Is There Unconscious Bias in the Orthopaedic Residency Interview Selection Process?

OBJECTIVE: Orthopaedic surgery has historically been a white male-dominated field. Given the diverse patient population presenting to providers with musculoskeletal pathology, it is thought that it would be beneficial for the orthopaedic workforce to more closely mirror this patient population. This study aims to elucidate whether unconscious bias may have an effect on the scoring of applications for residency interview selection. DESIGN: Applications for the 2019-2020 residency match cycle were initially reviewed and scored by faculty members. Applications were then redacted of all information suggestive of race or gender and returned to evaluators for rescoring after at least 6 months. The pre and post-redaction data was compared using ANOVA and student's two-tailed t tests. SETTING: Department of Orthopaedic Surgery, Medical College of Georgia at Augusta University. PARTICIPANTS: Thirteen attending surgeons scored 320 2019-2020 Electronic Residency Application System (ERAS) applications, unblinded and blinded of applicant identifying information. RESULTS: Interviewed applicants were similar to the non-interviewed group in all measured variables except for higher pre-redaction scores (8.73-7.81; p = 0.02) which was expected (Table 2). Minority applicants had significant differences in Step 1 scores (243 vs 247; p < 0.01), Step 2 scores (251 vs 254; p = 0.01), articles (5.9 vs 3.8; p < 0.01), posters (5.9 vs 3.5; p < 0.01), and pre-redaction scores (7.44 vs 8.07; p = 0.01) compared to white applicants (Table 4). There was no relationship noted between step score and number or type of research items (Table 5). Pre-redaction and post-redaction scores were significantly different in white applicants who experienced a negative change (8.07-7.88; p = 0.03 (Table 6)). Males had statistically significant differences compared to females in Step 1 score (246 vs 243; p = 0.01) (Table 7). CONCLUSIONS: This study was unable to prove unconscious bias based on a lack of statistically significant change of score when blinded, however the direction in change of scores was unlikely to be accounted for exclusively by objective differences between applicants, suggesting a trend toward unconscious bias. It remains unclear how influential subjective portions of the ERAS application such as personal statements, Letters of Recommendation, hobbies, and activities are on the overall assessment of an applicant and whether or not unconscious bias manifests in these subjective portions. Further investigation is needed in this area. Until then, residency programs should take immediate measures to mitigate potential implicit bias in the residency interview selection process. Actions can include implicit bias training for all faculty members involved in resident selection, standardization of application scoring and possibly redacting all or portions of the ERAS application so that only objective academic markers are presented to evaluators. Gaining a better understanding of these barriers is not only essential for their removal, but also allows for better preparation of applicants for success in the match with the ultimate goal being to correct the persistent disparity in the field of orthopaedic surgery.

Opioid requirements in primary versus revision reverse shoulder arthroplasty.

PURPOSE: The purpose of this study is to evaluate the inpatient pain medication use of patients who had a revision shoulder arthroplasty procedure performed and compare them to a cohort of patients who had a primary reverse total shoulder arthroplasty (rTSA) performed to determine whether revision shoulder arthroplasty requires more pain medication.. METHODS: A retrospective review was performed on patients undergoing revision arthroplasty (n = 75) and primary rTSA (n = 340). Inpatient medication records were reviewed to tabulate the visual analog pain (VAS) all narcotic medication use, and total morphine equivalent units (MEUs) were calculated for the duration of the inpatient stay. RESULTS: There was no significant difference between groups regarding age, sex, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists score, preoperative narcotic pain medication use, tobacco use, postoperative VAS scores or hospital length of stay. There were no predictors of total postoperative MEUs identified. Overall, patients in the revision arthroplasty group received significantly less total MEUs than those in the primary rTSA group, 134.96 MEUs vs. 69.79 MEUs, respectively (p < .0005). CONCLUSION: The perceived notion that revision shoulder arthroplasty is more painful may cause providers to be more inclined to increase narcotic use, or use more invasive pain control techniques. Based on these data, we found that revision shoulder arthroplasty did not require an increased opioid requirement, longer length of stay or increase VAS, suggesting that these patients can often be managed similarly to primary rTSA.

Utility of Allograft Talus as a Source for Grafting of Concurrent Humeral and Glenoid Defects Associated With Anterior Glenohumeral Instability: An Anthropometric Analysis.

PURPOSE: To compare morphologic data of the talus using magnetic resonance images with previously reported values of the humeral head and the glenoid as a potential graft source for both the humeral head as well as glenoid reconstruction in the setting of concomitant glenoid and humeral head defects. METHODS: All magnetic resonance images of the ankle were reviewed for assessment of the morphology and variation of the talus among individuals. Patients with post-traumatic, osteoarthritic, or surgical changes to the distal tibia about the mid- or hind- foot, or patients with incomplete medical records were excluded. Radiographic parameters that were measured included the maximum vertical height (MVH), the height to the talar neck, the radius of curvature (ROC) of the talar dome, ROC of the subtalar joint, and the maximum medial-to-lateral width of the talar dome. Demographic data also were collected on each individual. Statistical analysis was performed via a linear regression model with backwards elimination to determine which demographic data correlated most strongly with talar anthropometric values. RESULTS: A total of 82 study patients met inclusion criteria (59 male, 23 female; mean age 40.91 ± 14.69 years). Sex was found have a positive correlation of the following talar dimensions: MVH (P = .039), talar dome ROC (P < .001), and subtalar joint ROC (p = 0.001). Height was the most positive correlation for medial-to-lateral width (P < .001), height to the talar neck (P = .004), and also correlate for MVH (P = .004). Body mass index was found to have multicollinearity and was therefore not used as a variable. CONCLUSIONS: Allograft talus appears to be a viable graft, as demonstrated in this anthropometric study for both reconstruction of the glenoid and humeral head when cases of bipolar glenohumeral bone loss are present. CLINICAL RELEVANCE: This study aims to further evaluate potential allograft donor sites for bipolar lesions.

Routine postoperative laboratory tests are unnecessary after primary reverse shoulder arthroplasty.

BACKGROUND: Obtaining postoperative laboratory studies after primary reverse shoulder arthroplasty (RSA) is a common practice. However, justification of this practice remains unclear. This study assesses the utility of routine postoperative laboratory studies in RSA. METHODS: The electronic medical records of 369 patients who underwent RSA over 10 years were retrospectively reviewed. A total of 213 patients qualified for analysis. Primary outcomes were intervention related to abnormal laboratory values, length of stay, and 90-day emergency department visits/readmissions. Multivariate logistic regression analysis was performed to identify risk factors associated with abnormal laboratory values and postoperative visits/readmissions. RESULTS: Of 213 patients analyzed, 188 (88.7%) had abnormal postoperative laboratory values: 69% had an abnormal hemoglobin (Hgb) or hematocrit level, but only 12% underwent interventions. Lower preoperative Hgb was a significant predictor of receiving a transfusion. A significant association existed between abnormal postoperative electrolyte and creatinine levels with lower body mass index (BMI) and higher Charlson Comorbidity Index (CCI). Only 4 patients (1.8%) received non-transfusion related intervention. Emergency department visits were not statistically different between patients with positive or negative laboratory tests (P = .73). CONCLUSION: Because 87.3% of laboratory studies did not influence patient management, we recommend against routine testing for primary RSA. This study demonstrates that the practice of obtaining routine postoperative laboratory studies is not justified. We recommend selectively obtaining a postoperative basic metabolic profile in patients with increased American Society of Anesthesiologists classification and/or CCI with a lower BMI. We also recommend selectively ordering postoperative complete blood count in patients with a lower preoperative Hgb.

Use of the Contralateral Glenoid for Calculation of Glenoid Bone Loss: A Cadaveric Anthropometric Study.

PURPOSE: The purpose of this study was to determine if there are significant side-to-side anthropometric differences between paired glenoids. METHODS: Forty-six matched-pair cadaver glenoids were harvested, and their glenoid heights (GHs) and glenoid widths (GWs) were measured with digital calipers. The glenoid surface area was calculated using the standard assumption that the inferior two-thirds of the glenoid is a perfect circle. RESULTS: There was a statistically significant difference between matched-pair GHs of 0.96 ± 3.07 mm (P = .020) and GWs of 0.46 ± 1.64 mm (P = .033). There was a significant difference of glenoid cavity area of 20.30 ± 81.53 mm2 (P = .044), or a difference of ∼3%. A total of 4 of 46 pairs of glenoids (8.6%) showed a difference in width >3 mm. CONCLUSIONS: This study demonstrates the fallacy of use of the contralateral glenoid in measuring glenoid bone loss. Although many paired samples exhibited similar side-to-side glenoid measurements, the number of cadaveric pairs that showed differences of >3 mm was substantial. Caution should be taken when using calculation methods that include this assumption for surgical decision making, as surface area, GW, and GH were all shown to have statistically significant side-to-side differences in their measurements. CLINICAL RELEVANCE: Many methods exist for measuring glenoid bone loss after anterior shoulder dislocation, but some of the current methods may be inaccurate and lead to unreliable estimations.