Faculty Bibliography

BACKGROUND:Objective review of orthopedic resident medical records revealed significant variation in quality of clinical notes suggesting that the implementation of the electronic medical record (EMR) had altered resident perceptions of the purpose of clinical documentation. OBJECTIVE:The purpose of this study was to assess resident perceptions of the purpose and use of the EMR. METHODS:An 84-item survey was developed based on previously validated surveys. All 62 orthopedic residents within one academic institution completed the survey. Questions were divided into six domains and domain scores were calculated by summing responses within each domain; a more negative response on the Likert scale received a higher score. Scores were compared across postgraduate year (PGY). RESULTS:Survey results revealed that most residents agreed that they generally write good patient care notes, their notes contribute to the care of the patient, and as physicians they feel responsible for the accuracy of the information they enter into the EMR. However, residents were divided as to whether they have enough time to write a good patient care note. Domain scores did not significantly differ by PGY indicating that perceptions toward the EMR do not change even as residents increase their knowledge of orthopedics and become more skilled physicians. CONCLUSIONS:Although residents recognize that the information they enter in the EMR is valuable for patient care and safety, some feel unable to consistently utilize the EMR to its full potential due to time constraints.

INTRODUCTION/BACKGROUND:To aid implementing an ethics curriculum in an orthopaedic residency program, the American Academy of Orthopaedic Surgeons (AAOS) created 14 ethics scenarios. Because delivery of this curriculum could be burdensome, an online module-based curriculum might be optimal. METHODS:Two cohorts of orthopaedic residents participated: cohort I completed 14 online ethics modules converted from the 14 AAOS ethics scenarios. For each module, we gave a multiple-choice assessment immediately before the module, immediately afterward, and 3 months afterward. Cohort II completed only the 14-module assessments at similar time intervals without any educational content. RESULTS:Cohort I demonstrated improvement in 3-month postmodule assessment scores in 11 of the 14 modules, 3 of which had statistical differences in baseline scores for cohort I and cohort II. We observed no statistical difference in scores within cohort II on repeat testing. DISCUSSION/CONCLUSIONS:This study demonstrates that 11 of the 14 AAOS ethics scenarios, converted to online modules, teach ethical concepts to orthopaedic residents. Orthopaedic residency programs may find it valuable to engage their residents in the ethics scenarios created by the AAOS to complement their ethics curriculum.

The aim of this investigation was to examine graduating orthopedic resident case logs to evaluate trends in performing pediatric orthopedic procedures and compare pediatric orthopedic case volume among residents in the 90th, 50th, and 10th percentiles (by case volume) to identify caseload variation. Accreditation Council for Graduate Medical Education orthopedic resident case logs were examined for graduating years 2007-2013. Linear regression analyses were carried out to assess temporal trends in pediatric orthopedic case volume. Subgroup analyses were carried out to assess trends in cases by anatomic location. Comparisons of the number of pediatric cases performed by the 90th, 50th, and 10th percentiles of graduating residents were also performed. Pediatric orthopedic case volume increased significantly per graduating resident (295.9-373.2; P<0.001) from 2007 to 2013. Graduating residents in the 90th (494-573; P=0.001), 50th (264-334; P<0.001), and 10th (144-216; P=0.003) percentiles of case volume all sustained significant increases in the number of pediatric orthopedic cases performed. Subgroup analyses showed significant increases in pediatric orthopedic shoulder (4.8-7.3; P<0.001), humerus/elbow (25.9-32.7; P<0.001), forearm/wrist (28.6-40.4; P<0.001), hand/finger (15-16.9; P=0.005), femur/knee (44.5-51.9; P=0.002), leg/ankle (39.4-41.1; P=0.004), and spine case volume (24.9-33.6; P<0.001). On average, graduating residents in the 90th, 50th, and 10th percentiles performed 524, 302, and 169 cases, respectively. The current investigation shows significant growth in the number of pediatric orthopedic cases performed by graduating residents, particularly among upper extremity procedures. However, considerable variation in pediatric orthopedic case volume exists among residents. Although the educational effects of this case volume variation are incompletely understood, the current investigation may be beneficial in efforts to improve pediatric orthopedic educational quality.

OBJECTIVE: We developed a series of orthopedic unannounced standardized patient (USP) encounters for the purpose of objective assessment of residents during clinic encounters. DESIGN: Consecutive case-series. SETTING: NYU-Langone Multi-center Academic University Hospital System. PARTICIPANTS: NYU-Langone/Hospital for Joint Diseases Orthopedic Surgery residents; 48 consecutive residents assessed. METHODS: Four orthopedic cases were developed. USPs presented themselves as patients in outpatient clinics. Residents were evaluated on communication skills (information gathering, relationship development, and education and counseling). USPs globally rated whether they would recommend the resident. RESULTS: Forty-eight USP encounters were completed over a 2-year period. Communication skills items were rated at 51% (+/-30) "well done." Education and counseling skills were rated as the lowest communication domain at 33% (+/-33). Residents were globally recommended based on communication skills in 63% of the encounters recommended in 70% of encounters based on both professionalism and medical competence. CONCLUSIONS: The USP program has been useful in assessing residents' clinical skills, interpersonal and communications skills, and professionalism. Use of USP in orthopedic surgery training programs can be an objective means for trainee assessment.

OBJECTIVES/OBJECTIVE:To understand the personality factors associated with orthopedic surgery resident performance. DESIGN/METHODS:A prospective, cross-sectional survey of orthopedic surgery faculty that assessed their perceptions of the personality traits most highly associated with resident performance. Residents also completed a survey to determine their specific personality characteristics. A subset of faculty members rated the performance of those residents within their respective program on 5 dimensions. Multiple regression models tested the relationship between the set of resident personality measures and each aspect of performance; relative weights analyses were then performed to quantify the contribution of the individual personality measures to the total variance explained in each performance domain. Independent samples t-tests were conducted to examine differences between the personality characteristics of residents and those faculty identified as relevant to successful resident performance. SETTING/METHODS:throughout the United States. The level of clinical care provided by participating institutions varied. PARTICIPANTS/METHODS:Data from 175 faculty members and 266 residents across 12 programs were analyzed. RESULTS:The personality features of residents were related to faculty evaluations of resident performance (for all, p < 0.01); the full set of personality measures accounted for 4%-11% of the variance in ratings of resident performance. Particularly, the characteristics of agreeableness, neuroticism, and learning approach were found to be most important for explaining resident performance. Additionally, there were significant differences between the personality features that faculty members identified as important for resident performance and the personality features that residents possessed. CONCLUSION/CONCLUSIONS:Personality assessments can predict orthopedic surgery resident performance. However, results suggest the traits that faculty members value or reward among residents could be different from the traits associated with improved resident performance.

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.

Patient care is 1 of the 6 core competencies defined by the Accreditation Council for Graduate Medical Education (ACGME). The physical examination (PE) is a fundamental skill to evaluate patients and make an accurate diagnosis. The purpose of this study was to investigate 3 different methods to teach PE skills and to assess the ability to do a complete PE in a simulated patient encounter. DESIGN: Prospective, uncontrolled, observational. SETTING: Northeastern academic medical center. PARTICIPANTS: A total of 32 orthopedic surgery residents participated and were divided into 3 didactic groups: Group 1 (n = 12) live interactive lectures, demonstration on standardized patients, and textbook reading; Group 2 (n = 11) video recordings of the lectures given to Group 1 and textbook reading alone; Group 3 (n = 9): 90-minute modules taught by residents to interns in near-peer format and textbook reading. RESULTS: The overall score for objective structured clinical examinations from the combined groups was 66%. There was a trend toward more complete PEs in Group 1 taught via live lectures and demonstrations compared to Group 2 that relied on video recording. Near-peer taught residents from Group 3 significantly outperformed Group 2 residents overall (p = 0.02), and trended toward significantly outperforming Group 1 residents as well, with significantly higher scores in the ankle (p = 0.02) and shoulder (p = 0.02) PE cases. CONCLUSIONS: This study found that orthopedic interns taught musculoskeletal PE skills by near-peers outperformed other groups overall. An overall score of 66% for the combined didactic groups suggests a baseline deficit in first-year resident musculoskeletal PE skills. The PE should continue to be taught and objectively assessed throughout residency to confirm that budding surgeons have mastered these fundamental skills before going into practice.

The Accreditation Council of Graduate Medical Education requires that residency programs teach and assess trainees in six core competencies. Assessments are imperative to determine trainee competence and to ensure that excellent care is provided to all patients. A structured, direct observation program is feasible for assessing nontechnical core competencies and providing trainees with immediate constructive feedback. Direct observation of residents in the outpatient setting by trained faculty allows assessment of each core competency. Checklists are used to document residents' basic communication skills, clinical reasoning, physical examination methods, and medical record keeping. Faculty concerns regarding residents' professionalism, medical knowledge, fatigue, or ability to self-assess are tracked. Serial observations allow for the reinforcement and/or monitoring of skills and attitudes identified as needing improvement. Residents who require additional coaching are identified early in training. Progress in educational milestones is recorded, allowing an individualized educational program that ensures that future orthopaedic surgeons excel across all domains of medical and surgical competence.