Can traditional bonesetters become trained technicians? Feasibility study among a cohort of Nigerian traditional bonesetters.

BACKGROUND: Traditional bonesetters (TBS) provide the majority of primary fracture care in Nigeria and other low- and middle-income countries (LMICs). They are widely patronized and their services are commonly associated with complications. The aim of the study was to establish the feasibility of formal training of TBS and subsequent integration into the healthcare system. METHODS: Two focus group discussions were conducted involving five TBS and eight orthopaedic surgeons in Enugu Nigeria. Audio-recordings made during the focus groups were transcribed verbatim and analysed using a thematic analysis method. RESULTS: Four themes were identified: Training of TBS, their experiences and challenges; perception of traditional bonesetting by orthopaedic surgeons; need for formal training TBS and willingness to offer and accept formal training to improve TBS practice. Participants (TBS group) acquired their skills through informal training by apprenticeship from relatives and family members. They recognized the need to formalize their training and were willing to accept training support from orthopaedists. The orthopaedists recognized that the TBS play a vital role in filling the gap created by shortage of orthopaedic surgeons and are willing to provide training support to them. CONCLUSION: This study demonstrates the feasibility of providing formal training to TBS by orthopaedic surgeons to improve the quality of services and outcomes of TBS treatment. This is critical for integration of TBS into the primary healthcare system as orthopaedic technicians. Undoubtedly, this will transform the trauma system in Nigeria and other LMICs where TBS are widely patronized.

The Estimated Cost of Maintenance of Certification.

BACKGROUND: Maintenance of Certification (MOC) is a controversial topic in medicine for many different reasons. Studies have suggested that there may be associations between fewer negative outcomes and participation in MOC. However, MOC still remains controversial because of its cost. We sought to determine the estimated cost of MOC to the average orthopaedic surgeon, including fees and time cost, defined as the market value of the physician's time. METHODS: We calculated the total cost of MOC to be the sum of the fees required for applications, examinations, and other miscellaneous fees as well as the time cost to the physician and staff. Costs were calculated for the oral, written, and American Board of Orthopaedic Surgery Web-based Longitudinal Assessment (ABOS WLA) MOC pathways based on the responses of 33 orthopaedic surgeons to a survey sent to a state orthopaedic society. RESULTS: We calculated the average orthopaedic surgeon's total cost in time and fees over the decade-long period to be $71,440.61 ($7,144.06 per year) for the oral examination MOC pathway and $80,391.55 ($8,039.16 per year) for the written examination pathway. We calculated the cost of the American Board of Orthopaedic Surgery web-based examination pathway to be $69,721.04 ($6,972.10 per year). CONCLUSIONS: The actual cost of MOC is much higher than just the fees paid to organizations providing services. The majority of the cost comes in the form of time cost to the physician. The ABOS WLA was implemented to alleviate the anxiety of a high-stakes examination and to encourage efficient longitudinal learning. We found that the ABOS WLA pathway does save time and money when compared with the written examination pathway when review courses and study periods are taken. We believe that future policy changes should focus on decreasing physician time spent completing MOC requirements, and decreasing the cost of these requirements, while preserving the model of continued evidence-based medical education.

Professionalism: the James Pryor memorial lecture.

James Pryor was born in country Victoria in 1928 and died there in 2002. He received his medical degree from Melbourne University in 1950 with honours in surgery. He went on to become a Fellow of the Royal College of Surgeons and of the Royal Australasian College of Surgeons.

Can We Agree on Expectations and Assessments of Graduating Residents?: 2016 AOA Critical Issues Symposium.

Orthopaedic educators are responsible for training a prepared and competent workforce that will provide effective care for a growing number of patients with musculoskeletal conditions. Currently, there are both internal and external forces that pose substantial challenges to medical students, residents, program directors, faculty members, and chairs in achieving this goal. One area of particular concern is the education of surgeons, whose knowledge and professional behavior must be matched by their ability to acquire procedural skills. In order to address this issue, many training systems have implemented a competency-based training approach into their curricula. This article discusses the efforts that orthopaedic training bodies in Canada and Australia have taken toward competency-based education and what steps the American Board of Orthopaedic Surgery (ABOS), the Council of Orthopaedic Residency Directors (CORD), the American Orthopaedic Association (AOA), the American Academy of Orthopaedic Surgeons (AAOS), and the Accreditation Council for Graduate Medical Education (ACGME) are considering to improve residency education in the current and future environments.

Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident Education.

The quality of care delivered by orthopedic surgeons continues to grow in importance. Multiple orthopedic programs, organizations, and committees have been created to measure the quality of surgical care and reduce the incidence of medical adverse events. Structured root cause analysis and actions (RCA2) has become an area of interest. If performed thoroughly, RCA2 has been shown to reduce surgical errors across many subspecialties. The Accreditation Council for Graduate Medical Education has a new mandate for programs to involve residents in quality improvement processes. Resident engagement in the RCA2 process has the dual benefit of educating trainees in patient safety and producing meaningful changes to patient care that may not occur with traditional quality improvement initiatives. The RCA2 process described in this article can provide a model for the development of quality improvement programs. In this article, the authors discuss the history and methods of the RCA2 process, provide a stepwise approach, and give a case example. [Orthopedics. 2017; 40(4):e628-e635.].

Maintaining standards in surgical training: how effective is the accreditation by the Specialist Advisory Committee in the United Kingdom?

In order to assess the efficacy of inspection and accreditation by the Specialist Advisory Committee for higher surgical training in orthopaedic surgery and trauma, seven training regions with 109 hospitals and 433 Specialist Registrars were studied over a period of two years. There were initial deficiencies in a mean of 14.8% of required standards (10.3% to 19.2%). This improved following completion of the inspection, with a mean residual deficiency in 8.9% (6.5% to 12.7%.) Overall, 84% of standards were checked, 68% of the units improved and training was withdrawn in 4%. Most units (97%) were deficient on initial assessment. Moderately good rectification was achieved but the process of follow-up and collection of data require improvement. There is an imbalance between the setting of standards and their implementation. Any major revision of the process of accreditation by the new Post-graduate Medical Education and Training Board should recognise the importance of assessment of training by direct inspection on site, of the relationship between service and training, and the advantage of defining mandatory and developmental standards.

Physician tiering by health plans in Massachusetts.

BACKGROUND: Physician tiering is an emerging health-care strategy that purports to grade physicians on the basis of cost-efficiency and quality-performance measures. We investigated the consistency of tiering of orthopaedic surgeons by examining tier agreement between health plans and physician factors associated with top-tier ranking. METHODS: Health plan tier, demographic, and training data were collected on 615 licensed orthopaedic surgeons who accepted one or more of three health plans and practiced in Massachusetts. We then computed the concordance of physician tier rankings between the health plans. We further examined the factors associated with top-tier ranking, such as malpractice claims and socioeconomic conditions of the practice area. RESULTS: The concordance of physician tiering between health plans was poor to fair (range, 8% to 28%, κ = 0.06 to 0.25). The percentage of physicians ranked as top-tier varied widely among the health plans, from 21% to 62%. Thirty-eight percent of physicians were not rated top-tier by any of the health plans, whereas only 5.2% of physicians were rated top-tier by all three health plans. Multivariate analysis showed that board certification, accepting Medicaid, and practicing in a suburban location were the independent factors associated with being ranked in the top tier. More years in practice or fewer malpractice claims were not related to tier. CONCLUSIONS: Current methods of physician tiering have low consistency and manifest evidence of geographic and demographic biases.

Pay for performance in orthopaedic surgery.

In recent decades American medicine has undergone tremendous changes. Numerous reimbursement and systems approaches to controlling medical inflation and improving quality have failed to provide cost-effective, high-quality health care in most circumstances. Public and private payers are currently implementing pay for performance, a new reimbursement method linking physician pay to evidence of adherence to performance measures, to constrain costs, encourage efficiency, and maximize value for health care dollars. High-quality research regarding pay for performance and its impact is scarce, particularly in orthopaedic surgery. Although supporters argue pay for performance will remedy the fragmented, costly delivery of health services in the United States, skeptics raise concerns about disagreement over quality guidelines, financial implications for providers and hospitals, inadequate infrastructure, public reporting, system gaming, and physician support. Our survey of orthopaedic surgeons reveals limited understanding of pay for performance, marked skepticism of nonphysician stakeholders' intentions, and a strong desire for greater clinician involvement in shaping the pay for performance movement. As pay for performance will likely be a long-term change that will have an impact on every orthopaedic surgeon, clinician awareness and participation will be fundamental in creating successful pay for performance programs.