Implicit gender-career bias in postgraduate medical training still exists, mainly in residents and in females.

BACKGROUND: More and more female residents enter postgraduate medical training (PGMT). Meanwhile, women are still underrepresented in academic medicine, in leadership positions and in most surgical specialties. This suggests that female residents' career development may still be negatively impacted by subtle, often unconscious stereotype associations regarding gender and career-ambition, called implicit gender-career bias. This study explored the existence and strength of implicit gender-career bias in doctors who currently work in PGMT, i.e. in attending physicians who act as clinical trainers and in their residents. METHODS: We tested implicit gender-career bias in doctors working in PGMT by means of an online questionnaire and an online Implicit Association Test (IAT). We used standard IAT analysis to calculate participants' IAT D scores, which indicate the direction and strength of bias. Linear regression analyses were used to test whether the strength of bias was related to gender, position (resident or clinical trainer) or specialty (non-surgical or surgical specialty). RESULTS: The mean IAT D score among 403 participants significantly differed from zero (D-score = 0.36 (SD = 0.39), indicating bias associating male with career and female with family. Stronger gender-career bias was found in women (ßfemale =0 .11; CI 0.02; 0.19; p = 0.01) and in residents (ßresident 0.12; CI 0.01; 0.23; p = 0.03). CONCLUSIONS: This study may provide a solid basis for explicitly addressing implicit gender-career bias in PGMT. The general understanding in the medical field is that gender bias is strongest among male doctors' in male-dominated surgical specialties. Contrary to this view, this study demonstrated that the strongest bias is held by females themselves and by residents, independently of their specialty. Apparently, the influx of female doctors in the medical field has not yet reduced implicit gender-career bias in the next generation of doctors, i.e. in today's residents, and in females.

Rates and Causes of 90-day Complications and Readmissions Following Outpatient Hip and Knee Arthroplasty: A Retrospective Analysis of 525 Patients in a Single Institution.

BACKGROUND: Outpatient joint arthroplasty (OJA) has gained increasing popularity and success in a well-defined population. Safety concerns, in terms of complications and readmissions, however still exist. PATIENTS AND METHODS: This retrospective study included 525 patients (90 primary THAs, 277 primary TKAs, and 158 primary UKAs), initially planned for OJA. All complications and readmissions were evaluated for timing and cause (surgical vs medical) within a 90-day followup. Complications and readmissions were compared by the length of stay (LOS): same-day discharge (SDD) vs ≥1 day. Differences were assessed by the log-rank test. Complications and readmission risk were assessed using multivariable logistic regression analysis. RESULTS: The complication rate was 9.9% at 30 days and 15% at 90 days. The readmission rate was 2.5% at 30 days and 4.2% at 90 days. The majority of surgical complications and readmissions were the result of wound discharge (43% and 56%, respectively). Overall, we did not observe different rates between SDD and LOS ≥1. Following THA, but not TKA or UKA, the 90-day complication rate was significantly lower in patients that underwent SDD compared with LOS ≥1. The risk of complications was positively associated with TKA (vs THA and UKA), ASA III (vs ASA I), and Charnley C (vs Charnley A). The risk of readmissions was negatively associated with a BMI ranging from 25-29.9 kg/m2 (vs BMI <25 kg/m2). CONCLUSION: SDD following OJA did not result in more complications and hospital readmissions compared to a prolonged hospital stay. The majority of complications and readmissions were due to noninfected wound discharge.

Patients with hip resurfacing arthroplasty are not physically more active than those with a stemmed total hip.

Background and purpose - Hip resurfacing arthroplasty (HRA) was designed for the highly active patient because of the various theoretical advantages compared with stemmed total hip arthroplasty (THA), but has shown high failure rates. Physical activity (PA) after arthroplasty is frequently determined with the use of questionnaires, which are known for their subjective nature, recall bias, and ceiling effect. These disadvantages are not applicable to physical activity monitoring (AM) using sensors. We compared objectively measured PA at long-term follow-up in a matched cohort of HRA and stemmed THA subjects.Patients and methods - We compared 2 groups of 16 patients (12 males) in each group, one having received unilateral HRA (median age 56 years at surgery) and a matched group having received unilateral stemmed THA with a small diameter femoral head (28 mm) on conventional polyethylene (median age 60 years at surgery) with osteoarthritis as indication for surgery, 10 years after surgery. Groups were matched by sex, age at surgery, and BMI. The daily habitual PA was measured over 4 consecutive days in daily living using a 3-axis accelerometer, gyroscope, and magnetometer. Both quantitative parameters (time standing, sitting, walking, number of steps, and sit-stand transfers) and qualitative parameters (walking cadence) were determined.Results - The AM was worn for a median 13 (11-16) hours per day. The median daily step count was 5,546 (2,274-9,966) for the HRA group and 4,583 (1,567-11,749) for the stemmed THA-group with 39 (21-74) versus 37 (24-62) daily sit-stand transfers respectively. The other PA parameters were also similar in both groups.Interpretation - We found similar median PA levels and also identical ranges. While short-term effects may exist, ageing and related behavioral adaptations or other effects seem to render the theoretical activity benefits from HRA irrelevant at longer follow-up.

Who owns responsibility? An administrator's take on implementing time-variable medical training in teaching hospitals.

Introduction: Developments in outcome-based medical education led to the introduction of time-variable medical training (TVMT). Although this idea of training may be a consequence of competency-based training that calls for individualized learning, its implementation has posed significant challenges. As a new paradigm it is likely to have repercussions on the organization of teaching hospitals. The purpose of this study is therefore to explore how hospital administrators cope with this implementation process. Methods: We conducted an exploratory qualitative study for which we interviewed administrators of hospitals who were actively implementing TVMT in their postgraduate programs. Results: Several problems of implementation were identified: existing governance structures proved unfit to cope with the financial and organizational implications of TVMT. Administrators responded to these problems by delegating responsibilities to departments, reallocating tasks, learning from other hospitals and scaling up their teaching facilities. Conclusions: Hospital administrators perceived the implementation of TVMT as challenging. TVMT affects the existing equilibrium between education and clinical service. Administrators' initial attempts to regain control, using steering strategies that were based on known concepts and general outcomes, including cutting departmental budgets did not work, nor did their subsequent wait-and-see approach of leaving the implementation to the individual departments.

Effects of implementing time-variable postgraduate training programmes on the organization of teaching hospital departments.

INTRODUCTION: As competency-based education has gained currency in postgraduate medical education, it is acknowledged that trainees, having individual learning curves, acquire the desired competencies at different paces. To accommodate their different learning needs, time-variable curricula have been introduced making training no longer time-bound. This paradigm has many consequences and will, predictably, impact the organization of teaching hospitals. The purpose of this study was to determine the effects of time-variable postgraduate education on the organization of teaching hospital departments. METHODS: We undertook exploratory case studies into the effects of time-variable training on teaching departments' organization. We held semi-structured interviews with clinical teachers and managers from various hospital departments. RESULTS: The analysis yielded six effects: (1) time-variable training requires flexible and individual planning, (2) learners must be active and engaged, (3) accelerated learning sometimes comes at the expense of clinical expertise, (4) fast-track training for gifted learners jeopardizes the continuity of care, (5) time-variable training demands more of supervisors, and hence, they need protected time for supervision, and (6) hospital boards should support time-variable training. CONCLUSIONS: Implementing time-variable education affects various levels within healthcare organizations, including stakeholders not directly involved in medical education. These effects must be considered when implementing time-variable curricula.

Flexible competency based medical education: More time efficient, higher costs.

The financing of postgraduate medical education (PGME) becomes an important topic. PGME is costly, and in most western countries is partly paid by public funding. One of the models that can help to reduce costs is time-variable PGME. Moving to true outcome-based education can lead to more efficient training programs while maintaining educational quality. We analyzed the financial effects of time-variable PGME by identifying the educational activities of PGME programs and comparing the costs and revenues of these activities in gynecology training as an example. This resulted in a revenue-cost balance of PGME activities in gynecology. As gynecology consists of both surgical and non-surgical parts, this specialty is a good starting point for a training cost analysis that can be used for a more general discussion. Shortening PGME programs without losing educational quality appears to be possible with time-variable structures. However, shortening is only safely possible on those areas in which residents have already obtained the desired level of competence. This means that time can be gained at the expense of those educational activities in which residents generate the highest revenues. We therefore conclude that shorter education with the help of time-variable training schemes leads to overall higher costs at the hospital level.

Femoral Head Size is Correlated With Head Position in Very Elderly Patients.

BACKGROUND: In cases of femoral neck fracture, it is often not possible to accurately determine the original position of the head center to assess appropriate restoration of leg length. The aim of this study was to determine the accuracy of predicting the position of the femoral head center based on new and established correlations between the femoral head diameter (FHD) and the distance between the lesser trochanter and the femoral head center (LT-FHC) in the very elderly (aged ≥80 years) as the mainly affected but yet underinvestigated group. METHODS: The FHD and the LT-FHC distance were determined in 148 subjects (104 males, 44 females); 90 aged ≥80 years and 58 aged <80 years. For each age and gender subgroup one specific (LT-FHC)/FHD ratio was determined. The accuracy of the new determined ratios and the established ratios by others were compared by recalculating the LT-FHC distance of each individual subject. RESULTS: The FHD and the LT-FHC were significantly correlated, most strongly in elderly females (R = 0.554, P < .001). Using the new age- and gender-specific ratios, the LT-FHC distance could be predicted within 10 mm of the true value in 95% of the cases and in only 77% using previously reported formulas. CONCLUSION: Age- and gender-specific formulas yield higher accuracy than generic formulas. The formulas presented in this study can offer a practical, easy to use instrument for orthopedic surgeons performing hip arthroplasty in very elderly patients in addition to classic techniques to prevent significant leg-length discrepancy.

The Femoral Head Center Shifts in a Mediocaudal Direction During Aging.

BACKGROUND: Accurate reconstruction of hip joint biomechanics is the key stone in total hip arthroplasty. Although proximal femur morphology is known to vary with both age and gender, few studies investigated this in the very elderly (ie, ≥80 years). The purpose of this study was to compare basic morphological parameters describing the position of the femoral head between very elderly and middle-aged subjects. METHODS: Computed tomographic scans of the femur of 90 very elderly (mean 84 years, range 80-105 years) and 58 middle-aged subjects (mean 52 years, range 20-79 years) were made. After 3-dimensional reconstruction, the neck-shaft angle, femoral neck anteversion angle, femoral head height, femoral neck length, and mediolateral offset (ML-offset) were determined. RESULTS: The neck-shaft angle was on average 3.6° less in elderly males (125.9° ± 5.0°) than in middle-aged males (129.5° ± 5.1°) (P < .001). The femoral neck anteversion angle was not significantly different between both age and gender groups. The femoral head height was -12.3 mm in elderly females compared to -10.5 mm (Δ 17%) in elderly males (P = .284) and even -8.0 mm (Δ 54%) in middle-aged males. The ML-offset was 10% (4.1 mm) larger in elderly compared to middle-aged males (P < .001). CONCLUSION: These findings suggest that the femoral neck and head shift in a relative varus position during aging. Femoral prostheses with increased ML-offset and a lower caput-collum-diaphyseal angle are needed to accommodate the morphology of the femur in the very elderly. Care must be taken not to lengthen the operated leg, particularly in very elderly females.

Dealing with the complex dynamics of teaching hospitals.

Innovation and change in postgraduate medical education programs affects teaching hospital organizations, since medical education and clinical service are interrelated.Recent trends towards flexible, time-independent and individualized educational programs put pressure on this relationship. This pressure may lead to organizational uncertainty, unbalance and friction making it an important issue to analyze.The last decade was marked by a transition towards outcome-based postgraduate medical education. During this transition competency-based programs made their appearance. Although competency-based medical education has the potential to make medical education more efficient, the effects are still under debate. And while this debate continues, the field of medical education is already introducing next level innovations: flexible and individualized training programs. Major organizational change, like the transition to flexible education programs, can easily lead to friction and conflict in teaching hospital organizations.This article analyses the organizational impact of postgraduate medical education innovations, with a particular focus on flexible training and competency based medical education. The characteristics of teaching hospital organizations are compared with elements of innovation and complexity theory.With this comparison the article argues that teaching hospital organizations have complex characteristics and behave in a non-linear way. This perspective forms the basis for further discussion and analysis of this unexplored aspect of flexible and competency based education.

Adjustments in 2011 KSS increase the clinical suitability.

The 2011 KSS is a valid clinical TKA questionnaire, but with a low completion rate (42%). Adjustments, focusing on optimizing scale features, are required to improve its clinical use. The low completion rates, non-optimal scale features, lacking rules or a combination of these factors where addressed, leading to the development of the adjusted 2011 KSS (2011 KSS-A). Four-hundred-ninety-nine primary TKA patients were addressed pre- and postoperative by mail. Clinimetric quality was evaluated. Seventy percent responded and 90% completed the scale. Internal consistency proved excellent with Cronbach's Alpha≥0.79 for all subscales. Strong correlations were found between the Functional Activity subscales and KOOS-PS (r=-0.63 to -0.87). All subscales improved significantly after intervention (r-range 14-33%, effect size 0.50-2.85). Postoperatively, ceiling effects were found in the subscales Symptoms (16%) and Walking & Standing (26%). Adjustments led to a shortened and simplified questionnaire while maintaining its clinimetric quality.

The Morphology of the Proximal Femoral Canal Continues to Change in the Very Elderly: Implications for Total Hip Arthroplasty.

A shape mismatch between cementless stems and the femoral canal of very elderly patients could partly explain the inferior performance of cementless compared to cemented stems in this age group. Influences of age and gender on canal morphology were investigated by measuring coronal/sagittal dimensions on CT-scans of subjects ≥80 years old (n = 117) and subjects < 80 years old (n = 51). Absolute canal dimensions like width were larger in octogenarians than in younger subjects. These differences were larger in the sagittal plane than in the coronal plane (P < 0.001). Canal flaring changed asymmetrically with increased medial and less lateral flaring in octogenarians. Age-related changes were mainly observed in females and should be taken into consideration for implant design, selection and implantation in octogenarians.

A pilot study of a practice management training module for medical residents.

BACKGROUND: In 2005 a competency based curriculum was introduced in the Dutch postgraduate medical training programs. While the manager's role is one of the seven key competencies, there is still no formal management course in most postgraduate curricula. Based on a needs assessment we conducted, several themes were identified as important for a possible management training program. We present the results of the pilot training we performed to investigate two of these themes. METHODS: The topics "knowledge of the healthcare system" and "time management" were developed from the list of suggested management training themes. Fourteen residents participated in the training and twenty-four residents served as control. The training consisted of two sessions of four hours with a homework assignment in between. 50 True/false-questions were given as pre- and post-test to both the test and control groups to assess the level of acquired knowledge among the test group as well as the impact of the intervention. We also performed a qualitative evaluation using evaluation forms and in-depth interviews. RESULTS: All fourteen residents completed the training. Six residents in the control group were lost to follow up. The pre- and post-test showed improvement among the participating residents in comparison to the residents from the control group, but this improvement was not significant. The qualitative assessment showed that all residents evaluated the training positively and experienced it as a useful addition to their training in becoming a medical specialist. CONCLUSION: Our training was evaluated positively and considered to be valuable. This study supports the need for mandatory medical management training as part of the postgraduate medical curriculum. Our training could be an example of how to teach two important themes in the broad area of medical management education.

Perioperative Differences Between Outpatient and Inpatient Pathways Following Hip and Knee Arthroplasty.

Background: Optimization of clinical pathways and logistics led to the introduction of outpatient joint arthroplasty of the hip and knee. Nevertheless, little is known about what these current protocols look like and how they differ from "standard" inpatient protocols. This study aimed to find preoperative, intraoperative, and postoperative differences between outpatient and inpatient pathways. Methods: A questionnaire (ranging between 23 and 37 items) was developed and administered by email to orthopedic surgeons who were a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 38% (N = 117). Results: No significant differences were found in preoperative pathway characteristics. The administration regime for tranexamic acid significantly differed between outpatient and inpatient pathways (P < .001 and P = .002 for hip and knee arthroplasty, respectively), with outpatient pathways using a combined (eg, oral and intravenous) administration regime more frequently. The perioperative antibiotic prophylaxis regime also significantly differed between outpatient and inpatient pathways (P < .001 and P = .014, respectively), with outpatient pathways more frequently incorporating fewer antibiotic doses. Same-day postoperative mobilization significantly less often occurred if surgery took place later that day in inpatient hip arthroplasty pathways (24%; P = .034). Postoperative hemoglobin-check occurred significantly more often on indication in outpatient than in inpatient hip and knee arthroplasty pathways (∼75% vs ∼25%; P = .001). Conclusions: Few intraoperative and postoperative differences in outpatient and inpatient pathways were found and probably mainly relied on logistical grounds. Nonetheless, findings suggested that outpatient pathways tended to be more up-to-date and innovative than inpatient pathways.

In vivo measurements of blood flow and bone metabolism in osteoarthritis.

With increasing age, there may be a decrease in femoral blood flow. In some patients, this may result in local ischaemia, which subsequently may lead to local degenerative changes. Consequently, bone blood flow may play an important role in the aetiology of osteoarthritis of the hip. Little is known about bone blood flow in the femoral head of patients with advanced hip osteoarthritis. The purpose of this study was to evaluate bone blood flow and metabolism in vivo in patients with osteoarthritis of the hip. Ten patients with symptomatic osteoarthritis of the hip were enrolled prospectively. Femoral bone blood flow and metabolism were measured using positron emission tomography together with H2(15)O and [(18)F]fluoride, respectively. Blood flow was 0.054 ± 0.032 mL cm(-3) min(-1) and 0.041 ± 0.012 mL cm(-3) min(-1) in symptomatic and contralateral femoral heads, respectively (p = 0.435). The net flux of fluoride from plasma to bone mineral (K i ) was significantly (p = 0.027) higher in the femoral head of the osteoarthritic hip (0.022 ± 0.012 mL cm(-3) min(-1)) than in that of the contralateral hip (0.007 ± 0.005 mL cm(-3) min(-1)). This study showed significant increase in bone metabolism in the proximal femur of patients with symptomatic osteoarthritis of the hip joint. There was no evidence of decreased blood flow.

Survival rates of anatomically shaped and tapered slip cemented femoral implants: an analysis of 76,281 femoral implants of the Dutch arthroplasty register (LROI).

INTRODUCTION: In cemented total hip arthroplasty (THA) various shapes and geometries of femoral implants are in use. Collarless, polished, and tapered (CPT) implants, and anatomically shaped (AS) implants are most commonly used. Due to their different design features, this might lead to different survival outcomes. In this register-based study, overall implant survival and short-term complications of CPT and AS cemented implants were evaluated. METHODS: Data of the Dutch Arthroplasty Register (LROI) were used. Cemented femoral implants, which could be classified as CPT or AS were included in this study. Implants were excluded when no classification could be made or if implanted <100 times. Survival analyses were performed using Kaplan-Meier survival analysis and multivariable Cox-proportional hazard analysis. RESULTS: 76,281 cemented THAs were included. At a mean of 5.1 years follow-up (SD 3.1, range 0-12 years), the overall survival of the AS implants was higher compared with the CPT implants, with a survival, of 99.2% and 99.0% respectively (log-rank; p < 0.001). Multivariable regression analysis revealed a higher rate for revision because of loosening of the AS implants (HR 2; CI, 1.4-3.1). AS implants had a lower rate for periprosthetic fractures compared with the CPT implants (HR 0.13; CI, 0.07-0.23). CONCLUSIONS: Both designs show excellent overall survival rates at short-term follow-up. There is a higher overall survival of AS implants when compared with CPT implants. Revision for implant loosening, however, was statistically significantly higher in AS implants when compared with the CPT implants.

Age-Associated Changes in Proximal Femur Morphology Affect Femoral Component Sizing in Cementless Hip Arthroplasty.

Background: In cementless hip arthroplasty, the femoral component should obtain firm fixation within the endosteal bone and achieve adequate reconstruction of hip joint biomechanics simultaneously. Previous anatomical studies described age-related changes of the proximal femoral canal, such as canal widening, which theoretically necessitates the use of larger stem sizes in elderly patients. This study examines a potential association between patients' age at surgery and the implant size of a cementless femoral component. Material and methods: A total of 13,423 primary hip arthroplasties with a single cementless stem registered in the Dutch Arthroplasty Register (LROI) were included. Patient characteristics (ie patients' age, sex, height and weight at time of surgery) and femoral component size were derived. A one-way ANCOVA was used to compare the mean stem size between age groups, and multivariable linear regression analysis was used in order to investigate to which extent ageing impacted stem size. Results: Each subsequent age- group (ten-year intervals) had a significantly larger mean stem size than the prior age- group. Multivariable linear regression analysis revealed that age is positively correlated with stem size and that this correlation is more prominent in females than in males (beta = .046, P < .001 and beta = .028, P < .001 respectively). Interpretation: Implant size is positively correlated with age, in particular in females and independently from investigated anthropometric characteristics. The present study endorses that the femoral canal morphology is related to patients' characteristics such as age and sex. The morphology will subsequently influence implant sizing and therefore may have biomechanical and clinical implications.

Disappointing evaluation of a shared decision-making intervention for residents and orthopaedic surgeons.

OBJECTIVE: To evaluate a shared decision-making (SDM) intervention in orthopaedic hip and knee osteoarthritis care. METHODS: Using a pre- post intervention design study, we tested an intervention, that included a decision aid for patients (ptDA) and a SDM training course for residents in training and orthopaedic surgeons. The theory of planned behaviour was used for intervention development. Primary outcomes included patient reported decisional conflict, SDM, and satisfaction. Secondary outcomes were physicians' attitude and knowledge, and uptake of the ptDA. RESULTS: 317 patients were included. The intervention improved physicians' knowledge about SDM but had no effect on the primary outcomes. 19 eligible patients used the ptDA (17%). SDM was higher for middle educated patients compared to lower educated (mean difference 9.91, p=0.004), patients who saw surgeons instead of residents (mean difference 5.46, p=0.044) and when surgery was chosen and desired by patients compared to situations where surgery was desired but not chosen (mean difference 15.39, p=0.036). CONCLUSION: Our multifaceted intervention did not improve SDM and ptDA uptake was low. PRACTICE IMPLICATIONS: In orthopaedic hip and knee osteoarthritic care other ways should be explored to successful implement SDM. Since residents received lower SDM scores, special focus should go to this group.

Orthopaedic surgeons' perspective on the implementation of outpatient hip and knee arthroplasty - Results of a nationwide survey.

Background: Outpatient joint arthroplasty (OJA) for the hip and knee is gaining popularity among orthopaedic surgeons worldwide. The purposes of this study were to (1) assess the proportion of Dutch orthopaedic surgeons who perform OJA; (2) identify surgeons' willingness to implement OJA in the future; (3) identify reasons and barriers to implement OJA; and (4) gather surgeon's perspective on the implementation of OJA. Methods: A 20-item survey was developed and administered by email to orthopaedic surgeons who are a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 40% (N = 123). Results: Twenty-two respondents (18%) already implemented OJA, and 46% of respondents (who don't perform OJA) were interested to implement OJA in the future. Reasons to perform OJA included own positive experiences (82%), available evidence (77%) and patients' request (77%). Proponents' and opponents' view on safety and added value conflicted with each other. Other barriers included patient selection and organizational related (e.g., multidisciplinary support). Surgeons' view on evolution and relevance of OJA significantly differed by respondents who perform OJA versus respondents who don't perform OJA. Most respondents agreed with one another that the healthcare institution benefits most from OJA, and that optimization of the arthroplasty pathway could be reached through better patient education and -participation (e.g., eHealth, wearables). Conclusion: One in five respondents currently implement OJA pathways, and about half of the remaining respondents are interested to implement OJA in the future. OJA-opponents aren't convinced of the value and safety of OJA, despite accumulating evidence supporting OJA. Future research should inform patient-selection and -acceptance and organizational implementation.