Implementation of entrustable professional activities in multiple surgical residencies: A quality improvement approach.

BACKGROUND: The COVID-19 pandemic decreased the operative case volume for surgical residents. Our institution implemented Entrustable Professional Activities (EPAs) in all core surgical training programs to document the competency of graduating residents. Continuation of this project aimed to improve implementation. METHODS: This project occurred at a large academic center with eight surgical specialties during the 2020-21 (Year 1) and 2021-22 (Year 2) academic years. Each specialty chose five EPAs, and residents were asked to obtain three micro-assessments per EPA. After the initial pilot year, program directors were surveyed regarding perceptions of EPA utility and barriers to implementation. RESULTS: Seventy senior residents completed 732/906 (80.8%) micro-assessments. Of these, 99.6% were deemed practice ready. Total micro-assessment completion rates in four specialties, four specific EPAs (including one EPA identified "at risk" due to the COVID-19 pandemic), and overall were significantly higher in Year 2 than Year 1 (p â€‹< â€‹0.05) CONCLUSIONS: Implementing EPAs in all core surgical specialties at an institution is achievable, though expectedly initially imperfect. An ongoing quality collaborative initiative focused on barriers to implementation can improve completion rates.

Providing Orthopaedic Care to Vulnerably Underserved Patients: AOA Critical Issues.

ABSTRACT: Implementation of the Affordable Care Act has increased the number of Americans with health insurance. However, a substantial portion of the population is still considered underserved, including those who are uninsured, underinsured, and those who are enrolled in Medicaid. The patients frequently face substantial access-to-care issues. Many underlying social determinants of health impact this vulnerable, underserved population, and surgeons must understand the nuances of caring for the underserved. There are numerous opportunities to engage with this population, and providing care to the indigent can be rewarding for both the vulnerably underserved patient and their surgeon.

Subungual Exostosis of the Hand: A Case Report in a 5-Year-Old Boy and Literature Review.

Subungual exostosis is a relatively uncommon benign tumor that occurs at the distal end of the distal phalanx of the toes and rarely the hands. We present in this article a review of the currently published English literature and provide a case report of a 5 year old male with subungual exostosis of the thumb. A 5 year old male presented with a slow growing mass of the distal dorsal aspect of the left thumb. Radiographs showed dorsal calcifications on the thumb. Surgical removal of the mass and histopathological analysis was performed supporting a diagnosis of subungual exostosis. Post-operatively, the patient had complete excision of the mass, normal nail morphology, no reoccurrence, and no post-surgical complications. Subungual exostosis remains a rare entity especially in the upper extremity. Its cause is not fully understood, nor is there an agreed upon method of treatment. However, with careful dissection during surgical removal good outcomes can be obtained. To our knowledge, this is the largest literature review on subungual exostosis and our case report is an uncommon presentation in the youngest reported male patient. It is our hope that this literature review and case report lend to increased awareness of subungual exostosis and how to diagnose and treat this lesion.

Socioeconomic status does not change decision-making in the treatment of distal radius fractures at a level 1 trauma center.

Objectives: To compare operative rates, total hospital charges, and length of stay between different socioeconomic cohorts in treating distal radius fractures (DRFs). Design: A retrospective cohort study. Setting: Large public level 1 trauma center. Patients: A retrospective search of all trauma activations over a 7-year period (2013-2020) yielded 816 adult patients diagnosed with DRF. Patients were separated into cohorts of socioeconomic status based on 2010 US Census data and insurance status. Intervention: DRFs were treated either nonoperatively using closed reduction and splinting or operatively using open reduction and internal fixation, closed reduction percutaneous pinning, or external fixator application. Main Outcome Measurements: Operative rates of DRF, total hospital charges, and length of stay. Results: Patients who were uninsured or in the low-income socioeconomic cohort had no significant difference in operative rates, total hospital costs, or length of stay when compared with their respective insured or standard income groups. Younger patients and those with OTA/AO type C, bilateral, or open DRFs were more likely to undergo operative intervention. Conclusions: This study demonstrates that low socioeconomic status based on annual household income and insurance status was not associated with differences in operative rates on DRFs, length of stay, or total hospital charges. These results suggest that outcome disparities between groups may be caused by postoperative differences rather than treatment decision-making. Although this study investigates access to surgical care at a publicly funded level 1 trauma center, disparities may still exist in other models of care. Level of Evidence: Prognostic Level III.