Gender Representation in Major Orthopaedic Surgery Meetings: A Quantitative Analysis

Background

Orthopaedic surgery suffers from gender disparity, and annual conferences are visible opportunities to quantify gender representation within a field. Therefore, the purpose of this manuscript was to investigate the prevalence of female speakers and moderators, and male-only panel sessions, at 10 major Orthopaedic Surgery meetings.

Methods

Conference programs and details of faculty moderating or presenting in 10 Orthopaedic Surgery annual meetings in 2021 were retrieved. Conferences were selected with the aim of size and diversity in subspecialty topics and included American Association of Hip and Knee Surgeons, American Association for Hand Surgery, American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Canadian Orthopaedic Association (COA), European Federation of National Associations of Orthopaedics and Traumatology, North American Spine Society, Orthopaedic Research Society (ORS), Orthopaedic Trauma Association, and Pediatric Orthopaedic Society of North America (POSNA). Primary outcomes included percentage of female chairs and speakers and percentage of male-only panels, while secondary outcomes included number of publications, number of citations, and H-indexes of faculty. Further subgroup comparisons were performed between male-only panels and non-male-only panels and female members and male members.

Results

Of 207 included sessions, 121 (58.5%) were male-only panels and 150 (12.6%) of 1,188 faculty members were women. Conferences organized by the COA, ORS, and POSNA had higher percentages of female representation, while spine surgery and adult hip/knee reconstruction sessions had more than 70% male-only panels and fewer than 10% female members. There were no significant differences between male members and female members regarding years of practice; however, male members were more likely to hold the title of professor (p < 0.001). Male members and female members stratified by quartiles of publications, citations, and H-indexes, moderated or participated in similar numbers of sessions, indicating an absence of selection bias.

Conclusions

There is a high prevalence of male-only panels (58.5%) and an overall lack of female representation (12.6%) in 10 major Orthopaedic Surgery meetings. Male members and female members from these conferences were found to have similar qualifications academically. Specific strategies such as the elimination of male-only panels, selecting diverse conference organizers, and forming conference equity, diversity, and inclusion committees can help achieve cultural change.

Level of Evidence

Level V.

Sex-specific differences in 30-day outcomes following primary total hip replacement in 86,684 patients

INTRODUCTION

Although differential outcomes based on sex are widespread in medicine and surgery, evaluation of sex-specific differences in the field of orthopaedic surgery in general - and arthroplasty in particular - are lacking. We hypothesised that morbidly obese male and female patients would have differing risks of surgical complications following primary total hip replacement.

METHODS

We reviewed data contained within the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database from 2015 through 2018, inclusive. A multivariable binary logistic regression model was used to determine the adjusted odds ratios (OR) of relevant variables on primary and secondary outcomes.

RESULTS

A total of 86,684 patients undergoing THR were identified, of whom 9972 patients (4095 male and 5877 female) were morbidly obese. Among morbidly obese patients, odds of surgical site infection were higher in females than males within 30 days of surgery (adjusted OR 1.40; 95% CI, 1.10-1.79; p = 0.007). This comprised the odds of both superficial infection (1.8% vs. 1.1%, adjusted OR 1.67; 95% CI, 1.16-2.40; p = 0.006) and deep infection (1.9% vs. 1.4%, adjusted OR 1.22; 95% CI, 0.88-1.68; p = 0.24). Unexpected return to the operating room (i.e., reoperation) within 30 days of the surgical procedure was also higher among females than males (4.2% vs. 3.1%, adjusted OR 1.38, 95% CI, 1.10-1.71, p = 0.005). There were no differences between male and female patients in the non-obese cohort.

CONCLUSIONS

Among patients with morbid obesity, the risk of surgical site infection and reoperation within the first 30 days is greater in women as compared to men. Future research must address whether this early increased risk among morbidly obese women persists in the longer term, and whether it results in compromised function or quality of life.

Impact of interactive multi-media learning for physicians in musculoskeletal education - a pilot study

BACKGROUND

The aim of this educational study was to investigate the use of interactive case-based modules relating to the screening and identification of early-stage inflammatory arthritis in both online technology (OLT) and paper (PF) formats with identical content.

METHODS

Forty learners from family medicine or rheumatology residency programs were recruited. Content pertaining to a "Sore Hands, Sore Feet" (SHSF) and Gait Arms Legs Spine (GALS) screening tool modules were selected, reviewed and developed based on a validated curriculum from the World Health Organization and Canadian Curriculum for MSK conditions. Both the SHSF module and GALS screening tool were assessed via a randomized control trial. Assessments were completed during an orientation with all learners; then prior to the intervention (T1); at the end of the module (T2) and 3 months following the modules (T3) to assess retention. Focus groups were conducted to determine learners' satisfaction with the different learning formats. Baseline data was collated, and analysis performed after randomization into the PF (control) and OLT (experimental) groups. Repeated measures ANOVA was used for statistical analyses.

RESULTS

Forty participants were recruited and randomized into the PF or OLT group (n = 20 each). At 3 months, there were n = 31 participants for SHSF (PF n = 19, OLT n = 12) and n = 32 for GALS (PF n = 19, OLT n = 13). There was no significant difference between the OLT and PF groups in both analyses. A significant increase in scores from Pre- to Post-Module in SHSF (F (1, 18) = 24.62. p < .0001) and GALS (F (1, 30) = 40.08, p < .0001) were identified to suggest learning occurred with both formats. The repeated measures ANOVA to assess retention revealed a significant decrease in scores from Post-Module to Follow-up for both learning format groups for SHSF (F (1, 29) = 4.68. p = .039), and GALS (F (1, 30) = 18.27. p < .0001) suggesting 3 months may be too long to retain this educational information.

CONCLUSIONS

Both formats led to residents' ability to screen, identify and initially manage inflammatory arthritis. The hypothesis is rejected because both OLT and PF groups demonstrated significant learning during the process regardless of format. It is important to emphasize that from T1 (pre-module) to T2 (post-module), the residents demonstrated learning regardless of group to which they were assigned. However, learning retention declined from T2 (post-module) to T3 (three-month follow-up). Regular review of knowledge may be required earlier than 3 months to retain information learned. This study may impact educational strategies in MSK health.

TRIAL REGISTRATION

This study did not involve "patients" rather learners and as such it was not registered.

Distress in orthopedic trainees and attending surgeons: a Canadian national survey

Background

Physician health is of increasing concern in health care systems. The purpose of this study was to determine the prevalence of distress among orthopedic surgeons and trainees and to identify factors associated with distress.

Methods

Voluntary, anonymous online surveys were sent to attending orthopedic surgeons and orthopedic trainees across Canada. The survey for attending surgeons used the Expanded Physician Well-Being Index, and the survey for trainees used the Resident/Fellow Well-Being Index. Demographic information was also collected. To look for predictors of physician distress, we evaluated the relationship between respondents' classification as "distressed" and "not distressed" against demographic factors.

Results

In total, 1138 attending orthopedic surgeons and 493 orthopedic trainees were invited to complete the survey. The survey response rate was 31.2% for attending orthopedic surgeons and 24.3% for orthopedic trainees. Overall, 55.4% of attending surgeons and 40.0% of trainees screened positive for distress. Among both attending surgeons and trainees, having dependents was not a risk factor for distress, nor was gender. Practice location was not a risk factor for distress among attending surgeons. Attending surgeons who were classified as distressed had spent significantly fewer years in practice (median 11 yr) than those who were classified as "not distressed" (median 16 yr) (p = 0.004).

Conclusion

We found a higher rate of distress among orthopedic surgeons than has been previously reported. The distress rate among orthopedic trainees in this population is similar to that reported in other international publications, although self-reported rates of burnout were higher. The findings from this study may indicate a need for continuing research to determine intrinsic and extrinsic risk factors for distress among orthopedic surgeons and trainees and for the evaluation of prescriptive, evidence-based initiatives to address this crisis.

Cognitive and Psychomotor Entrustable Professional Activities: Can Simulators Help Assess Competency in Trainees?

BACKGROUND

An entrustable professional activity describes a professional task that postgraduate residents must master during their training. The use of simulation to assess performance of entrustable professional activities requires further investigation.

QUESTIONS/PURPOSES

(1) Is simulation-based assessment of resident performance of entrustable professional activities reliable? (2) Is there evidence of important differences between Postgraduate Year (PGY)-1 and PGY-4 residents when performing simulated entrustable professional activities?

METHODS

Three entrustable professional activities were chosen from a list of competencies: management of the patient for total knee arthroplasty (TKA); management of the patient with an intertrochanteric hip fracture; and management of the patient with an ankle fracture. Each assessment of entrustable professional activity was 40 minutes long with three components: preoperative management of a patient (history-taking, examination, image interpretation); performance of a technical procedure on a sawbones model; and postoperative management of a patient (postoperative orders, management of complications). Residents were assessed by six faculty members who used checklists based on a modified Delphi technique, an overall global rating scale as well as a previously validated global rating scale for the technical procedure component of each activity. Nine PGY-1 and nine PGY-4 residents participated in our simulated assessment. We assessed reliability by calculating the internal consistency of the mean global rating for each activity as well as the interrater reliability between the faculty assessment and blinded review of videotaped encounters. We sought evidence of a difference in performance between PGY-1 and PGY-4 residents on the overall global rating scale for each station of each entrustable professional activity.

RESULTS

The reliability (Cronbach's α) for the hip fracture activity was 0.88, it was 0.89 for the ankle fracture activity, and it was 0.84 for the TKA activity. A strong correlation was seen between blinded observer video review and faculty scores (mean 0.87 [0.07], p < 0.001). For the hip fracture entrustable professional activity, the PGY-4 group had a higher mean global rating scale than the PGY-1 group for preoperative management (3.56 [0.5] versus 2.33 [0.5], p < 0.001), postoperative management (3.67 [0.5] versus 2.22 [0.7], p < 0.001), and technical procedures (3.11 [0.3] versus 3.67 [0.5], p = 0.015). For the TKA activity, the PGY-4 group scored higher for postoperative management (3.5 [0.8] versus 2.67 [0.5], p = 0.016) and technical procedures (3.22 [0.9] versus 2.22 [0.9], p = 0.04) than the PGY-1 group, but no difference for preoperative management with the numbers available (PGY-4, 3.44 [0.7] versus PGY-1 2.89 [0.8], p = 0.14). For the ankle fracture activity, the PGY-4 group scored higher for postoperative management (3.22 [0.8] versus 2.33 [0.7], p = 0.18) and technical procedures (3.22 [1.2] versus 2.0 [0.7], p = 0.018) than the PGY-1 groups, but no difference for preoperative management with the numbers available (PGY-4, 3.22 [0.8] versus PGY-1, 2.78 [0.7], p = 0.23).

CONCLUSIONS

The results of our study show that simulated assessment of entrustable professional activities may be used to determine the ability of a resident to perform professional tasks that are critical components of medical training. In this manner, educators can ensure that competent performance of these skills in the simulated setting occurs before actual practice with patients in the clinical setting.

Cause and Effect: Testing a Mechanism and Method for the Cognitive Integration of Basic Science

BACKGROUND

Methods of integrating basic science with clinical knowledge are still debated in medical training. One possibility is increasing the spatial and temporal proximity of clinical content to basic science. An alternative model argues that teaching must purposefully expose relationships between the domains. The authors compared different methods of integrating basic science: causal explanations linking basic science to clinical features, presenting both domains separately but in proximity, and simply presenting clinical features

METHOD

First-year undergraduate health professions students were randomized to four conditions: (1) science-causal explanations (SC), (2) basic science before clinical concepts (BC), (3) clinical concepts before basic science (CB), and (4) clinical features list only (FL). Based on assigned conditions, participants were given explanations for four disorders in neurology or rheumatology followed by a memory quiz and diagnostic test consisting of 12 cases which were repeated after one week.

RESULTS

Ninety-four participants completed the study. No difference was found on memory test performance, but on the diagnostic test, a condition by time interaction was found (F[3,88] = 3.05, P < .03, ηp = 0.10). Although all groups had similar immediate performance, the SC group had a minimal decrease in performance on delayed testing; the CB and FL groups had the greatest decreases.

CONCLUSIONS

These results suggest that creating proximity between basic science and clinical concepts may not guarantee cognitive integration. Although cause-and-effect explanations may not be possible for all domains, making explicit and specific connections between domains will likely facilitate the benefits of integration for learners.

Reliability, validity, and responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index for elderly patients with a femoral neck fracture

BACKGROUND

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture.

METHODS

Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older.

RESULTS

The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%).

CONCLUSIONS

The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations.

CLINICAL RELEVANCE

The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.

How to assess communication, professionalism, collaboration and the other intrinsic CanMEDS roles in orthopedic residents: use of an objective structured clinical examination (OSCE)

BACKGROUND

Assessing residents' understanding and application of the 6 intrinsic CanMEDS roles (communicator, professional, manager, collaborator, health advocate, scholar) is challenging for postgraduate medical educators. We hypothesized that an objective structured clinical examination (OSCE) designed to assess multiple intrinsic CanMEDS roles would be sufficiently reliable and valid.

METHODS

The OSCE comprised 6 10-minute stations, each testing 2 intrinsic roles using case-based scenarios (with or without the use of standardized patients). Residents were evaluated using 5-point scales and an overall performance rating at each station. Concurrent validity was sought by correlation with in-training evaluation reports (ITERs) from the last 12 months and an ordinal ranking created by program directors (PDs).

RESULTS

Twenty-five residents from postgraduate years (PGY) 0, 3 and 5 participated. The interstation reliability for total test scores (percent) was 0.87, while reliability for each of the communicator, collaborator, manager and professional roles was greater than 0.8. Total test scores, individual station scores and individual CanMEDS role scores all showed a significant effect by PGY level. Analysis of the PD rankings of intrinsic roles demonstrated a high correlation with the OSCE role scores. A correlation was seen between ITER and OSCE for the communicator role, while the ITER medical expert and total scores highly correlated with the communicator, manager and professional OSCE scores.

CONCLUSION

An OSCE designed to assess the intrinsic CanMEDS roles was sufficiently valid and reliable for regular use in an orthopedic residency program.

Learning styles of first-year orthopedic surgical residents at 1 accredited institution

BACKGROUND

This study represents 1 arm of a 5-year prospective study investigating the learning styles of orthopedic residents and their surgical educators.

METHODS

This project investigates the learning styles of the 2009-2010 year 1 orthopedic surgical residents. A cross-sectional survey using the Kolb Learning Style Inventory was completed by 13 first year orthopedic residents. Direct 1-to-1 interviews were completed with the primary investigator and each participant using the Kolb Learning Style Inventory and learning styles were determined.

RESULTS

Converging learning style was the most common among the residents (53.8%). Residents demonstrated a high tendency toward the learning skill of abstract conceptualization combined with active experimentation, and a transition from action-oriented to more reflective learning style with age and postgraduate education.

CONCLUSIONS

These results may be useful in creating strategies specific to each learning style that will be offered to residents to enhance future teaching and learning.

The effectiveness of patient verbalization on informed consent

OBJECTIVE

To determine if preoperative patient verbalization of the risks and benefits of anterior cruciate ligament (ACL) reconstruction enhances understanding of the risks and benefits of that procedure.

DESIGN

A randomized clinical trial.

SETTING

A referral-based outpatient sport medicine clinic.

SUBJECTS

Twenty patients from the general population with clinically diagnosed ACL tears requiring elective reconstruction surgery were randomly assigned to 2 groups. Twelve patients who made up a control group received a standard surgical consultation, consisting of knee models, diagrams, open dialogue and informed consent to surgery. Eight patients in the experimental group were exposed to the same surgical consultation and were required to accurately verbalize the associated risks and benefits before operation. One month after informed consent was obtained, patients answered 3 questions about the risks and benefits of ACL reconstruction.

INTERVENTION

ACL reconstruction.

MAIN OUTCOME MEASURES

A 3-question questionnaire, addressing 2 risks and 1 benefit of ACL reconstruction.

MAIN RESULTS

Patients in the experimental group were able to answer all 3 questions correctly. In the control group, 4 patients answered all 3 questions correctly, but 1 patient answered all 3 questions incorrectly, and 7 patients answered 1 question incorrectly. There was a statistically significant difference (p = 0.03) between the control group and the experimental group.

CONCLUSION

Patients who verbalized the risks and benefits during their surgical consultation demonstrated a significantly greater understanding of the risks and benefits of an ACL reconstruction procedure.