I-PSI: Short- and Long-Term Efficacy of a Comprehensive Initiative to Promote Patient Safety Event Reporting by Trainees.

Despite benefits of safety event reporting, few are trainee initiated. A comprehensive intervention was created to increase trainee reporting, partnering a trainee safety council with high-level faculty. Data were collected for 12 months pre intervention and 30 months post intervention, including short-term (1-12 mo) and long-term (13-30 mo) follow-up. A total of 2337 trainee events were submitted over the study period, primarily communication-related (40%) and on the medicine service (39%). Monthly submissions increased from 29.3 pre intervention to 66.2, 77.7, and 58.6 events/mo at post intervention, short-term follow-up, and long-term follow-up, respectively (P < 0.001). Proportion of hospital events submitted by trainees increased from 2.3% pre intervention to 4.1%, 4.9%, and 3.6% at post intervention, short-term, and long-term follow-up, respectively (P < 0.001). Trainee monthly submissions (P = 0.015) and proportion of hospital events (P < 0.001) declined from short- to long-term follow-up. Low- and intermediate-level harm events significantly increased post intervention (P < 0.001) while high-level events did not (P = 0.15-1.0). Our comprehensive intervention increased trainee event submissions at long-term follow-up.

Personality Predictors of Communication Skills Among Orthopedic Surgery Residents.

INTRODUCTION: This study examined the relationship between personality traits and interpersonal communication skills among first-year orthopedic surgery residents. METHOD: This study performed a retrospective analysis on the data collected in the 2 phases among the 6 cohorts of first-year orthopedic surgery residents (n = 73) during a 6-year period at an urban academic medical hospital. Resident personality was assessed through self-report prior to entry into the program and included a total of 7 personality traits. These traits were broken down into 2 categories, day to day, or usual, tendencies, which measured personality traits when no stress was present and stress tendencies, which measured personality traits when stressed or fatigued. The "day to day" tendencies measured were Emotional Stability, Agreeableness, Conscientiousness and Openness) and "stress" tendencies measured were Excitable, Skeptical and Imaginative. Communication skills were measured across 4 specific dimensions of patient communication (Engage, Empathy, Educate, Enlist) in an Objective Structured Clinical Examination (OSCE). RESULTS: Multiple regression analyses showed that the personality traits identified as "stress" tendencies predicted performance on 2 of the 4 communication skills dimensions measured by the OSCE and accounted for up to 34.8% of the total variance in the ratings of empathic communication and up to 67.2% of the total variance in education-related communication. CONCLUSIONS: Our research identifies specific personality traits that affect resident communication skills related to patient education and empathy in simulated encounters. Three stress-related personality traits (Excitable, Skeptical, Imaginative) had a strong negative influence on communication skills, while day to day personality traits (Emotional Stability, Agreeableness, Conscientiousness) positively influenced communication skills.

Orthopaedic Faculty and Resident Racial/Ethnic Diversity is Associated With the Orthopaedic Application Rate Among Underrepresented Minority Medical Students.

INTRODUCTION: Orthopaedic surgery is among the least diverse fields in all of medicine. To promote the recruitment of minorities, a commonly proposed strategy is to increase the exposure of minority medical students to orthopaedic surgeons and residents who are minorities themselves. This study examines the degree to which the racial/ethnic diversity of the orthopaedic faculty and residency program influences underrepresented in medicine (URM) medical students at that institution to pursue a career in orthopaedics. METHODS: Using data provided by the Association of American Medical Colleges, we identified all US medical schools that were affiliated with an orthopaedic department and an orthopaedic residency program (n = 110). For each institution, data were collected on URM representation among the orthopaedic faculty and residents (2013 to 2017), as well as the proportion of URM medical students who applied to an orthopaedic residency program (2014 to 2018). The association between institutional factors and the URM medical student orthopaedic application rate was then assessed. RESULTS: Of 11,887 URM students who graduated from medical school during the 5-year study period, 647 applied to an orthopaedic residency program (5.4%). URM students who attended medical school at institutions with high URM representation on the orthopaedic faculty were more likely to apply in orthopaedics (odds ratio 1.27, 95% confidence interval 1.04 to 1.55, P = 0.020), as were URM students at institutions with high URM representation in the residency program (odds ratio 1.45, 95% confidence interval 1.17 to 1.79, P < 0.001). DISCUSSION: The benefits of a diverse orthopaedic workforce are widely acknowledged. In this study, we found that increased URM representation among the orthopaedic faculty and residents was associated with a greater likelihood that URM medical students at that institution would apply in orthopaedics. We also suggest a set of strategies to break the cycle and promote the recruitment of minorities into the field of orthopaedic surgery.

A Review of Orthopedic Resident Outpatient Notes Are Perceptions of the EMR Reflected in Current Documentation Practices?

INTRODUCTION: Systems-based Practice 3 (SBP 3) in the orthopedic residency developmental milestones evaluates residents' knowledge, understanding, and utilization of the electronic medical record (EMR). In order to better assess SBP 3, we conducted a review of residents' clinical notes in order to quantify the current state of orthopedic residents' documentation in the EMR. The purpose of this study was to objectively evaluate orthopedic resident documentation in the EMR. METHODS: Orthopedic resident medical notes from a single orthopedic residency at one academic medical center were scored by faculty members who had directly observed the clinical encounter. These notes were then independently scored by one investigator (N.F.) using clinical contentspecific, objective criteria. Sixty-five medical records were reviewed. All 62 orthopedic residents anonymously completed an 84-question survey on the value of EMR utilization and documentation within the medical record. RESULTS: Many key elements necessary to diagnosing a patient's injury and developing a treatment plan were often omitted (e.g., "Mechanism of Injury" in 32.3% of records), and the majority of notes did not include "Decision Making and Patient Preference" (95.2%) or "Risks/Benefits of Surgery" (93.7%). However, 95.2% of residents agreed that their notes reflect their medical knowledge and 96.8% agreed that their notes reflect their clinical reasoning. DISCUSSION: The results of this objective review revealed significant deficits in orthopedic resident documentation not identified by faculty observers.

An Economic Analysis of the Costs Associated with Pre-Weaning Management Strategies for Dairy Heifers.

Dairy calves are raised in various housing and feeding environments on dairy farms around North America. The objective of this study was to develop a simulation model to calculate the cost of raising replacement dairy heifers using different inputs that reflect different management decisions and evaluate their influence on the total cost. In this simulation, 84 calves were modeled between 0-2 months of age to reflect a 1000 heifer herd. The decisions associated with housing, liquid diet source and allowance, labor utilization, and health were calculated. Costs and biological responses were reflective of published surveys, literature, and market conditions. A 10,000-iteration economic simulation was used for each management scenario using @Risk and PrecisionTree add-ons (Palisade Corporation, Ithaca, NY, USA) to account for variation in pre-weaning mortality rate, weaning age, and disease prevalence. As milk allotment increased, total feed cost increased. Feeding calves a higher allowance of milk resulted in a lower cost per kg of gain. Average feed cost percentage of the total cost was 46% (min, max: 33%, 59%) while labor, and fixed and variable cost represented 33% (20%, 45%), 9% (2%, 12%), and 12% (10%, 14%), respectively. Total pre-weaning costs ranged from $258.56 to $582.98 per calf across all management scenarios and milk allotments.

Orthopaedic Faculty and Resident Sex Diversity Are Associated with the Orthopaedic Residency Application Rate of Female Medical Students.

BACKGROUND: The representation of women in orthopaedics in the United States remains among the lowest in all fields of medicine, and prior research has suggested that this underrepresentation may stem from lower levels of interest among female medical students. Of the many proposed reasons for this lack of interest, the male-dominated nature of the field is one of the most commonly cited. The purpose of this study was to determine the degree to which the representation of women among orthopaedic faculty and residents influences female medical students at that institution to apply for a residency in orthopaedics. METHODS: Using data provided by the Association of American Medical Colleges, we identified all U.S. medical schools that were affiliated with an orthopaedic surgery department and an orthopaedic surgery residency program (n = 107). For each institution, data on the representation of women among the orthopaedic faculty and residents from 2014 through 2016 were collected, as well as data on the proportion of female medical school graduates who applied to an orthopaedic residency program from 2015 through 2017. The association between institutional factors and the female medical student orthopaedic application rate was assessed. RESULTS: Of 22,707 women who graduated from medical school during the 3-year study period, 449 (1.98%) applied to an orthopaedic surgery residency program. Women who attended medical school at institutions with high orthopaedic faculty sex diversity were more likely to apply for a residency in orthopaedics (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.04 to 1.64; p = 0.023), as were women who attended medical school at institutions with high orthopaedic resident sex diversity (OR, 1.30; 95% CI, 1.05 to 1.61; p = 0.019). CONCLUSIONS: In this study, we found that increased sex diversity among orthopaedic faculty and residents was associated with a greater likelihood that female medical students at that institution would apply for an orthopaedic residency. These results suggest that at least some of the factors currently impeding female medical student interest in orthopaedics may be modifiable. These findings may have important implications for efforts to improve the sex diversity of the field of orthopaedics going forward.

Patient Safety Room Assessing Orthopedic Surgery Interns' Abilities to Identify Patient Safety Hazards.

OBJECTIVE: An important part of clinical training is learning how to identify and prevent hospital-acquired conditions or injuries. Despite this, there are few standardized methods in graduate medical education (GME) for teaching and assessing resident patient safety skills. Residents often do not report safety events, and increasing resident engagement can positively impact patient safety. In the current study, we sought to apply such a tool in gauging the capacity of orthopedic surgery interns at a large academic medical center to identify patient safety hazards and begin a discussion regarding the management of potential patient safety issues. METHODS: A total of 27 orthopedic surgery interns at a single large academic medical center participated in the current observational study divided into two distinct groups in the summers of 2016 and 2017. A patient room was simulated with a training mannequin lying supine in a hospital bed. A mock patient chart and handoff were created in the electronic medical record (EMR) on the bedside computer. Patient safety hazards and errors of care were placed around the room and in the EMR, including several derived from the Joint Commission's National Patient Safety Goals. Each intern was given a maximum of 20 minutes to identify as many of the simulated patient safety hazards as possible. A debrief was conducted at the end of the exercise to discuss their responsibility to speak up when hazards are identified in a non-simulated patient room. For analysis, the hazards were distributed into four categories: room organization, EMR, patient care, and white board. Each intern's individual score (number of complete identifications/total number of hazards) and the group's performance as a whole in each category were calculated. RESULTS: The mean individual score was 51.54% (26.67% to 70.00%) in group A and 40.41% (25.71% to 54.29%) in group B. In group A, room organization hazards were identified more than any other category (74.62%), followed by patient care errors (40.38%), EMR hazards (40.17%), and white board errors (38.46%). In group B, room organization was identified the most (57.74%), followed by EMR (50%), and patient care and white board hazards (28.57% each). Certain critical safety hazards were identified by a small number of interns. For example, the inadequate handoff was only identified by four interns in each group. CONCLUSIONS: Hazards related to room cleanliness were easier to identify than hazards related to specific errors in patient care. A wide variation in the identification of critical safety issues was observed among the trainees assessed. This type of simulated educational experience provides important opportunities for resident-specific education in the realm of patient safety and health care quality.

"I Cannot Take This Any More!": Preparing Interns to Identify and Help a Struggling Colleague.

BACKGROUND: Few programs train residents in recognizing and responding to distressed colleagues at risk for suicide. AIM: To assess interns' ability to identify a struggling colleague, describe resources, and recognize that physicians can and should help colleagues in trouble. SETTING: Residency programs at an academic medical center. PARTICIPANTS: One hundred forty-five interns. PROGRAM DESIGN: An OSCE case was designed to give interns practice and feedback on their skills in recognizing a colleague in distress and recommending the appropriate course of action. Embedded in a patient "sign-out" case, standardized health professionals (SHP) portrayed a resident with depressed mood and an underlying drinking problem. The SHP assessed intern skills in assessing symptoms and directing the resident to seek help. PROGRAM EVALUATION: Interns appreciated the opportunity to practice addressing this situation. Debriefing the case led to productive conversations between faculty and residents on available resources. Interns' skills require further development: while 60% of interns asked about their colleague's emotional state, only one-third screened for depression and just under half explored suicidal ideation. Only 32% directed the colleague to specific resources for his depression (higher among those that checked his emotional state, 54%, or screened for depression, 80%). DISCUSSION: This OSCE case identified varying intern skill levels for identifying and assessing a struggling colleague while also providing experiential learning and supporting a culture of addressing peer wellness.

Teaching Professionalism in Orthopaedic Residency: Efficacy of the American Academy of Orthopaedic Surgeons Ethics Modules.

INTRODUCTION: To aid implementing an ethics curriculum in an orthopaedic residency program, the American Academy of Orthopaedic Surgeons (AAOS) created 14 ethics scenarios. Because delivery of this curriculum could be burdensome, an online module-based curriculum might be optimal. METHODS: Two cohorts of orthopaedic residents participated: cohort I completed 14 online ethics modules converted from the 14 AAOS ethics scenarios. For each module, we gave a multiple-choice assessment immediately before the module, immediately afterward, and 3 months afterward. Cohort II completed only the 14-module assessments at similar time intervals without any educational content. RESULTS: Cohort I demonstrated improvement in 3-month postmodule assessment scores in 11 of the 14 modules, 3 of which had statistical differences in baseline scores for cohort I and cohort II. We observed no statistical difference in scores within cohort II on repeat testing. DISCUSSION: This study demonstrates that 11 of the 14 AAOS ethics scenarios, converted to online modules, teach ethical concepts to orthopaedic residents. Orthopaedic residency programs may find it valuable to engage their residents in the ethics scenarios created by the AAOS to complement their ethics curriculum.

A Comparison of Assessment Tools: Is Direct Observation an Improvement Over Objective Structured Clinical Examinations for Communications Skills Evaluation?

BACKGROUND: Evaluation of resident physicians' communications skills is a challenging task and is increasingly accomplished with standardized examinations. There exists a need to identify the effective, efficient methods for assessment of communications skills. OBJECTIVE: We compared objective structured clinical examination (OSCE) and direct observation as approaches for assessing resident communications skills. METHODS: We conducted a retrospective cohort analysis of orthopaedic surgery resident physicians at a single tertiary care academic institution, using the Institute for Healthcare Communication "4 Es" model for effective communication. Data were collected between 2011 and 2015. A total of 28 residents, each with OSCE and complete direct observation assessment checklists, were included in the analysis. Residents were included if they had 1 OSCE assessment and 2 or more complete direct observation assessments. RESULTS: There were 28 of a possible 59 residents (47%) included. A total of 89% (25 of 28) of residents passed the communications skills OSCE; only 54% (15 of 28) of residents passed the direct observation communications assessment. There was a positive, moderate correlation between OSCE and direct observation scores overall (r = 0.415, P = .028). There was no agreement between OSCE and direct observation in categorizing residents into passing and failing scores (κ = 0.205, P = .16), after adjusting for chance agreement. CONCLUSIONS: Our results suggest that OSCE and direct observation tools provide different insights into resident communications skills (simulation of rare and challenging situations versus real-life daily encounters), and may provide useful perspectives on resident communications skills in different contexts.

Assessing Resident Perceptions of Electronic Medical Record Utilization What Affects the Quality of Clinical Notes?

BACKGROUND: Objective review of orthopedic resident medical records revealed significant variation in quality of clinical notes suggesting that the implementation of the electronic medical record (EMR) had altered resident perceptions of the purpose of clinical documentation. OBJECTIVE: The purpose of this study was to assess resident perceptions of the purpose and use of the EMR. METHODS: An 84-item survey was developed based on previously validated surveys. All 62 orthopedic residents within one academic institution completed the survey. Questions were divided into six domains and domain scores were calculated by summing responses within each domain; a more negative response on the Likert scale received a higher score. Scores were compared across postgraduate year (PGY). RESULTS: Survey results revealed that most residents agreed that they generally write good patient care notes, their notes contribute to the care of the patient, and as physicians they feel responsible for the accuracy of the information they enter into the EMR. However, residents were divided as to whether they have enough time to write a good patient care note. Domain scores did not significantly differ by PGY indicating that perceptions toward the EMR do not change even as residents increase their knowledge of orthopedics and become more skilled physicians. CONCLUSIONS: Although residents recognize that the information they enter in the EMR is valuable for patient care and safety, some feel unable to consistently utilize the EMR to its full potential due to time constraints.

Personality Factors Associated With Resident Performance: Results From 12 Accreditation Council for Graduate Medical Education Accredited Orthopaedic Surgery Programs.

OBJECTIVES: To understand the personality factors associated with orthopedic surgery resident performance. DESIGN: A prospective, cross-sectional survey of orthopedic surgery faculty that assessed their perceptions of the personality traits most highly associated with resident performance. Residents also completed a survey to determine their specific personality characteristics. A subset of faculty members rated the performance of those residents within their respective program on 5 dimensions. Multiple regression models tested the relationship between the set of resident personality measures and each aspect of performance; relative weights analyses were then performed to quantify the contribution of the individual personality measures to the total variance explained in each performance domain. Independent samples t-tests were conducted to examine differences between the personality characteristics of residents and those faculty identified as relevant to successful resident performance. SETTING: Data were collected from 12 orthopedic surgery residency programs1 throughout the United States. The level of clinical care provided by participating institutions varied. PARTICIPANTS: Data from 175 faculty members and 266 residents across 12 programs were analyzed. RESULTS: The personality features of residents were related to faculty evaluations of resident performance (for all, p < 0.01); the full set of personality measures accounted for 4%-11% of the variance in ratings of resident performance. Particularly, the characteristics of agreeableness, neuroticism, and learning approach were found to be most important for explaining resident performance. Additionally, there were significant differences between the personality features that faculty members identified as important for resident performance and the personality features that residents possessed. CONCLUSION: Personality assessments can predict orthopedic surgery resident performance. However, results suggest the traits that faculty members value or reward among residents could be different from the traits associated with improved resident performance.

Clinical Skills and Professionalism: Assessing Orthopaedic Residents With Unannounced Standardized Patients.

OBJECTIVE: We developed a series of orthopedic unannounced standardized patient (USP) encounters for the purpose of objective assessment of residents during clinic encounters. DESIGN: Consecutive case-series. SETTING: NYU-Langone Multi-center Academic University Hospital System. PARTICIPANTS: NYU-Langone/Hospital for Joint Diseases Orthopedic Surgery residents; 48 consecutive residents assessed. METHODS: Four orthopedic cases were developed. USPs presented themselves as patients in outpatient clinics. Residents were evaluated on communication skills (information gathering, relationship development, and education and counseling). USPs globally rated whether they would recommend the resident. RESULTS: Forty-eight USP encounters were completed over a 2-year period. Communication skills items were rated at 51% (±30) "well done." Education and counseling skills were rated as the lowest communication domain at 33% (±33). Residents were globally recommended based on communication skills in 63% of the encounters recommended in 70% of encounters based on both professionalism and medical competence. CONCLUSIONS: The USP program has been useful in assessing residents' clinical skills, interpersonal and communications skills, and professionalism. Use of USP in orthopedic surgery training programs can be an objective means for trainee assessment.

Variation in pediatric orthopedic case volume among residents: an assessment of Accreditation Council for Graduate Medical Education case logs.

The aim of this investigation was to examine graduating orthopedic resident case logs to evaluate trends in performing pediatric orthopedic procedures and compare pediatric orthopedic case volume among residents in the 90th, 50th, and 10th percentiles (by case volume) to identify caseload variation. Accreditation Council for Graduate Medical Education orthopedic resident case logs were examined for graduating years 2007-2013. Linear regression analyses were carried out to assess temporal trends in pediatric orthopedic case volume. Subgroup analyses were carried out to assess trends in cases by anatomic location. Comparisons of the number of pediatric cases performed by the 90th, 50th, and 10th percentiles of graduating residents were also performed. Pediatric orthopedic case volume increased significantly per graduating resident (295.9-373.2; P<0.001) from 2007 to 2013. Graduating residents in the 90th (494-573; P=0.001), 50th (264-334; P<0.001), and 10th (144-216; P=0.003) percentiles of case volume all sustained significant increases in the number of pediatric orthopedic cases performed. Subgroup analyses showed significant increases in pediatric orthopedic shoulder (4.8-7.3; P<0.001), humerus/elbow (25.9-32.7; P<0.001), forearm/wrist (28.6-40.4; P<0.001), hand/finger (15-16.9; P=0.005), femur/knee (44.5-51.9; P=0.002), leg/ankle (39.4-41.1; P=0.004), and spine case volume (24.9-33.6; P<0.001). On average, graduating residents in the 90th, 50th, and 10th percentiles performed 524, 302, and 169 cases, respectively. The current investigation shows significant growth in the number of pediatric orthopedic cases performed by graduating residents, particularly among upper extremity procedures. However, considerable variation in pediatric orthopedic case volume exists among residents. Although the educational effects of this case volume variation are incompletely understood, the current investigation may be beneficial in efforts to improve pediatric orthopedic educational quality.

Examination to assess the clinical examination and documentation of spine pathology among orthopedic residents.

BACKGROUND CONTEXT: The Accreditation Council for Graduate Medical Education (ACGME) guidelines requires residency programs to teach and evaluate residents in six overarching "core competencies" and document progress through educational milestones. To assess the progress of orthopedic interns' skills in performing a history, physical examination, and documentation of the encounter for a standardized patient with spinal stenosis, an objective structured clinical examination (OSCE) was conducted for 13 orthopedic intern residents, following a 1-month boot camp that included communications skills and curriculum in history and physical examination. Interns were objectively scored based on their performance of the physical examination, communication skills, completeness and accuracy of their electronic medical record (EMR), and their diagnostic conclusions gleaned from the patient encounter. PURPOSE: The purpose of this study was to meaningfully assess the clinical skills of orthopedic post-graduate year (PGY)-1 interns. The findings can be used to develop a standardized curriculum for documenting patient encounters and highlight common areas of weakness among orthopedic interns with regard to the spine history and physical examination and conducting complete and accurate clinical documentation. STUDY SETTING: A major orthopedic specialty hospital and academic medical center. METHODS: Thirteen PGY-1 orthopedic residents participated in the OSCE with the same standardized patient presenting with symptoms and radiographs consistent with spinal stenosis. Videos of the encounters were independently viewed and objectively evaluated by one investigator in the study. This evaluation focused on the completeness of the history and the performance and completion of the physical examination. The standardized patient evaluated the communication skills of each intern with a separate objective evaluation. Interns completed these same scoring guides to evaluate their own performance in history, physical examination, and communications skills. The interns' documentation in the EMR was then scored for completeness, internal consistency, and inaccuracies. RESULTS: The independent review revealed objective deficits in both the orthopedic interns' history and the physical examination, as well as highlighted trends of inaccurate and incomplete documentation in the corresponding medical record. Communication skills with the patient did not meet expectations. Further, interns tended to overscore themselves, especially with regard to their performance on the physical examination (p<.0005). Inconsistencies, omissions, and inaccuracies were common in the corresponding medical notes when compared with the events of the patient encounter. Nine of the 13 interns (69.2%) documented at least one finding that was not assessed or tested in the clinical encounter, and four of the 13 interns (30.8%) included inaccuracies in the medical record, which contradicted the information collected at the time of the encounter. CONCLUSIONS: The results of this study highlighted significant shortcomings in the completeness of the interns' spine history and physical examination, and the accuracy and completeness oftheir EMR note. The study provides a valuable exercise for evaluating residents in a multifaceted, multi-milestone manner that more accurately documents residents' clinical strengths and weaknesses. The study demonstrates that orthopedic residents require further instruction on the complexities of the spinal examination. It validates a need for increased systemic support for improving resident documentation through comprehensive education and evaluation modules.

Using Objective Structured Clinical Examinations to Assess Intern Orthopaedic Physical Examination Skills: A Multimodal Didactic Comparison.

Patient care is 1 of the 6 core competencies defined by the Accreditation Council for Graduate Medical Education (ACGME). The physical examination (PE) is a fundamental skill to evaluate patients and make an accurate diagnosis. The purpose of this study was to investigate 3 different methods to teach PE skills and to assess the ability to do a complete PE in a simulated patient encounter. DESIGN: Prospective, uncontrolled, observational. SETTING: Northeastern academic medical center. PARTICIPANTS: A total of 32 orthopedic surgery residents participated and were divided into 3 didactic groups: Group 1 (n = 12) live interactive lectures, demonstration on standardized patients, and textbook reading; Group 2 (n = 11) video recordings of the lectures given to Group 1 and textbook reading alone; Group 3 (n = 9): 90-minute modules taught by residents to interns in near-peer format and textbook reading. RESULTS: The overall score for objective structured clinical examinations from the combined groups was 66%. There was a trend toward more complete PEs in Group 1 taught via live lectures and demonstrations compared to Group 2 that relied on video recording. Near-peer taught residents from Group 3 significantly outperformed Group 2 residents overall (p = 0.02), and trended toward significantly outperforming Group 1 residents as well, with significantly higher scores in the ankle (p = 0.02) and shoulder (p = 0.02) PE cases. CONCLUSIONS: This study found that orthopedic interns taught musculoskeletal PE skills by near-peers outperformed other groups overall. An overall score of 66% for the combined didactic groups suggests a baseline deficit in first-year resident musculoskeletal PE skills. The PE should continue to be taught and objectively assessed throughout residency to confirm that budding surgeons have mastered these fundamental skills before going into practice.

Direct Observation: Assessing Orthopaedic Trainee Competence in the Ambulatory Setting.

The Accreditation Council of Graduate Medical Education requires that residency programs teach and assess trainees in six core competencies. Assessments are imperative to determine trainee competence and to ensure that excellent care is provided to all patients. A structured, direct observation program is feasible for assessing nontechnical core competencies and providing trainees with immediate constructive feedback. Direct observation of residents in the outpatient setting by trained faculty allows assessment of each core competency. Checklists are used to document residents' basic communication skills, clinical reasoning, physical examination methods, and medical record keeping. Faculty concerns regarding residents' professionalism, medical knowledge, fatigue, or ability to self-assess are tracked. Serial observations allow for the reinforcement and/or monitoring of skills and attitudes identified as needing improvement. Residents who require additional coaching are identified early in training. Progress in educational milestones is recorded, allowing an individualized educational program that ensures that future orthopaedic surgeons excel across all domains of medical and surgical competence.

Difficult conversations in orthopaedics.

There is an overall lack of training in the communication skills needed by physicians to effectively navigate challenging patient encounters. So-called difficult patients have specific obstructive behaviors that make it challenging to establish a successful doctor-patient partnership and can elicit strong negative emotions in the physician. Instead of labeling the patient as difficult, it is more useful to consider encounters as difficult events and rely on diagnostic and interventional techniques similar to those used in solving any other clinical problem. In difficult interactions, patients may have the perception that the physician is less technically skilled, they were allotted inadequate time, received poor explanations, and were overall dissatisfied with the visit. Physicians who experience difficult encounters may find it difficult to communicate with patients. The physician is often not attuned to the psychosocial aspects of patient care and is frustrated and uneasy with patients. To improve patient and physician satisfaction and healthcare outcomes, it is helpful to review the skills and strategies for delivering bad news, managing angry patients, addressing financial concerns, and dealing with drug-seeking patients.