Do patient race and sex change surgeon recommendations for TKA?

BACKGROUND: Prior investigations have suggested that physician-related factors may contribute to differential use of TKA among women and ethnic minorities. We sought to evaluate the effect of surgeon bias on recommendations for TKA. QUESTIONS/PURPOSE: Using an experimental approach with standardized patient scenarios, we sought to evaluate surgeon recommendations regarding TKA, specifically to determine whether recommendations for TKA are influenced by (1) patient race, and (2) patient sex. METHODS: We developed four computerized scenarios for all combinations of race (white or black) and sex (male or female) for otherwise similar patients with end-stage knee osteoarthritis. Patients gave an orthopaedic history of 2 years worsening pain with decreased functional status and failure of oral antiinflammatory medications and corticosteroid intraarticular injections. Orthopaedic surgeons attending the 2012 annual meetings of the New York State Society of Orthopaedic Surgeons and American Association of Hip and Knee Surgeons were recruited for the study. Surgeons passing an open recruitment table at each meeting were asked to participate. Of the 1111 surgeons in attendance at either meeting, 113 (10.2%) participated in the study. All participants viewed the control patient\u27s story (white male) and were randomized to view one of the three experimental scenarios (white female, black male, black female). After viewing each scenario, the participants were anonymously asked whether they would recommend TKA. An a priori power analysis showed that 112 participants were needed to detect a 15% difference in the likelihood of recommending surgery for white versus nonwhite patients in the test scenarios evaluated with 90% power at a level of significance of 0.05. RESULTS: Of the 39 surgeons who viewed the white male plus black female scenario, there were 33 (85%) concordant responses (TKA offered to both patients) and six discordant responses (TKA offered to only one of the patients), with no effect of patient race and sex (p = 0.99). Of the 37 surgeons who viewed the white male plus black male scenario, there were 33 (89%) concordant responses and four discordant responses, with no effect of patient race (p = 0.32). Of the 37 surgeons who viewed the white male plus white female scenario, there were 30 (77%) concordant responses and seven discordant responses, with no effect of patient sex (p = 0.71). CONCLUSION: After orthopaedic surgeons viewed video scenarios of patients with end-stage knee osteoarthritis, patient race and sex were not associated with a different likelihood of a surgical recommendation. Our findings support the notion that patient race and sex may be less influential on decision making when there are strong clinical data to support a decision. Physician bias may have a greater effect on decision making in situations where the indications for surgery are less clear

Subspecialty Rotation Exposure Across Accreditation Council for Graduate Medical Education-Accredited Orthopaedic Surgery Residency Programs.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) mandates certain procedural minimums for graduating residents of orthopaedic surgery programs and provides residency programs with comparative data on surgical case volume. It provides much less guidance and feedback to programs regarding the amount of time residents should spend on different rotations during residency. Comparative data regarding how much time residents are spending on general and subspecialty rotations may be of use to educational leadership as they consider curriculum changes and alternative training structures. The purpose of this study is to summarize the subspecialty rotation exposure across ACGME-accredited orthopaedic residency programs and to correlate the subspecialty rotation exposure with available program-specific factors. METHODS: This study contacted 162 ACGME-accredited orthopaedic residency programs and received rotation schedules from 115 programs (70.1%). Rotation schedules for postgraduate year 2 to 5 residents were categorized into the number of months spent on the following rotations: general orthopaedics, trauma, pediatrics, hand, sport, foot and ankle, arthroplasty, oncology, spine, research, and elective. The percentage of residency spent in each category was then calculated as the number of months divided by 48 months. Differences in the percent of residency spent on subspecialty rotations were compared for the following variables: program size and presence of subspecialty fellowships at the institution. RESULTS: On average, the greatest percentage of residency spent was in the following categories: trauma (16.6%; 8.0 months), general orthopaedics (13.7%; 6.6 months), and pediatrics (12.5%; 6.0 months). Rotations with the highest variation between programs included the following: general orthopaedics (SD 5.8 months; range 0 to 30 months), sport (SD 2.5 months; range 0 to 15 months), and arthroplasty (SD 2.3 months; range 0 to 11.8 months). Sixty-seven programs (63.2%) had dedicated blocks for research, and 25 programs (23.6%) had dedicated blocks for electives. No notable correlations were found between subspecialty exposure and program size or availability of subspecialty fellowship training at the program. CONCLUSION: Variability exists between ACGME-accredited orthopaedic surgery residency programs in subspecialty rotation exposure. Summarizing the subspecialty rotation exposure across accredited orthopaedic residency programs is useful to graduate medical education leadership for comparative purposes because they design and modify resident curricula

Comparative Assessment of Grit, Conscientiousness, and Self-Control in Applicants Interviewing for Residency Positions and Current Orthopaedic Surgery Residents.

OBJECTIVE: The purpose of this study was to quantify grit, conscientiousness, and self-control in orthopaedic residency applicants and current orthopaedic surgery residents. As part of a continual reassessment of the selection process, this study will help to improve this process by assessing the introduction of these non-cognitive assessments. This is the first study to both evaluate and compare the applicants\u27 scores to those of current residents. This introduction will allow selection of not only the current top performers but those who have the wherewithal (read grit) to sustain their efforts throughout their residency. DESIGN: A cross-sectional study composed of a confidential electronic survey consisting of a 17-item Grit scale, 10-item Self-control scale, and 9-item Conscientiousness scale was completed by medical school applicants and orthopaedic residents. SETTING: Department of Orthopaedic Surgery, Hospital for Special Surgery. PARTICIPANTS: Fifty-six (100%) medical student applicants (mean age = 27) were invited to participate in our study following a full day of interviews. Forty-five residents (mean age = 31) were asked and 32 (72%) completed the same surveys 4 months later. RESULTS: There was a significant difference in grit for medical students (M = 4.19, SD = 0.34) and residents (M =3.86, SD = 0.48); t(86) = 3.76, p = 0.000. All grit subscales were also significantly different for medical students versus residents. Medical students (conscientiousness M = 4.60, SD = 0.41; self-control M = 3.51, SD = 0.30) and residents (conscientiousness M = 4.42, SD = 0.53; self-control M = 3.31, SD = 0.73) scored similarly in the conscientiousness t(86) = 1.75, p = 0.084 and self-control scales t(86) = 1.74, p = 0.086. Academic performance indicators such as the USMLE scores and residency ranking were also compared among medical student applicants. CONCLUSIONS: The similar and above average levels of conscientiousness and self-control demonstrate the persevering nature of the individual who elects to pursue an orthopaedic residency program. Although the grit levels were different between medical school student and residents, they were above average for both groups, again demonstrating the type of individual willing to pursue an orthopaedic residency program. This study was the first to demonstrate varying degrees of grit for high-performing students versus residents in a competitive program, which seems to suggest that grit can vary over time. Future studies will investigate the validity of these non-cognitive variables in predicting achievement prospectively in a residency program

Urban outpatient views on quality and safety in primary care.

OBJECTIVE: The Minimizing Errors Maximizing Outcomes Study is designed to examine the effect of workplace conditions on quality of care and medical errors. In the first phase of the study, patients were asked to tell their stories via focus groups. DESIGN: Moderators used a standard question guide. Researchers read the transcripts independently and reached consensus on major themes. Two coders independently assigned transcript statement to themes. SETTING: Three focus groups were conducted in three cities, including 21 patients from three clinics. PATIENTS: Patients with previously scheduled appointments at participating clinics were invited to join the focus groups. MEASUREMENTS AND MAIN RESULTS: Agreement between the two coders was 77.5% (kappa value 0.66). All but 2% of 187 distinct comments could be grouped into four categories: (1) Systems Issues (44% of comments). Long waits for providers and lack of access were the most common frustrations. Understaffing, underfunding and lack of health insurance were perceived as contributing to poor quality of care; (2) Interpersonal Skills (37%). Physician listening skills were valued. Participants felt patient attitudes affected care. (3) Knowledge and Technical Skills (9%). (4) Errors (7%). Medication errors, errors of inattention and technical errors were discussed. CONCLUSIONS: Patients provide important insights into complex systems issues, which can guide planners in improving quality and reducing errors. According to focus group participants, healthcare could be improved and made safer by increasing timely access to patients\u27 own physicians, decreasing the time patients spend in waiting rooms, and adding staff to double-check prescriptions

Assessing Gender Differences in Technical Skills and Confidence in Orthopaedic Surgery Residency Applicants.

INTRODUCTION: Variations in confidence for procedural skills have been demonstrated when comparing male and female medical students in surgical training. This study investigates whether differences in technical skill and self-reported confidence exist between male and female medical students applying to orthopaedic residency. METHODS: All medical students (2017 to 2020) invited to interview at a single orthopaedic residency program were prospectively evaluated on their technical skills and self-reported confidence. Objective evaluation of technical skill included scores for a suturing task as evaluated by faculty graders. Self-reported confidence in technical skills was assessed before and after completing the assigned task. Scores for male and female students were compared by age, self-identified race/ethnicity, number of publications at the time of application, athletic background, and US Medical Licensing Examination Step 1 score. RESULTS: Two hundred sixteen medical students were interviewed, of which 73% were male (n = 158). No gender differences were observed in suture task technical skill scores or mean difference in simultaneous visual task scores. The mean change from pre-task and post-task self-reported confidence scores was similar between sexes. Although female students trended toward lower post-task self-reported confidence scores compared with male students, this did not achieve statistical significance. Lower self-reported confidence was associated with a higher US Medical Licensing Examination score and with attending a private medical school. DISCUSSION: No difference in technical skill or confidence was found between male and female applicants to a single orthopaedic surgery residency program. Female applicants trended toward self-reporting lower confidence than male applicants in post-task evaluations. Differences in confidence have been shown previously in surgical trainees, which may suggest that differences in skill and confidence may develop during residency training

Can a web-based curriculum improve students\u27 knowledge of, and attitudes about, the interpreted medical interview?

OBJECTIVES: To develop and evaluate a web-based curriculum to introduce first year medical students to the knowledge and attitudes necessary for working with limited English proficient (LEP) patients through interpreters. METHOD: Six hundred and forty first year medical students over 4 consecutive years took this curriculum as part of their Patient Physician and Society course. They viewed 6 patient-physician-interpreter video vignettes, gave open text analyses of each vignette, and compared their responses to those generated by experts, thereby receiving immediate formative feedback. They listened to video commentaries by a cultural expert, lawyer, and ethicist about working with LEP patients, completed pre- and postmodule questionnaires, which tested relevant knowledge and attitudes, and were provided a summative assessment at the end of the module. Students completed an optional survey assessing the educational value of, and providing open text commentary about, the module. RESULTS: Seventy-one percent (n=456) of first year students who completed the module consented to have their data included in this evaluation. Mean knowledge (19 items) scores improved (46% pre- to 62% postmodule, P CONCLUSION: Our web-curriculum resulted in short-term improvement in the knowledge and attitudes necessary to interact with LEP patients and interpreters. The interactive format allowed students to receive immediate formative feedback and be cognizant of the challenges and effective strategies in language discordant medical encounters. This is important because studies suggest that the use of these skills in patient encounters leads to greater patient and provider satisfaction and improved health outcomes

An Initiative to Standardize the Identification of and Acute Response to Postoperative Lower-Extremity Neurological Deficits: Effects on Provider Knowledge, Confidence, and Communication Skills.

BACKGROUND: Although relatively uncommon, neurological deficits following hip and knee arthroplasty can have permanent and debilitating consequences. This study was conducted to quantify the effectiveness of an educational curriculum aimed at standardizing the identification of and acute response to postoperative neurological deficits in the inpatient setting, specifically with respect to improvements in clinician knowledge, confidence levels, and communication skills. METHODS: A multidisciplinary committee at a single, high-volume academic institution created an algorithm delineating the appropriate clinical actions and escalation procedures in the setting of a postoperative neurological deficit for each clinical practitioner involved in care for patients who undergo arthroplasty. An educational curriculum composed of online learning modules and an in-person boot camp featuring simulations with standardized patients was developed, along with assessments of clinician knowledge, confidence levels, and communication skills. Nurses, physical therapists, physician assistants, residents, fellows, and attending surgeons were encouraged to participate. The intervention spanned a 5-month period in 2015 with a mean time of 18.4 weeks between baseline assessments and the time of the latest follow-up. RESULTS: Online modules were completed by 322 individuals, boot camp was completed by 70 individuals, and latest assessments were completed by 38 individuals. The percentage correct on the knowledge assessment increased from 74.5% before the learning modules to 89.5% immediately after (p \u3c 0.001) but degraded over time such that there was no significant difference between baseline and the latest follow-up scores (p = 0.11). Over the course of the boot camp, physician assistants and residents successfully performed approximately 91% of the indicated actions on the scoring rubric; physical therapists and nurses successfully performed 78%. Scores on the communication skills assessment showed a significant mean increase (p = 0.02) over the course of the intervention from 30.32 to 32.50, and the mean self-assessed confidence survey scores increased by 16.7%, from 7.2 to 8.4 (p \u3c 0.001). CONCLUSIONS: A multimodality educational curriculum aimed at quality improvement can produce significant knowledge improvements, but these gains may not be maintained over time without further instruction. Gains in confidence and communication skills appear to be more long-lasting

Surgical Games: A Simulation-Based Structured Assessment of Orthopedic Surgery Resident Technical Skill.

BACKGROUND: Simulation-based education and objective evaluation of surgical skill have been incorporated into many surgical training programs. We describe the development and implementation of a timed, multitask, station-based Surgical Games to evaluate orthopedic resident surgical skills. METHODS: Participants in the study were postgraduate-year 2 to 5 orthopedic surgery residents from a single institution. Residents completed 4-timed simulated tasks: cadaveric carpal tunnel release (CTR), Sawbones model of total knee arthroplasty (TKA), Sawbones model of ankle fracture open reduction internal fixation (ORIF), and knee arthroscopy simulator (KAS) of removal of loose body. Evaluations were performed using standardized score sheets by attending surgeons. Resident performance was analyzed by postgraduate-year and number of weeks of prior task-related residency training. RESULTS: A total of 32 residents were assessed at the 4 stations. Total scores were significantly different for CTR (p = 0.006), TKA (p = 0.05), and the KAS (p = 0.004) by year of training, but not for the ankle ORIF task. Residents with more task-specific experience performed significantly better on the KAS (p \u3c 0.001), TKA (p = 0.002), and CTR (p = 0.02) tasks but not on the ankle ORIF task (p = 0.1). Overall, residents rated the exercise valuable to their education with mean scores of 3.9 ± 0.54 on a 5-point Likert Scale. CONCLUSIONS: This Surgical Games exercise provided an objective evaluation of surgical skill that correlated with year-in-training and prior experience in skill-specific rotations for the KAS, TKA, and CTR tasks. This surgical skills assessment provided an opportunity for effective structured feedback and identification of areas for improvement

Correction to: At the US Epicenter of the COVID-19 Pandemic, an Orthopedic Residency Program Reorganizes.

[This corrects the article DOI: 10.1007/s11420-020-09765-5.]