Donna Phillips

Management of lateral humeral condylar fracture in children.

Abstract Lateral condylar fractures constitute 12% to 20% of all pediatric distal humerus fractures. These fractures are easily missed and when not managed appropriately can displace. Missed fracture is a common cause of nonunion and deformity; thus, a high index of suspicion and adequate clinical and radiographic evaluation are required. Displaced fractures are associated with a high rate of nonunion. Nondisplaced fractures or those displaced ≤2 mm are managed with cast immobilization and frequent radiographic followup. Fractures displaced >2 mm are managed with surgical fixation. Successful outcomes have been reported with closed reduction, open reduction, and arthroscopically assisted techniques. Complications associated with pediatric lateral condylar fracture include cubitus varus, cubitus valgus, fishtail deformity, and tardy ulnar nerve palsy.

Teaching Professionalism in Orthopaedic Surgery Residency Programs

Professionalism is difficult to define, to measure, and to teach. The word derives from the Latin verb profiteri , which means “to declare publicly.”1 This etymology embodies the dual nature of professionalism as a personal quality and an active behavior. Professionals must publicly declare the ideals to which they commit themselves and then expect that the public will hold them accountable for meeting those ideals. Members of a profession are also entrusted with the responsibility to educate and self-regulate its members. This paper will review the teaching and assessment of professionalism in orthopaedic surgery residency training. Several fields of medicine have defined professionalism. The American Academy of Pediatrics identified honesty and integrity, reliability, responsibility, respect for others, self-improvement, compassion and empathy, communication, collaboration, self-awareness, and altruism as professionalism’s central components2. The American Board of Internal Medicine, the European Federation of Internal Medicine, and the American College of Physicians (ACP) developed three principles and ten responsibilities of the medical professional. The “principles” are the primacy of patient welfare, patient autonomy, and social justice. Some of the “responsibilities” are commitments to ideals such as honesty, confidentiality, access to care, and trust3. Some have taken a philosophical approach to defining professionalism. For example, DeRosa proposed that professionalism is a moral undertaking that requires commitment to virtues such as fidelity, trust, benevolence, intellectual honesty, courage, compassion, and truthfulness4. Baldwin and Bunch built on work by psychologists and proposed that professionalism is a developmental process in which individuals progress from an awareness of, and sensitivity to, professionalism to actual professional conduct5. Christian et al. suggested that professionalism is grounded in altruism, or putting another’s interests ahead of one’s own6. Given the difficulty of defining professionalism, The Accreditation Council for Graduate Medical Education (ACGME) has …

Do orthopaedic fracture skills courses improve resident performance

INTRODUCTION We hypothesized that resident participation in a hands-on fracture fixation course leads to significant improvement in their performance as assessed in a simulated fracture fixation model. METHODS Twenty-three junior orthopaedic surgery residents were tasked to treat radial shaft fractures with standard fixation techniques in a sawbones fracture fixation simulation twice during the year. Before the first simulation, 6 of the residents participated in a fraction fixation skills course. The simulation repeated 6 months later after all residents attended the course. Residents also completed a 15-question written examination. Assessment included evaluation of each step of the procedure, a score based on the objective structured assessment of technical skill (OSATS) system, and grade on the examination. Comparisons were made between the two cohorts and the two testing time points. RESULTS Significant improvements were present in the percentage of tasks completed correctly (64.1% vs 84.3%) the overall OSATS score (13.8 vs 17.1) and examination correct answers (8.6 vs 12.5) for the overall cohort between the two testing time points (p<0.001, p<0.03, p<0.04 respectively). Residents who had not participated in the surgical skills course at the time of their initial simulation demonstrated significant improvements in percentage of tasks completed correctly (61.3% vs 81.2%) and OSATS score (12.4 vs 17.0) (p<0.002, p<0.01 respectively). No significant difference was noted in performance for the cohort who had already participated in the course (p=0.87 and p=0.68). The cohort that had taken the course prior to the initial simulation showed significantly higher scores at initial evaluation (88.5% vs 58.5% percentage of tasks completed correctly, 17.3 vs 12.0 OSATS score, 12.5 vs 8.6 correct answers on the examination). At the second simulation, no significant difference was seen with task completion or examination grade, but a significant difference still existed with respect to the OSATS score (20.0 vs 17.0; p<0.03). CONCLUSION Participation in a formal surgical skills course significantly improved practical operative skills as assessed by the simulation. The benefits of the course were maintained to 6 months with residents who completed the training earlier continuing to demonstrate an advantage in skills. Such courses are a valuable training resource which directly impact resident performance.

Direct Observation: Assessing Orthopaedic Trainee Competence in the Ambulatory Setting.

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.

Using Objective Structured Clinical Examinations to Assess Intern Orthopaedic Physical Examination Skills: A Multimodal Didactic Comparison

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.

Personality Factors Associated With Resident Performance: Results From 12 Accreditation Council for Graduate Medical Education Accredited Orthopaedic Surgery Programs

OBJECTIVES To understand the personality factors associated with orthopedic surgery resident performance. DESIGN 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 Data were collected from 12 orthopedic surgery residency programs1 throughout the United States. The level of clinical care provided by participating institutions varied. PARTICIPANTS 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 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.

Variation in pediatric orthopedic case volume among residents: an assessment of Accreditation Council for Graduate Medical Education case logs.

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.