Interpersonal Interactions and Biases in Orthopaedic Surgery Residency: Do Experiences Differ Based on Gender?

BACKGROUND: Women residents are underrepresented in orthopaedic surgery. The causes of the deficit of women in orthopaedic surgery are multifactorial, but by identifying the perceptions of women in orthopaedic residency training and comparing them with the perceptions of men, we can improve our understanding of ways to enhance the recruitment of qualified and diverse candidates. QUESTIONS/PURPOSES: (1) What differences exist in the perceived experiences of residents identifying as women and men regarding professional, social, and personal interactions during residency training? (2) Are there differences in the percentage of women and men residents who have experienced harassment or discrimination in preresidency interviews, and are there differences in the type of harassment or discrimination experienced? METHODS: A survey was generated using Academy of Critical Care: Development, Evaluation, and Methodology guidelines. Two focus groups with seven attending orthopaedic surgeons who participate in the Collaborative Orthopaedic Education Research Group and who are experts on gender diversity in orthopaedics were held to improve survey validity. The survey included binary-response, Likert, and free-text questions on the perception of professional, social, and personal interactions held by the resident being surveyed. The questions focused on a respondent's perception of interactions with staff members, patients, resident colleagues, and attending surgeons, as well as sexual harassment. Program directors at 10 selected Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic residency programs that participate in the Collaborative Orthopaedic Education Research Group shared the survey with residents at their institutions. There were 95 programs in the Collaborative Orthopaedic Education Research Group at the time this survey was distributed. In this program, directors or other interested teaching faculty in orthopaedic residency programs voluntarily participate to discuss and develop quality research on resident and fellow education. These 95 programs account for 46% of the ACGME-accredited programs in the United States at the time the survey was created and distributed. The 10 residency programs had a total of 232 enrolled residents; 15% (34) identified as women. This gender distribution models the national sample of orthopaedic residents. Survey reliability was assessed by calculating the Cronbach alpha after determining the variance in each relevant (nondemographic) survey item. The final survey was found to have excellent internal reliability (alpha = 0.95). Responses from residents identifying as women and those identifying as men were compared using Fisher exact tests for all categorical data, and two-tailed independent t-tests were used for all continuous data. Differences in each survey category (professional interactions, social interactions, personal interactions, and sexual harassment in preresidency interview experiences) were calculated. RESULTS: Women reported experiencing microaggressions (left undefined to the survey respondent, but generally considered to be subtle, stunning, often automatic, and nonverbal exchanges that are "put downs") at work more frequently than men did (40% [six of 15] versus 5% [four of 74]; p < 0.001). Specifically, women perceived being interrupted (53% [eight of 15] versus 5% [four of 75]); p < 0.001) by men colleagues, called by their first name (67% [10 of 15] versus 4% [3 of 72]; p < 0.001), and given administrative tasks (27% [four of 15] versus 1% [one of 75]; p = 0.004) more often than men. More women than men perceived that patients (33% [five of 15] versus 0 of 74 [0%]; p < 0.001) and hospital staff (27% [four of 15] versus 7% [five of 74]; p = 0.01) respected their opinion less than that of men. More women than men perceived that group humor negatively targeted their gender (47% [seven of 15] versus 1% [one of 75]; p < 0.001) and that criticism of their surgical skill was based on their gender rather than their ability (33% [five of 15] versus 5% [four of 78]; p = 0.005). In residency or subinternship interviews, 20% of women reported experiencing sexual harassment as defined by a listing of known types of harassment in the question stem, compared with 0% of men (p = 0.004). Women reported harassment in the form of verbal remarks of a sexual nature and obscene images in the workplace, whereas men did not report any form of harassment during interviews. CONCLUSION: These findings suggest that the greatest discrepancies in the perceived experiences of women and men residents lie in professional interactions, and women residents are more likely to experience sexual harassment and disparaging humor than men residents. CLINICAL RELEVANCE: Addressing these discrepancies, particularly in the professional setting, will help to create a more inclusive work environment and attract more women to orthopaedic surgery. Annual distribution of the survey used in this study by program directors to residents in their programs can help to identify discrepant perceptions that, coupled with the collection of objective data, can be targeted for improvement.

Postinterview Communication in Orthopaedic Surgery Residency Interviews: A Survey of Match Applicants.

Background: To maintain the integrity of the match, postinterview communication (PIC) from programs to applicants is monitored and discouraged. The most recent report on the prevalence of PIC in orthopaedics found that 64% of surveyed applicants in 2014 and 2015 had received some form of PIC during their match cycle. In July 2019, the American Orthopaedic Association's Council of Orthopaedic Residency Directors (AOA/CORD) released a guideline recommending the elimination of all PIC in any form. The goal of this follow-up study was to determine the current prevalence of PIC with orthopaedic surgery applicants and assess the perspectives of medical students who recently applied for orthopaedic surgery residency positions. Methods: A 35-question survey was e-mailed to all orthopaedic surgery residency applicants of 4 geographically diverse residency programs in postmatch March 2020. The survey was open for 1 month, and the responses were reported using descriptive statistics. Results: Of the 229 respondents (21% response rate), 91 (39.7%) received PIC during the 2019 to 2020 residency match cycle. The program director was most commonly identified (80.2%) as the person who communicated with the applicants. At the interview day, 198 respondents (86.5%) were told that programs would not be contacting the applicants with PIC. However, over a quarter of respondents (25.3%) who received PIC answered that those programs contacted applicants after announcing they would not. Nearly half of the respondents (48.5%) agreed or strongly agreed that PIC causes added stress on applicants, and over half (52.9%) agreed or strongly agreed that all programs should stop participating in any form of PIC. Conclusions: Although the prevalence of PIC seems to have decreased since the 2014 and 2015 match, there is still room for improvement toward eliminating PIC. The AOA/CORD position statement from July 2019 should be disseminated to all members of the residency selection team to ensure consistency from all programs. The primary limitation of this study was the 21% response rate. Level of Evidence: Level IV (survey study).

Workplace Hazards in Orthopaedic Surgery Training: A Nationwide Resident Survey Involving Sharps-related Injuries.

INTRODUCTION: Surgical specialties are at an increased risk for occupational hazards, including sharps-related injuries. The objective of this study was to report the frequency of sharps injuries and evaluate which characteristics influence the number of injuries and reporting behaviors. METHODS: A web-based, anonymous survey was available for 10 weeks to 46 US orthopaedic surgery residency programs (1,207 potential residents) participating in an education research collaborative. The survey was divided into the following areas: demographics, training and attitudes concerning occupational hazards, and sharps injuries and reporting. Logistic regression was used to evaluate the association between the above variables on experiencing sharps injuries with significance threshold set at P < 0.05. RESULTS: In this study, 518 surveys were included yielding a response rate of 42.9% (518/1,207). Nearly 80% of the residents recalled some form of safety training during intern orientation and 62% of the respondents felt that they received adequate occupation safety training specifically related to orthopaedic surgery. Four hundred seventeen residents (80.5%) experienced a sharps injury (mean 2.8). Nearly 20% of the respondents experienced ≥5 sharps injuries. Needle sticks (38.8%) were responsible for the greatest percentage of injuries, followed by Kirschner wires (33.6%), scalpel (22.5%), and bone (17.3%). Only 42% of the residents consistently reported all injuries. Reasons included feelings of no risk (63.1%), too much hassle (58.9%), embarrassment (14.5%), other (8.7%), forgot (5.8%), and unclear what to do (3.3%). Inadequate safety training specific to orthopaedic surgery (odds ratio, 2.32 [95% confidence interval, 1.20 to 4.46]; P = 0.012) and greater training seniority (odds ratio, 2.04 [95% confidence interval, 1.64 to 2.52]; P < 0.0001) were associated with acquiring five or more sharps injuries. DISCUSSION: Sharps injuries are a prevalent and concerning reality for orthopaedic surgical trainees. Despite this common occurrence, only 42% of the residents always reported their injuries. Inadequate training specific to orthopaedic surgery and each subsequent year of postgraduate training are associated with increased sharps injuries. STUDY TYPE: Level III, retrospective observational survey.

Financial Literacy in Orthopaedic Surgery Residents: A COERG Survey.

INTRODUCTION: Financial literacy is the individual ability and skill to make informed decisions in the management of resources within the financial marketplace to yield a lifetime of financial well-being. Residents across several subspecialties have demonstrated low levels of financial literacy, and it is thought that more financial education is needed during residency training. The purpose of this study is to perform a comprehensive evaluation on financial literacy and financial attitudes of orthopaedic surgery residents. The authors hypothesize that orthopaedic residents will have low levels of financial literacy and financial satisfaction. METHODS: A 46-question anonymous survey was administered through COERG (Collaborative Orthopaedic Educational Research Group) to 1028 orthopaedic surgery residents of all postgraduate year at 43 programs with broad national distribution. Resident demographics and survey responses regarding knowledge of finance and investment topics, application of financial principles, and personal financial status were compared. RESULTS: The survey response rate was 48% (494/1028). The average financial literacy score of all orthopaedic resident participants was 60.9% (±16.5%). A total of 35.5% of orthopaedic residents were satisfied with their current financial situation. Saving for retirement and lower loan burdens correlated with greater financial satisfaction in financial situation. Scores were higher in orthopaedic residents with greater childhood annual household income, no credit card debt, higher levels of parent education, and active retirement savings plans. CONCLUSIONS: Orthopaedic residents show significant deficits in overall financial and investment knowledge combined with a dissatisfaction with financial situations while in residency. Orthopaedic residency programs have the opportunity to implement program-sponsored training and financial resources to enhance the resident education experience.

The US Medical Licensing Examination Step 1 Scoring Change: A Survey of Orthopaedic Surgery Residency Applicants From the 2019 to 2020 Match Cycle.

INTRODUCTION: The USMLE Step 1 examination has been used as an objective measure for comparing residency applicants. Recently, the National Board of Medical Examiners and the Federation of State Medical Boards decided that the USMLE Step 1 examination will transition to a pass/fail result starting no earlier than 2022. The purpose of this study was to investigate the perspective of medical students who applied for orthopaedic surgery residency positions during the 2019 to 2020 interview cycle on the USMLE scoring change, and the potential effect this change may result in for future applicants and the residency selection process. METHODS: A 15-item anonymous web-based survey was sent to 1,090 orthopaedic surgery residency applicants from four regionally diverse residency programs. The survey elicited attitudes toward the transition of the Step 1 examination to pass/fail and perspectives this change may or may not have on the residency selection process. RESULTS: Responses were received from 356 applicants (32.7%). The majority (61.6%) disagreed with the change to pass/fail scoring, and 68.5% do not believe that the change will decrease stress levels in medical students. For interview invitations, respondents chose Step 2 clinical knowledge, letters of recommendation, and performance on away rotations as the most influential factors in the absence of a Step 1 score. CONCLUSION: Most of the students surveyed who applied for an orthopaedic surgery residency position during the most recent application cycle disagreed with the National Board of Medical Examiner/Federation of State Medical Board decision to change Step 1 to pass/fail and feel that this change may have disadvantage in certain student groups while either increasing or having no effect on medical student stress. LEVEL OF EVIDENCE: IV.

Gender diversity in United States neurosurgery training programs.

OBJECTIVE: Neurosurgery continues to be one of the medical specialties with the lowest representation of females in both the resident and faculty workforce. Currently, there are limited available data on the gender distribution of faculty and residents in Accreditation Council for Graduate Medical Education (ACGME)-accredited neurosurgery training programs. This information is critical to accurately measure the results of any effort to improve both the recruitment and retention of women in neurosurgery. The objective of the current study was to define the current gender distribution of faculty and residents in ACGME-accredited neurosurgery training programs. METHODS: Data publicly available through institutional and supplemental websites for neurosurgical faculty and residents at ACGME-accredited programs were analyzed for the 2017-2018 academic year. Data collected for faculty included gender, age, year of residency graduation, academic rank, h-index, American Board of Neurological Surgery certification status, and leadership positions. Resident data included gender and postgraduate year of training. RESULTS: Among the 109 ACGME-accredited neurosurgical residency programs included in this study, there were 1350 residents in training, of whom 18.2% were female and 81.8% were male. There are 1320 faculty, of whom 8.7% were female and 91.3% were male. Fifty-eight programs (53.2%) had both female faculty and residents, 35 programs (32.1%) had female residents and no female faculty, 4 programs (3.7%) had female faculty and no female residents, and 6 programs (5.5%) lacked both female residents and faculty. Six programs (5.5%) had incomplete data. Female faculty were younger, had lower h-indices, and were less likely to be board certified and attain positions of higher academic rank and leadership. CONCLUSIONS: This study serves to provide a current snapshot of gender diversity in ACGME-accredited neurosurgery training programs. While there are still fewer female neurosurgeons achieving positions of higher academic rank and serving in leadership positions than male neurosurgeons, the authors' findings suggest that this is likely due to the small number of women in the neurosurgical field who are the farthest away from residency graduation and serves to highlight the significant progress that has been made toward achieving greater gender diversity in the neurosurgical workforce.

Acute Workplace Hazards in Orthopedic Surgery: Resident Survey Regarding Splash and Workplace Violence Events.

INTRODUCTION: Orthopedic surgery residents are at risk for daily work-related hazards and exposures. Hazards related specific to this specialty includes radiation exposure, smoke inhalation (from electrocautery), and disease transmission through contact with surgical instruments or sharps during procedures. However, minimal research has been focused on other occupational hazard risks in orthopedic surgery including surgical splash events and workplace violence. This study focused on determining (1) whether or not use of protective eyewear in the workplace would be related to the availability of personal protective equipment (PPE); (2) resident education; and (3) the rate of workplace violence toward orthopedic surgery residents during their training. METHODS: An invitation to participate in a web-based, anonymous survey to 46 US allopathic orthopedic surgery residency programs (1207 potential resident respondents). The survey was conceptually divided into the following areas: (1) demographics; (2) training and attitudes concerning occupational hazards; (3) PPE provision and use; (4) sharps injuries and reporting; and (5) general safety knowledge and violence in the workplace. Those who answered yes to having a splatter event or receiving a threat at the hospital were compared to those who did not. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between these outcomes and selected independent variables of interest. p-Values of <0.05 were considered statistically significant. RESULTS: From January 18 to March 31, 2016, 518 surveys were received and included for analysis for a response rate of 42.9% (518/1207). One survey was excluded from analysis due to <50% completed response items. Self-reported program types were 64.5% (334/518) public university-affiliated, 23.2% (120/518) private university affiliated, 7.1% (37/518) community, and 5.2% (27/518) military. Residents were 83.0% = male and 17.0% = female. Overall, reported eye protection usage was 95% amongst all residents and 22% of residents reported experiencing a violent threat in the workplace. The risk of experiencing a splatter event was not statistically associated with residency type, gender, or geographic region. Senior residents were at an increased likelihood of experiencing a splatter event (OR 1.22, [95% CI 1.06-1.41], p = 0.006) when compared to PGY-1 residents. The risk of a violent experience at work was not statistically associated with residency type, year of residency training, or gender. Residents in the Northeast were more likely to have a violent experience (OR 2.78 [95% CI 1.41-5.49] p = 0.003). Overall, residents felt that they had adequate training to prevent occupational hazards (mean of 3.9/5 on Likert scale) and respond to hazards (mean of 3.7/5 Likert). CONCLUSIONS: Occupational hazards are not uncommon in orthopedic surgery training with high rates of improper eyewear PPE use and poor awareness of Occupational Safety and Health Administration and AAOS guidelines. Violence in the workplace impacts over one in 4 residents and training programs and hospitals should improve education and report efforts. Continual yearly PPE training and awareness of AAOS guidelines could be intertwined with duty hour and/or case logs in order to ensure residents are exposed to this material on a regular basis.

Association of State Legislation and Industry Compensation to Orthopaedic Residents: A 3-Year Review of the Centers for Medicare and Medicaid Services Open Payments Database.

BACKGROUND: The Sunshine Act aims to increase the transparency of physicians receiving compensation from pharmaceutical and medical device companies. Nine states have supplementary legislation in addition to the Federal Sunshine Act. The purpose of this study is to assess the characteristics of financial compensation to orthopaedic residents on the Centers for Medicare and Medicaid Services (CMS) Open Payments Database in states with more restrictive regulations compared with those without additional restrictions. METHODS: A complete list of accredited orthopaedic residency programs in the United States was compiled using the Accreditation Council for Graduate Medical Education and American Osteopathic Academy of Orthopedics websites. The website of each orthopaedic residency program was searched to compile a list of residents who attended their program from 2014 to 2016. The CMS Open Payments Database was used to search the residents identified for the corresponding years. All data available on the CMS Open Payments Database were recorded. RESULTS: Over the 3-year period, 3,622 residents were identified from 151 programs. A total of 41% of the residents were reported as receiving compensation from the industry. The percent of residents reported from programs in less restrictive states was 45% versus 28% in more restrictive states (P < 0.001). Residents had a mean of 5.3 transactions per year in less restrictive states and 2.4 transactions per year in more restrictive states (P < 0.001). The mean compensation per resident reported was $2,730 for less restrictive sates versus $1,937 for more restrictive states (P < 0.001). DISCUSSION: Overall, 41% of orthopaedic residents were reported on the CMS Open Payments Database with fewer transactions and less compensation going to residents in states with more restrictive legislature. Potential implications on resident education remain unknown.

Orthopaedic Surgery Residency Milestones: Initial Formulation and Future Directions.

Milestones specific to orthopaedic surgical training document individual resident progress through skill development in multiple dimensions. Residents increasingly interact with and are assessed by surgeons in both academic and private practice environments. Milestones describe the skills that support competence. One of the primary goals of milestones is to provide continuous data for educational quality improvement of residency programs. They provide a dialogue between surgeons who supervise residents or fellows and the program's Clinical Competency Committee throughout a resident's education. The orthopaedic milestones were developed jointly by the Accreditation Council for Graduate Medical Education and the American Board of Orthopaedic Surgery. The working team was designed with broad representation within the specialty. The milestones were introduced to orthopaedic residencies in 2013. Orthopaedics is a 5-year training program; the first comprehensive longitudinal data set is now available for study. This summary provides historical perspective on the development of the milestones, state of current milestone implementation, attempts to establish validity, challenges with the milestones, and the development of next-generation assessment tools.

Business Modeling of Orthopaedic Trauma in the Emergency Department: An Untapped Revenue Stream.

INTRODUCTION: Emergency departments (EDs) and emergency medicine and orthopaedic residencies can be faced with financial challenges while caring for patients. Procedures performed by residents are a potentially viable source of revenue that may make orthopaedic coverage of the ED a financially viable service line. METHODS: A custom text-mining program was created and validated, which allowed evaluation of all orthopaedic resident notes. Procedures performed in the ED were quantified, allowing for the calculation of professional fee billing data. The patients with distal radius fractures were followed after fracture reduction through final outpatient clinic follow-up to identify additional professional fee billing. RESULTS: Over a 1-year period, more than $445,000 in uncaptured professional fees charged was identified in the 12 most common Current Procedural Terminology codes for splint application and fracture reduction in the ED. More than $395,000 of outpatient professional revenue was received for patients who had reduction of distal radius fractures in the ED. CONCLUSION: A notable, previously unrecognized and uncaptured source of revenue was identified and quantified. Professional fee billing for distal radius fracture reduction in the ED did not have a negative effect on outpatient professional fee revenue received for these patients.

Resident Surgical Skills Web-Based Evaluation: A Comparison of 2 Assessment Tools.

BACKGROUND: Evaluation of surgical skill competency is necessary as graduate medical education moves toward a competency-based curriculum. This study by the American Board of Orthopaedic Surgery (ABOS) and the Council of Orthopaedic Residency Directors (CORD) compares 2 web-based evaluation tools that assess the level of autonomy that is demonstrated by residents during surgical procedures in the operating room as measured by faculty. METHODS: Two hundred and ninety-four residents from 16 orthopaedic surgery residency programs were evaluated by 370 faculty using 2 web-based evaluation tools in a crossover design in which residents requested faculty review of their surgical skills before starting a case. One thousand, one hundred and fifty Ottawa Surgical Competency Operating Room Evaluation (O-Score) assessments, which included a 9-question evaluation of 8 steps of the surgical procedure, were compared with 1,186 P-score evaluations, which included a single-question summative evaluation. Twenty-five different surgical procedures were evaluated. RESULTS: There were no significant differences in rates of resident requests or faculty completion of the 2 scores. The most common surgical procedures that were assessed were total knee arthroplasty (n = 254, 11%), carpal tunnel release (n = 191, 8%), open reduction and internal fixation (ORIF) of stable hip fractures (n = 170, 7%), ORIF of simple ankle fractures (n = 169, 7%), and total hip arthroplasty (n = 166, 7%). Both instruments disclosed significant differences in competency among entry, intermediate, and advanced-level residents. The findings support the construct validity of the evaluation method. The survey results indicated that >70% of the faculty were confident that use of either the P-score or the O-score allowed them to distinguish a resident who can perform the surgery independently from one who needs additional training. CONCLUSIONS: This research has led to the modification of the O-score and the P-score into a combined OP-score instrument. The ABOS envisions that the OP-score instrument can be used with an expanded number of surgical procedures as a required element of residency training in the near future. CLINICAL RELEVANCE: This study allows the profession of orthopaedic surgery education to take a leadership role in the measurement of competence for surgical skills for orthopaedic surgeons in residency training, an important clinically relevant topic to the practice of orthopaedic surgery.

An Analysis of Research Quality and Productivity at Six Academic Orthopaedic Residencies.

OBJECTIVE: It remains largely unknown what factors impact the research productivity of residency programs. We hypothesized that dedicated resident research time would not affect the quantity and quality of a program's peer-reviewed publication within orthopedic residencies. These findings may help programs improve structure their residency programs to maximize core competencies. DESIGN: Three hundred fifty-nine residents and 240 staff from six different US orthopedic residency programs were analyzed. All publications published by residents and faculty at each program from January 2007 to December 2015 were recorded. SCImago Journal Rankings (SJR) were found for each journal. RESULTS: There were no significant differences in publications by residents at each program (p > 0.05). Faculty with 10+ years of on staff, had significantly more publications than those with less than 10 years (p < 0.01). Programs with increased resident research time did not consistently produce publications with higher SJR than those without dedicated research time. CONCLUSIONS: Increased dedicated resident research time did not increase resident publication rates or lead to publications with higher SJR.

Post-Discharge Opioid Prescribing and Use after Common Surgical Procedure.

BACKGROUND: The number of deaths from prescription opioids in the US continues to increase and remains a major public health concern. Opioid-related deaths parallel prescribing trends, and postoperative opioids are a significant source of opioids in the community. Our objective was to identify opioid prescribing and use patterns after surgery to inform evidence-based practices. STUDY DESIGN: Data from a 340-bed academic medical institution and its affiliated outpatient surgical facility included retrospective medical record data and prospective telephone questionnaire and medical record data. Retrospective data included patients discharged after 1 of 19 procedure types, from July 2015 to June 2016 (n = 10,112). Prospective data included a consecutive sample of general and orthopaedic surgery and urology patients undergoing 1 of 13 procedures, from July 2016 to February 2017 (n = 539). Primary outcomes were the quantity of opioid prescribed and used in morphine milligram equivalents (MME), and the proportion of patients receiving instructions on disposal and nonopioid strategies. RESULTS: In the retrospective dataset, 76% of patients received an opioid after surgery, and 87% of prescriptions were prescribed by residents or advanced practice providers. Median prescription size ranged from 0 to 503 MME, with wide interquartile ranges (IQR) for most procedures. In the prospective dataset, there were 359 participants (67% participation rate). Of these, 92% of patients received an opioid and the median proportion used was 27%, or 24 MME (IQR 0 to 96). Only 18% of patients received disposal instructions, while 84% of all patients received instructions on nonopioid strategies. CONCLUSIONS: Median opioid use after surgery was 27% of the total prescribed, and only 18% of patients reported receiving disposal instructions. Significant variability in opioid prescribing and use after surgery warrants investigation into contributing factors.

What Leads to Lead: Results of a Nationwide Survey Exploring Attitudes and Practices of Orthopaedic Surgery Residents Regarding Radiation Safety.

BACKGROUND: Excessive radiation to health-care providers has been linked to risks of cancer and cataracts, but its negative effects can be substantially reduced by lead aprons, thyroid shields, and leaded glasses. Hospitals are required to provide education and proper personal protective equipment, yet discrepancies exist between recommendations and compliance. This article presents the results of a survey of U.S. orthopaedic surgery residents concerning attitudes toward radiation exposure and personal protective equipment behavior. METHODS: An invitation to participate in a web-based, anonymous survey was distributed to 46 U.S. allopathic orthopaedic surgery residency programs (1,207 potential resident respondents). The survey was conceptually divided into the following areas: demographic characteristics, training and attitudes concerning occupational hazards, personal protective equipment provision and use, and general safety knowledge. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated for the association between these characteristics and compliance with thyroid shield or lead gown wear. RESULTS: In this study, 518 surveys were received, with 1 survey excluded because of insufficient response, leaving 517 surveys for analysis (42.8% response rate). Ninety-eight percent of residents believed that personal protective equipment should be provided by the hospital or residency program. However, provision of personal protective equipment was not universal, with 33.8% reporting none and 54.2% reporting provision of a gown and thyroid shield. The prevalence of leaded glasses usage was 21%. Poor lead gown compliance and thyroid shield wear were associated with difficulty finding the corresponding equipment: PR, 2.51 (95% CI, 1.75 to 3.62; p < 0.001) for poor lead gown compliance and PR, 2.14 (95% CI, 1.46 to 3.16; p < 0.0001) for poor thyroid shield wear. Not being provided with personal protective equipment was also significantly associated with low compliance with both lead gowns (PR, 1.47 [95% CI, 1.04 to 2.08]; p = 0.03) and thyroid shields (PR, 1.69 [95% CI, 1.18 to 2.41]; p = 0.004). Respondents from the Southeast, West, or Midwest had lower compliance with lead gown usage. Forgetting was the number 1 reason to not wear a lead apron (42%). CONCLUSIONS: Radiation exposure is associated with increased risk of serious health problems. Our findings identified that the availability of lead personal protective equipment leads to increased compliance among residents surveyed. In addition to yearly occupational hazard training specific to orthopaedic surgery, greater efforts by residency programs and hospitals are needed to improve access to lead personal protective equipment and compliance for orthopaedic residents.

Burnout in Orthopaedic Surgeons: A Challenge for Leaders, Learners, and Colleagues: AOA Critical Issues.

Burnout, depression, suicidal ideation, and dissatisfaction with work-life balance have been reported in all medical specialties and at all stages of medical education and practice experience. Burnout consists of progressive emotional, attitudinal, and physical exhaustion. Physicians with burnout may treat patients as objects and feel emotionally depleted. Burnout is characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment. The most complete study of emotional burnout among different medical specialties demonstrated that orthopaedic surgery is one of the specialties with the highest burnout rate. Qualitative descriptive studies are available. There was a 45.8% burnout rate among physicians in the U.S. in 2012, and a 2014 update suggested even higher rates. Burnout has a correlation with medical education. Burnout rates are similar to those in the general population when medical students enter school, and increase steadily through medical education prior to residency. Burnout rates in residents are high, reported to be between 41% and 74% across multiple specialties. This impacts our young physician workforce in orthopaedics. The purpose of this review is to provide the available information that characterizes burnout and addresses the issues inherent to preventing burnout, and to build awareness in orthopaedic surgeons. Wellness "goes beyond merely the absence of distress and includes being challenged, thriving, and achieving success in various aspects of personal and professional life." The challenge for the orthopaedic community is to develop interventions and strategies that are personalized to the individuals in this specialty.

Solid Renal Masses in Transplanted Allograft Kidneys: A Closer Look at the Epidemiology and Management.

The objective of this review is to explore the available literature on solid renal masses (SRMs) in transplant allograft kidneys to better understand the epidemiology and management of these tumors. A literature review using PubMed was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Fifty-six relevant studies were identified from 1988 to 2015. A total of 174 SRMs in 163 patients were identified, with a mean tumor size of 2.75 cm (range 0.5-9.0 cm). Tumor histology was available for 164 (94.3%) tumors: clear cell renal cell carcinoma (RCC; 45.7%), papillary RCC (42.1%), chromophobe RCC (3%), and others (9.1%). Tumors were managed by partial nephrectomy (67.5%), radical nephrectomy (19.4%), percutaneous radiofrequency ablation (10.4%), and percutaneous cryoablation (2.4%). Of the 131 patients (80.3%) who underwent nephron-sparing interventions, 10 (7.6%) returned to dialysis and eight (6.1%) developed tumor recurrence over a mean follow-up of 2.85 years. Of the 110 patients (67.5%) who underwent partial nephrectomy, 3.6% developed a local recurrence during a mean follow-up of 3.12 years. The current management of SRMs in allograft kidneys mirrors management in the nontransplant population, with notable findings including an increased rate of papillary RCC and similar recurrence rates after partial nephrectomy in the transplant population despite complex surgical anatomy.

Potential Association Between Physician Burnout Rates and Operating Margins: Specialty-Specific Analysis.

Physician burnout rates have increased across most specialties betweer 2011 and 2014, and there may be an association with financial metrics. WE examined the ordinal ranking of operating margins for each physician spe. cialty from the University of Vermont Medical Center and the correspond. ing physician burnout ranking according to previously published data Physician specialties were categorized into one of four groups accordinc to high or low operating margin and burnout. Radiology, dermatology, otolaryngology, emergency medicine, family medicine, anesthesia, anc neurology were consistently categorized by high operating margin and high burnout rank. Our study provides a framework to explore the impaci of financial metrics on specialty-specific satisfaction and burnout. This information is relevant to the way hospital administrators guide revenue streams, medical students select specialties, and the extent to which physicians pursue their careers.

Immune reconstitution following rabbit antithymocyte globulin.

Depletional induction therapies are routinely used to prevent acute rejection and improve transplant outcome. The effects of depleting agents on T-cell subsets and subsequent T-cell reconstitution are incompletely defined. We used flow cytometry to examine the effects of rabbit antithymocyte globulin (rATG) on the peripheral T-cell repertoire of pediatric and adult renal transplant recipients. We found that while rATG effectively depleted CD45RA+CD27+ naïve and CD45RO+CD27+ central memory CD4+ T cells, it had little effect on CD45RO+CD27- CD4+ effector memory or CD45RA+CD31-, CD45RO+CD27+ and CD45RO+CD27- CD8+ T cell subsets. When we performed a kinetic analysis of CD31+ recent thymic emigrants and CD45RA+/RO+ T cells, we found evidence for both thymopoiesis and homeostatic proliferation contributing to immune reconstitution. We additionally examined the impact of rATG on peripheral CD4+Foxp3+ T cells. We found that in adults, administration of rATG-induced peripheral expansion and new thymic emigration of T cells with a Treg phenotype, while CD4+Foxp3+ T cells of thymic origin predominated in children, providing the first evidence that rATG induces Treg in vivo. Collectively our data indicate that rATG alters the balance of regulatory to memory effector T cells posttransplant, providing an explanation for how it positively impacts transplant outcome.