Holding the Knife on Perceptions of Surgery.

OBJECTIVE: Negative stereotypes associated with surgery by medical students are well documented in literature. Many cite long hours, poor work-life balance, pessimism, mean personalities, and cynicism as pervasive among surgeons and operating room culture. If allowed to persist, these negative perceptions can deter otherwise interested students from pursuing surgical subspecialties. DESIGN: Incorporation of peer-teaching in the third-year clerkship to not only illuminate the hidden curriculum in surgery but adequately prepare students to participate in the operating room is paramount to taking steps to improve student perception as well as success as clerkship students. SETTING: An academic medical center. PARTICIPANTS: Pre-clinical medical students. RESULTS: One-hundred and forty-three third year clerkship students were surveyed with pre- and postinstruments. Students who participated in these pre clerkship peer-teaching sessions reported significant improvements in their ability to identify surgical anatomy (p < 0.001), an increased confidence in answering questions from attendings about anatomy and function as well as in identifying anatomical abnormalities (all p < 0.001). Students also reported significantly improved perceptions about surgeons as teachers and their willingness to support students pursuing surgery. CONCLUSION: This study demonstrates that the incorporation of an immersive orientation prior to the start of the surgery clerkship has significantly positive impacts on the learning experience and confidence of medical students. Increased efforts should be made to introduce students to surgeons, surgical careers, and the operating room prior to the surgery clerkship, being sure to incorporate aspects of the hidden curriculum, to address the negative perceptions that continue to exist regarding surgical fields.

Intimidating Attendings: The Importance of Near-Peer Mentorship During Third-Year Surgical Clerkship.

INTRODUCTION: Near-peer instruction has grown in popularity in medical education; however, limited data exist to support its effectiveness. This study investigates the perceptions of near-peer style instruction in third-y medical students undergoing a surgical clinical clerkship. We hypothesized that near-peer instruction would provide a beneficial educational experience to third-y medical students during their surgical clinical clerkship. METHODS: The authors anonymously surveyed third-y medical students undergoing their clinical clerkship in surgery on their perception of the near-peer instruction and mentorship they received from fourth-y medical students at the beginning of the clerkship. Near-peer instruction included teaching suturing techniques, surgical procedures and anatomy, operating room literacy, and sharing anecdotal experiences. Surveys were distributed 24 h after receiving the formal instruction. RESULTS: A total of 85 students completed the survey (78% response rate). Students reported a similar or increase in value of learning from near-peer mentors compared to attending physicians (less valuable: 1.2%; just as valuable: 52.9%; more valuable: 45.9%). The majority of students indicated they would like to experience more near-peer style instruction in medical school as demonstrated in surgical clerkship training (absolutely no: 0%; probably not: 0%; on the fence: 4.7%; probably yes: 25.9%; absolutely yes: 69.4%). After experiencing near-peer instruction and mentoring, students were more interested in becoming near-peer mentors (less interested: 1.2%; just as interested: 29.4%; more interested: 69.4%). CONCLUSIONS: Students appreciate and desire near-peer instruction, seeing it as an effective learning method. Mentees undergoing near-peer style instruction have an increased interest in becoming near-peer mentors.

MRI Accurately Predicts Quadrupled Semitendinosus Autograft Size Using Posterior Hamstring Harvest for ACL Reconstruction.

Purpose: To determine the effectiveness of preoperative magnetic resonance imaging (MRI) measurements of the cross-sectional area (CSA) of the semitendinosus tendon in predicting the intraoperative quadrupled semitendinosus graft diameter of a posteriorly harvested hamstring autograft for anterior cruciate ligament (ACL) reconstruction. Methods: A retrospective review of patients who underwent ACL reconstruction with autograft using a posterior hamstring harvest was performed. Patient demographics and operative reports were reviewed, and measurements of the CSA of the semitendinosus on MRI were performed. Multiple linear regression was used to analyze the predictors for graft diameter. A P value < .05 was considered statistically significant. Interrater and intrarater reliability were calculated. Results: 280 patients were included. Patient height (P < .0001), and CSA of the semitendinosus (P < .0001) were significant predictors. Patients shorter than 63 inches had an average graft diameter of 7.89 mm compared to 8.69 mm for patients above 63 in (P < .001). The formula for the model is as follows: Graft diameter (mm2) = 2.74 + .067·Height (in) + .00009 · Weight (lbs) + .0018 · Age (years) +.12·Gender (1 if M, 0 if F) + 8.56 · CSA (cm2). The R2 for the model (0.5620), was greater than models using only height (R2 = .4092) or only CSA Semitendinosus (R2 = .3932). None of the interaction terms between covariates (e.g., height, weight, age, gender) were significant. Age (P =.6400), weight (P = .9970), and gender (P = .6700) were not significant predictors. Both intraclass (ICC = 0.864, 95% CI=[0.791, 0.912]) and interclass correlation (ICC=0.827, 95% CI=[0.715, 0.894]) showed good reliability. Conclusion: CSA semitendinosus tendon and patient height independently perform similarly as predictors of graft diameter. When used together, CSA and height accurately predict the graft diameter. In particular, for patients under 63 in tall who demonstrated an average graft diameter below the minimum 8 mm, as suggested by the literature, this may be a useful tool for preoperative planning of patients intending to undergo ACL reconstruction with posterior hamstring harvest. Level of Evidence: Level III, diagnostic: retrospective cohort study.

Perceived Value of Public Health and Health Policy Information Among Medical Students: A Cross-sectional Study.

Introduction: Health educators have had difficulty introducing health policy and public health training into an already intensive medical school curriculum. Although the COVID-19 pandemic may have changed perspectives on the importance of public health, it may not change educational approaches. Assessment of medical student opinions and perceptions of health policy and public health might influence the weight given to these topics in medical education. Methods: We used a 39-item instrument to cross-sectionally survey medical students, to assess their perceptions of the value of public health and health policy within their professional education. Results: One hundred two students completed the survey (13% response rate). Most students reported an interest in public health (94.1%) and health policy (92.2%). Although interested, most students lacked confidence in their knowledge of public health and health policy on both state (health policy 34.3% confident; public health 43.1%) and national (health policy 41.0%; public health 44.1%) levels. Most students perceived that their institution has not sufficiently prepared them to understand health policy (34% felt prepared) and most reported insufficient information to participate in policy discussions (30.3% sufficiently informed). Conclusions: Medical students reported an interest in public health and health policy while also reporting a lack of confidence in their level of preparedness to understand and participate in these fields, thus demonstrating a need for increased public health and health policy education within medical school curricula.

Managing Post-Operative Pain in Orthopedic Patients: An International Comparison.

Introduction: Opioids play a crucial role in post-operative pain management in America, but not in some other countries. We sought to determine if a discrepancy in opioid use between the United States (U.S.) and Romania, a country that administers opioids in a conservative fashion, would show in subjective pain control differences. Methods: Between May 23, 2019, and November 23, 2019, 244 Romanian patients and 184 American patients underwent total hip arthroplasty or the surgical treatment of the following fractures: bimalleolar ankle, distal radius, femoral neck, intertrochanteric, and tibial-fibular. Opioid and non-opioid analgesic medication use and subjective pain scores during the first and second 24 hours after surgery were analyzed. Results: Subjective pain scores for the first 24 hours were higher among patients in Romania compared to the U.S. (p < 0.0001), but Romanians reported lower pain scores than U.S. patients in the second 24-hours (p < 0.0001). The quantity of opioids given to U.S. patients did not differ significantly based on sex (p = 0.4258) or age (p = 0.0975). However, females reported higher pain scores than male patients following the studied procedures (p = 0.0181). No sex-based differences in pain scores were noted among Romanian patients. Conclusions: Higher pain scores in American females, despite equivalent amounts of narcotics to their male counterparts, and the absence of a difference in Romanians suggested that the current American post-operative pain regimen may be tailored to the needs of male patients. In addition, it pointed to the impacts of gender, compared to sex, in pain experiences. Future research should look for the safest, most efficacious pain regimen suitable for all patients.

Traumatic Peroneal Nerve Injuries: A Systematic Review.

BACKGROUND: The common peroneal nerve (CPN) is the most commonly injured peripheral nerve of the lower extremity in patients with trauma. Traumatic CPN injuries have historically been associated with relatively poor outcomes and patient satisfaction, although improved surgical technique and novel procedures appear to improve outcomes. Given the variety of underlying injury modalities, treatment options, and prognostic variables, we sought to evaluate and summarize the current literature on traumatic CPN injuries and to provide recommendations from an analysis of the included studies for treatment and future research. METHODS: A systematic review was performed using PubMed, Embase, and Cochrane databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Search terms consisted of variations of "peroneal nerve" or "fibular nerve" combined with "injury," "laceration," "entrapment," "repair," or "neurolysis." Information with regard to treatment modality, outcomes, and patient demographic characteristics was recorded and analyzed. RESULTS: The initial search yielded 2,301 articles; 42 met eligibility criteria. Factors associated with better outcomes included a shorter preoperative interval, shorter graft length when an interposed graft was used, nerve continuity, and younger patient age. Gender or sex was not mentioned as a factor affecting outcomes in any study. Motor grades of ≥M3 on the British Medical Research Council (MRC) scale are typically considered successful outcomes. This was achieved in 81.4% of patients who underwent neurolysis, 78.8% of patients who underwent end-to-end suturing, 49.0% of patients who underwent nerve grafting, 62.9% of patients who underwent nerve transfer, 81.5% of patients who underwent isolated posterior tibial tendon transfer (PTTT), and 84.2% of patients who underwent a surgical procedure with concurrent PTTT. CONCLUSIONS: Studies included in this review were heterogenous, complicating our ability to perform further analysis. It is not possible to uniformly advocate for the best treatment option, given diverse injury modalities and patient presentations and a variety of prognostic factors. Many studies do not show outcomes with respect to injury modality. Future studies should show preoperative muscle strengths and should clearly define outcomes based on the injury modality and surgical treatment option. This would allow for greater analysis of the most appropriate treatment option for a given mechanism of injury. Newer surgical techniques are promising and should be further explored. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Unicompartmental knee arthroplasty: A PearlDiver study evaluating complications rates, opioid use and utilization in the Medicare population.

PURPOSE: Despite increased utilization of unicompartmental knee arthroplasty (UKA) for unicompartmental knee osteoarthritis, outcomes in Medicare patients are not well-reported. The purpose of this study is to analyze practice patterns and outcome differences between UKA and TKA in the Medicare population. It is hypothesized that UKA utilization will have increased over the course of the study period and that UKA will be associated with reduced opioid use and lower complication rates compared to TKA. METHODS: Using PearlDiver, the Humana Claims dataset and the Medicare Standard Analytic File (SAF) were analyzed. Patients who underwent UKA and TKA were identified by CPT codes. Postoperative complications were identified by ICD-9/ICD-10 codes. Opioid use was analyzed by the number of days patients were prescribed opioids postoperatively. Survivorship was defined as conversion to TKA. RESULTS: In the Humana dataset, 7,808 UKA and 150,680 TKA patients were identified. 8-year survivorship was 87.7% (95% CI [0.861,0.894]). Postoperative opioid use was significantly higher after TKA (186.1 days) compared to UKA (144.7 days) (p < 0.01, Δ = 41.1, 95% CI = [30.41, 52.39]). In the SAF dataset, 20,592 UKA patients and 110,562 TKA patients were identified. Survivorship was highest in patients > 80 years old and lowest in patients < 70 years old. In both datasets, postoperative complication rates were higher in TKA patients compared to UKA patients in nearly all categories. CONCLUSIONS: UKA represents an increasingly utilized treatment for osteoarthritis in the Medicare population and may be comparatively advantageous to TKA due to reduced opioid use and complication rates after surgery. LEVEL OF EVIDENCE: Level III.

Defining Return to Sport: A Systematic Review.

BACKGROUND: Return to sport (RTS) commonly serves as a measure for assessment of clinical outcomes in orthopaedic sports medicine surgery. Unfortunately, while RTS is commonly utilized in research for this purpose, currently there is no widely accepted or standardized definition for when an athlete has officially returned to his or her sport. PURPOSE: To conduct a systematic review to evaluate and report the differences in specific definitions of RTS utilized in the orthopaedic surgery literature. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was performed using PubMed, EMBASE, and Cochrane Trials databases per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Search terms consisted of variations of "RTS" combined with variations of "orthopedic surgery" and "define" to capture as many relevant articles as possible. The definition of RTS was recorded and analyzed. RESULTS: A total of 718 articles were identified in the initial search, 29 of which met eligibility criteria, providing a clear definition of RTS. Of the 29 studies included, 20 (69.0%) defined RTS as an athlete competing in a game or other competitive play. Three (10.3%) defined this as the athlete competing in a game or other competitive play but with an explicitly stated competition-level modifier of the athlete returning to his or her preinjury level of competition. Two articles (6.9%) included returning to training or practice, and the remaining 4 articles (13.8%) used terminology other than the standard RTS. CONCLUSION: There is variability in the definition of RTS used in orthopaedic sports medicine literature. Most studies refer to the athlete competing in a game or other competitive play. Other variants include returning to practice/training and explicitly defined competition levels and objectives. Future studies should aim to standardize the definition of RTS to facilitate more precise assessment of outcome after sports medicine surgery. Using terminology that describes components of the recovery and rehabilitation process, such as "return to participation" and "return to performance," in addition to RTS will allow us to more clearly understand the athlete's recovery and associated level of competition or performance.