaedic surgery residents. Three independent matching programs are currently being used by the nine orthopaedic subspecialties. Subspecialties vary in the proportion of programs with Accreditation Council for Graduate Medical Education accreditation. Subspecialties with American Board of Orthopaedic Surgery Subspecialty Certificates have a significantly greater proportion of fellowship programs accredited by the Accreditation Council for Graduate Medical Education compared with those without Subspecialty Certificates.

CLINICAL RELEVANCE

Orthopaedic subspecialty fellowship programs are rapidly becoming a perceived necessity as part of orthopaedic surgery training. Fellowships continue to vary in matching system and their accreditation characteristics.

The Current State of United States Spine Surgery Training: A Survey of Residency and Spine Fellowship Program Directors

STUDY DESIGN

Program director survey.

OBJECTIVES

To collect data on spine surgical experience during orthopedic and neurological surgery residency and assess the opinions of program directors (PDs) from orthopedic and neurological surgery residencies and spine surgery fellowships regarding current spine surgical training in the United States.

SUMMARY OF BACKGROUND DATA

Current training for spine surgeons in the United States consists of a residency in either orthopedic or neurological surgery followed by an optional spine surgery fellowship. Program director survey data may assist in efforts to improve contemporary spine training.

METHODS

An anonymous questionnaire was distributed to all PDs of orthopedic and neurological surgery residencies and spine fellowships in the United States (N = 382). A 5-point Likert scale was used to assess attitudinal questions. A 2-tailed independent-samples t test was used to compare responses to each question independently.

RESULTS

A total of 147 PDs completed the survey. Orthopedic PDs most commonly indicated that their residents participate in 76 to 150 spine cases during residency, whereas neurological surgery PDs most often reported more than 450 spine cases during residency (p < .0001). Over 88% of orthopedic surgery program directors and 0% of neurological surgery PDs recommended that their trainees complete a fellowship if they wish to perform community spine surgery (p < .001). In contrast, 98.1% of orthopedic PDs and 86.4% of neurological surgery PDs recommended that their trainees complete a fellowship if they wish to perform spinal deformity surgery (p = .038). Most PDs agreed that surgical simulation and competency-based training could improve spine surgery training (76% and 72%, respectively).

CONCLUSIONS

This study examined the opinions of orthopedic and neurological surgery residency and spine fellowship PDs regarding current spine surgery training in the United States. A large majority of PDs thought that both orthopedic and neurological surgical trainees should complete a fellowship if they plan to perform spinal deformity surgery. These results provide a background for further efforts to optimize contemporary spine surgical training.

Duty hours and home call: the experience of plastic surgery residents and fellows

BACKGROUND

Although resident duty hours are strictly regulated by the Accreditation Council for Graduate Medical Education, there are fewer restrictions on at-home call for residents. To date, no studies have examined the experience of home call for plastic surgery trainees or the impact of home call on patient care and education in plastic surgery.

METHODS THE AUTHORS DISTRIBUTED

an anonymous electronic survey to plastic surgery trainees at 41 accredited programs. They sought to produce a descriptive assessment of home call and to evaluate the perceived impact of home call on training and patient care.

RESULTS

A total of 214 responses were obtained (58.3 percent completion rate). Nearly all trainees reported taking home call (98.6 percent), with 66.7 percent reporting call frequency every third or fourth night. Most respondents (63.3 percent) felt that home call regulations are vague but that Council regulation (44.9 percent) and programmatic oversight (56.5 percent) are adequate. Most (91.2 percent) believe their program could not function without home call and that home call helps to avoid strict duty hour restrictions (71.5 percent). Nearly all respondents (92.3 percent) preferred home call to in-house call.

CONCLUSIONS

This is the first study to examine how plastic surgery residents experience and perceive home call within the framework of Accreditation Council for Graduate Medical Education duty hour regulations. Most trainees feel the impact of home call is positive for education (50.2 percent) and quality of life (56.5 percent), with a neutral impact on patient care (66.7 percent). Under the Council's increasing regulations, home call provides a balance of education and patient care appropriate for training in plastic and reconstructive surgery.

A qualitative assessment of internal medicine resident perceptions of graduate medical education following implementation of the 2011 ACGME duty hour standards

BACKGROUND

In 2011, the Accreditation Council of Graduate Medical Education implemented updated guidelines for medical resident duty hours, further limiting continuous work hours for first-year residents. We sought to investigate the impact of these restrictions on graduate medical education among internal medicine residents.

METHODS

We conducted eight focus groups with internal medicine residents at the University of Alabama at Birmingham in 06/2012-07/2012. Discussion questions included, "How do you feel the 2011 ACGME work hour restrictions have impacted your graduate medical education?" Transcripts of the focus groups were reviewed and themes identified using a deductive/inductive approach. Participants completed a survey to collect demographic information and future practice plans.

RESULTS

Thirty-four residents participated in our focus groups. Five themes emerged: decreased teaching, decreased experiential learning, shift-work mentality, tension between residency classes, and benefits and opportunities. Residents reported that since implementation of the guidelines, teaching was often deferred to complete patient-care tasks. Residents voiced concern that PGY-1 s were not receiving adequate clinical experience and that procedural and clinical reasoning skills are being negatively impacted. PGY-1 s reported being well-rested and having increased time for independent study.

CONCLUSIONS

Residents noted a decline in teaching and are concerned with the decrease in "hands-on" clinical education that is inevitably impacted by fewer hours in the hospital, though some benefits were also reported. Future studies are needed to further elucidate the impact of decreased resident work hours on graduate medical education.

Development of an orthopedic surgery trauma patient handover checklist

BACKGROUND

In surgery, preoperative handover of surgical trauma patients is a process that must be made as safe as possible. We sought to determine vital clinical information to be transferred between patient care teams and to develop a standardized handover checklist.

METHODS

We conducted standardized small-group interviews about trauma patient handover. Based on this information, we created a questionnaire to gather perspectives from all Canadian Orthopaedic Association (COA) members about which topics they felt would be most important on a handover checklist. We analyzed the responses to develop a standardized handover checklist.

RESULTS

Of the 1106 COA members, 247 responded to the questionnaire. The top 7 topics felt to be most important for achieving patient safety in the handover were comorbidities, diagnosis, readiness for the operating room, stability, associated injuries, history/mechanism of injury and outstanding issues. The expert recommendations were to have handover completed the same way every day, all appropriate radiographs available, adequate time, all appropriate laboratory work and more time to spend with patients with more severe illness.

CONCLUSION

Our main recommendations for safe handover are to use standardized checklists specific to the patient and site needs. We provide an example of a standardized checklist that should be used for preoperative handovers. To our knowledge, this is the first checklist for handover developed by a group of experts in orthopedic surgery, which is both manageable in length and simple to use.