Faculty Bibliography

BACKGROUND: The Accreditation Council of Graduate Medical Education (ACGME) guidelines require residency programs to teach and evaluate residents in six overarching "core competencies" and document progress through educational milestones. In order to assess the progress of orthopaedic interns' skills in performing a history, physical exam, and documentation of the encounter for a standardized patient with spinal stenosis, a Structured Objective Clinical Examination (OSCE) was conducted for 13 orthopaedic intern residents, following a one month boot camp that included communications skills and curriculum in history and physical examination. Interns were objectively scored based upon their performance of the physical exam, communication skills, completeness and accuracy of their electronic medical record (EMR), and their diagnostic conclusions gleaned from the patient encounter. PURPOSE: The purpose of this study was to meaningfully assess the clinical skills of orthopaedic PGY-1 interns. The findings can be utilized to develop a standardized curriculum for documenting patient encounters and highlight common areas of weakness among orthopaedic interns with regard to the spine history and physical examination and conducting complete and accurate clinical documentation. STUDY SETTING: A major orthopaedic specialty hospital and academic medical center METHODS: 13 PGY-1 orthopaedic residents participated in the OSCE with the same standardized patient presenting with symptoms and radiographs consistent with spinal stenosis. Videos of the encounters were independently viewed and objectively evaluated by one investigator in the study. This evaluation focused on the completeness of the history and the performance and completion of the physical exam. The standardized patient evaluated the communication skills of each intern with a separate objective evaluation. Interns completed these same scoring guides to evaluate their own performance in history, physical examination and communications skills. The interns' documentation in the electronic medical record (EMR) was then scored for completeness, internal consistency, and inaccuracies. RESULTS: The independent review revealed objective deficits in both the orthopaedic interns' history and physical examination, as well as highlighted trends of inaccurate and incomplete documentation in the corresponding medical record. Communication skills with the patient did not meet expectations. Further, interns tended to over-score themselves, especially with regards to their performance on the physical exam (p<.0005). Inconsistencies, omissions, and inaccuracies were common in the corresponding medical notes when compared to the events of the patient encounter. 9/13 interns (69.2%) documented at least one finding that was not assessed or tested in the clinical encounter, and 4/13 interns (30.8%) included inaccuracies in the medical record which contradicted the information collected at the time of the encounter. CONCLUSIONS: The results of this study highlighted significant shortcomings in the completeness of the interns' spine history and physical exam, and the accuracy and completeness of their EMR note. The study provides a valuable exercise for evaluating residents in a multifaceted, multi-milestone manner that more accurately documents residents' clinical strengths and weaknesses. The study demonstrates that orthopaedic residents require further instruction on the complexities of the spinal exam. It validates a need for increased systemic support for improving resident documentation through comprehensive education and evaluation modules.

OBJECTIVES: To identify the association between social and moderate alcohol consumption and functional outcomes after surgical management of orthopaedic fractures. DESIGN: Prospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Seven hundred eighty-four patients who were operatively treated for an isolated orthopaedic fracture were prospectively followed. Patients were categorized into groups according to self-reported drinking frequencies based on NIAAA guidelines. MAIN OUTCOME MEASUREMENTS: SMFA scores at baseline, 3, 6, and 12 months postoperatively; postoperative complications; and subsequent operations. RESULTS: There were 367 (46.8%) abstinent, 327 (41.7%) social, 52 (6.6%) moderate, and 38 (4.8%) heavy drinkers. Mean SMFA scores of social and moderate drinkers were significantly lower than those of abstinent patients at 3-, 6-, and 12-month follow-ups, denoting better functional outcomes (social: 24.3 vs. 30.5, P = 0.001; 14.8 vs. 21.5, P < 0.005; and 10.1 vs. 18.8, P < 0.005); (moderate: 18.3 vs. 30.5, P = 0.001; 9.7 vs. 21.5, P = 0.001; and 5.4 vs. 18.8, P < 0.005). Multiple linear regression revealed that social drinking and baseline SMFA scores were the only statistically significant independent predictors of lower SMFA scores at 12 months after surgery. CONCLUSIONS: Social to moderate drinking may have a protective effect on functional outcomes at 3, 6, and 12 months after surgery. Social drinking may also have a protective effect on postoperative complications and reoperation rates. Further studies should be performed to fully appreciate the clinical effect of social and moderate drinking after operative treatment of orthopaedic fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION: This study sought to assess and compare long-term functional and clinical outcomes in patients with tibial plateau fractures that are treated nonsurgically. METHODS: Over a period of 8 years, 305 consecutive tibial plateau fractures were treated by three surgeons at a single institution and followed prospectively in an Institutional Review Board-approved study. Overall, 41 patients (13%) were treated nonsurgically and 37 were available for follow-up. Indications for nonsurgical management were minimal fracture displacement or preclusion of surgery because of comorbidities. A series of univariate retrospective analyses were used to identify individual risk factors potentially predictive of Short Musculoskeletal Functional Assessment scores. RESULTS: Thirty-seven patients were included with a mean follow-up of 21 +/- 14.9 months. Overall, 59% of patients (n = 22) attained good to excellent functional outcomes. In patients for whom surgery was precluded because of comorbidities, outcome scores were significantly poorer (38.8 +/- 23.0 versus 12.7 +/- 14.2; P = 0.001). Surgery precluded by a factor other than minimal fracture displacement predicted poor outcome (P = 0.002). DISCUSSION: Carefully selected patients with minimally displaced tibial plateau fractures can expect good to excellent outcomes when treated nonsurgically. LEVEL OF EVIDENCE: Level III, retrospective comparative study.