Diagnosing conflict: Conflicting data, interpersonal conflict, and conflicts of interest in clinical competency committees.

Clinical competency committees (CCCs) are increasingly used within health professions education as their decisions are thought to be more defensible and fairer than those generated by previous training promotion processes. However, as with most group-based processes, it is inevitable that conflict will arise. In this paper the authors explore three ways conflict may arise within a CCC: (1) conflicting data submissions that are presented to the committee, (2) conflicts between members of the committee, and (3) conflicts of interest between a specific committee member and a trainee. The authors describe each of these conflict situations, dissect out the underlying problems, and explore possible solutions based on the current literature.

Patient Factors That Matter in Predicting Hip Arthroplasty Outcomes: A Machine-Learning Approach.

BACKGROUND: Despite the success of total hip arthroplasty (THA), approximately 10%-15% of patients will be dissatisfied with their outcome. Identifying patients at risk of not achieving meaningful gains postoperatively is critical to pre-surgical counseling and clinical decision support. Machine learning has shown promise in creating predictive models. This study used a machine-learning model to identify patient-specific variables that predict the postoperative functional outcome in THA. METHODS: A prospective longitudinal cohort of 160 consecutive patients undergoing total hip replacement for the treatment of degenerative arthritis completed self-reported measures preoperatively and at 3 months postoperatively. Using four types of independent variables (patient demographics, patient-reported health, cognitive appraisal processes and surgical approach), a machine-learning model utilizing Least Absolute Shrinkage Selection Operator (LASSO) was constructed to predict postoperative Hip Disability and Osteoarthritis Outcome Score (HOOS) at 3 months. RESULTS: The most predictive independent variables of postoperative HOOS were cognitive appraisal processes. Variables that predicted a worse HOOS consisted of frequent thoughts of work (ß = -0.34), frequent comparison to healthier peers (ß = -0.26), increased body mass index (ß = -0.17), increased medical comorbidities (ß = -0.19), and the anterior surgical approach (ß = -0.15). Variables that predicted a better HOOS consisted of employment at the time of surgery (ß = 0.17), and thoughts related to family interaction (ß = 0.12), trying not to complain (ß = 0.13), and helping others (ß = 0.22). CONCLUSIONS: This clinical prediction model in THA revealed that the factors most predictive of outcome were cognitive appraisal processes, demonstrating their importance to outcome-based research. LEVEL OF EVIDENCE: Prognostic Level 1.

Training disrupted: Practical tips for supporting competency-based medical education during the COVID-19 pandemic.

The COVID-19 pandemic has disrupted healthcare systems around the world, impacting how we deliver medical education. The normal day-to-day routines have been altered for a number of reasons, including changes to scheduled training rotations, physical distancing requirements, trainee redeployment, and heightened level of concern. Medical educators will likely need to adapt their programs to maximize learning, maintain effective care delivery, and ensure competent graduates. Along with a continued focus on learner/faculty wellness, medical educators will have to optimize existing training experiences, adapt those that are no longer viable, employ new technologies, and be flexible when assessing competencies. These practical tips offer guidance on how to adapt medical education programs within the constraints of the pandemic landscape, stressing the need for communication, innovation, collaboration, flexibility, and planning within the era of competency-based medical education.

Competency-based resident education-The Canadian perspective.

Canada has been a leader in competency-based medical education for some years. Postgraduate training programs are typically 5 years in duration with opportunities to pursue 2-year subspecialty training after certification in a primary specialty. The introduction of competency-based models in Canada has progressed from a single orthopedic surgery training program at the University of Toronto through the adoption of competency-based medical education in 29 training programs at a single medical school, and the implementation across all 68 disciplines overseen by the Royal College of Physicians and Surgeons of Canada. This article outlines the introduction of competency-based medical education in postgraduate medical education in Canada.

Surgical simulation training in orthopedics: current insights.

BACKGROUND: While the knowledge required of residents training in orthopedic surgery continues to increase, various factors, including reductions in work hours, have resulted in decreased clinical learning opportunities. Recent work suggests residents graduate from their training programs without sufficient exposure to key procedures. In response, simulation is increasingly being incorporated into training programs to supplement clinical learning. This paper reviews the literature to explore whether skills learned in simulation-based settings results in improved clinical performance in orthopedic surgery trainees. MATERIALS AND METHODS: A scoping review of the literature was conducted to identify papers discussing simulation training in orthopedic surgery. We focused on exploring whether skills learned in simulation transferred effectively to a clinical setting. Experimental studies, systematic reviews, and narrative reviews were included. RESULTS: A total of 15 studies were included, with 11 review papers and four experimental studies. The review articles reported little evidence regarding the transfer of skills from simulation to the clinical setting, strong evidence that simulator models discriminate among different levels of experience, varied outcome measures among studies, and a need to define competent performance in both simulated and clinical settings. Furthermore, while three out of the four experimental studies demonstrated transfer between the simulated and clinical environments, methodological study design issues were identified. CONCLUSION: Our review identifies weak evidence as to whether skills learned in simulation transfer effectively to clinical practice for orthopedic surgery trainees. Given the increased reliance on simulation, there is an immediate need for comprehensive studies that focus on skill transfer, which will allow simulation to be incorporated effectively into orthopedic surgery training programs.

Eight-year outcomes of a competency-based residency training program in orthopedic surgery.

Background: The Division of Orthopaedic Surgery at the University of Toronto implemented a pilot residency training program that used a competency-based framework in July of 2009. The competency-based curriculum (CBC) deployed an innovative, modularized approach that dramatically intensified both the structured learning elements and the assessment processes. Methods: This paper discusses the initial curriculum design of the CBC pilot program; the refinement of the curriculum using curriculum mapping that allowed for efficiencies in educational delivery; details of evaluating resident competence; feedback from external reviews by accrediting bodies; and trainee and program outcomes for the first eight years of the program's implementation. Results: Feedback from the residents, the faculty, and the postgraduate residency training accreditation bodies on the CBC has been positive and suggests that the essential framework of the program may provide a valuable tool to other programs that are contemplating embarking on transition to competency-based education. Conclusions: While the goal of the program was not to shorten training per se, efficiencies gained through a modular, competency-based program have resulted in shortened time to completion of residency training for some learners.

Assessment of Technical Skills Competence in the Operating Room: A Systematic and Scoping Review.

PURPOSE: While academic accreditation bodies continue to promote competency-based medical education (CBME), the feasibility of conducting regular CBME assessments remains challenging. The purpose of this study was to identify evidence pertaining to the practical application of assessments that aim to measure technical competence for surgical trainees in a nonsimulated, operative setting. METHOD: In August 2016, the authors systematically searched Medline, Embase, and the Cochrane Database of Systematic Reviews for English-language, peer-reviewed articles published in or after 1996. The title, abstract, and full text of identified articles were screened. Data regarding study characteristics, psychometric and measurement properties, implementation of assessment, competency definitions, and faculty training were extracted. The findings from the systematic review were supplemented by a scoping review to identify key strategies related to faculty uptake and implementation of CBME assessments. RESULTS: A total of 32 studies were included. The majority of studies reported reasonable scores of interrater reliability and internal consistency. Seven articles identified minimum scores required to establish competence. Twenty-five articles mentioned faculty training. Many of the faculty training interventions focused on timely completion of assessments or scale calibration. CONCLUSIONS: There are a number of diverse tools used to assess competence for intraoperative technical skills and a lack of consensus regarding the definition of technical competence within and across surgical specialties. Further work is required to identify when and how often trainees should be assessed and to identify strategies to train faculty to ensure timely and accurate assessment.

Overarching challenges to the implementation of competency-based medical education.

Medical education is under increasing pressure to more effectively prepare physicians to meet the needs of patients and populations. With its emphasis on individual, programmatic, and institutional outcomes, competency-based medical education (CBME) has the potential to realign medical education with this societal expectation. Implementing CBME, however, comes with significant challenges. This manuscript describes four overarching challenges that must be confronted by medical educators worldwide in the implementation of CBME: (1) the need to align all regulatory stakeholders in order to facilitate the optimization of training programs and learning environments so that they support competency-based progression; (2) the purposeful integration of efforts to redesign both medical education and the delivery of clinical care; (3) the need to establish expected outcomes for individuals, programs, training institutions, and health care systems so that performance can be measured; and (4) the need to establish a culture of mutual accountability for the achievement of these defined outcomes. In overcoming these challenges, medical educators, leaders, and policy-makers will need to seek collaborative approaches to common problems and to learn from innovators who have already successfully made the transition to CBME.

Implementing competency-based medical education: What changes in curricular structure and processes are needed?

Medical educators must prepare for a number of challenges when they decide to implement a competency-based curriculum. Many of these challenges will pertain to three key aspects of implementation: organizing the structural changes that will be necessary to deliver new curricula and methods of assessment; modifying the processes of teaching and evaluation; and helping to change the culture of education so that the CBME paradigm gains acceptance. This paper focuses on nine key considerations that will support positive change in first two of these areas. Key considerations include: ensuring that educational continuity exists amongst all levels of medical education, altering how time is used in medical education, involving CBME in human health resources planning, ensuring that competent doctors work in competent health care systems, ensuring that information technology supports CBME, ensuring that faculty development is supported, ensuring that the rights and responsibilities of the learner are appropriately balanced in the workplace, preparing for the costs of change, and having appropriate leadership in order to achieve success in implementation.

Changing the culture of medical training: An important step toward the implementation of competency-based medical education.

OBJECTIVE: The current medical education system is steeped in tradition and has been shaped by many long-held beliefs and convictions about the essential components of training. The objective of this article is to propose initiatives to overcome biases against competency-based medical education (CBME) in the culture of medical education. MATERIALS AND METHODS: At a retreat of the International Competency Based Medical Education (ICBME) Collaborators group, an intensive brainstorming session was held to determine potential barriers to adoption of CBME in the culture of medical education. This was supplemented with a review of the literature on the topic. RESULTS: There continues to exist significant key barriers to the widespread adoption of CBME. Change in educational culture must be embraced by all components of the medical education hierarchy. Research is essential to provide convincing evidence of the benefit of CBME. CONCLUSIONS: The widespread adoption of CBME will require a change in the professional, institutional, and organizational culture surrounding the training of medical professionals.

Learning Through Experience: Influence of Formal and Informal Training on Medical Error Disclosure Skills in Residents.

BACKGROUND: Residents' attitudes toward error disclosure have improved over time. It is unclear whether this has been accompanied by improvements in disclosure skills. OBJECTIVE: To measure the disclosure skills of internal medicine (IM), paediatrics, and orthopaedic surgery residents, and to explore resident perceptions of formal versus informal training in preparing them for disclosure in real-world practice. METHODS: We assessed residents' error disclosure skills using a structured role play with a standardized patient in 2012-2013. We compared disclosure skills across programs using analysis of variance. We conducted a multiple linear regression, including data from a historical cohort of IM residents from 2005, to investigate the influence of predictor variables on performance: training program, cohort year, and prior disclosure training and experience. We conducted a qualitative descriptive analysis of data from semistructured interviews with residents to explore resident perceptions of formal versus informal disclosure training. RESULTS: In a comparison of disclosure skills for 49 residents, there was no difference in overall performance across specialties (4.1 to 4.4 of 5, P = .19). In regression analysis, only the current cohort was significantly associated with skill: current residents performed better than a historical cohort of 42 IM residents (P < .001). Qualitative analysis identified the importance of both formal (workshops, morbidity and mortality rounds) and informal (role modeling, debriefing) activities in preparation for disclosure in real-world practice. CONCLUSIONS: Residents across specialties have similar skills in disclosure of errors. Residents identified role modeling and a strong local patient safety culture as key facilitators for disclosure.

Do Transcortical Screws in a Locking Plate Construct Improve the Stiffness in the Fixation of Vancouver B1 Periprosthetic Femur Fractures? A Biomechanical Analysis of 2 Different Plating Constructs.

OBJECTIVES: This biomechanical study compared Vancouver B1 periprosthetic femur fractures fixed with either a locking plate and anterior allograft strut construct or an equivalent locking plate with locking attachment plates construct in paired cadaveric specimens. METHODS: After 9 pairs of cadaveric femora were implanted with a cemented primary total hip arthroplasty, an oblique osteotomy was created distal to the cement mantle. Femora underwent fixation with either: (1) a locking plate with anterior strut allograft (locking compression plating (LCP)-Allograft) or (2) a locking plate with 2 locking attachment plates (LAPs) (LCP-LAP). Construct stiffness was compared in nondestructive mechanical testing for 2 modes of compression (20 degrees abduction and 20 degrees flexion), 2 four-point bending directions (anterior-posterior and medial-lateral), and torsion. A final load to failure test evaluated the axial compression required to achieve fracture gap closure or construct yield. Fixation was compared through paired t tests (α = 0.05). RESULTS: The LCP-Allograft construct demonstrated higher stiffness values in compressive abduction (207 ± 57 vs.151 ± 40 N/mm), torsion (1666 ± 445 vs. 1125 ± 160 N mm/degree) and medial-lateral four-point bending (413 ± 135 vs. 167 ± 68 N/mm) compared with the LCP-LAP construct (P < 0.05). No differences were identified between the 2 constructs in compressive flexion, anterior-posterior bending, or the load to failure test (P > 0.05). CONCLUSION: Use of the anterior allograft strut created a stiffer construct compared with the LCP-LAP for the treatment of a Vancouver B1 periprosthetic femur fracture only in loading modes with increased medial-lateral bending. Although these static load results are indicative of the early postoperative environment, further fatigue testing is required to better understand the importance of the reduced medial-lateral stiffness over a longer period.

Simulation for Teaching Orthopaedic Residents in a Competency-based Curriculum: Do the Benefits Justify the Increased Costs?

BACKGROUND: Although simulation-based training is becoming widespread in surgical education and research supports its use, one major limitation is cost. Until now, little has been published on the costs of simulation in residency training. At the University of Toronto, a novel competency-based curriculum in orthopaedic surgery has been implemented for training selected residents, which makes extensive use of simulation. Despite the benefits of this intensive approach to simulation, there is a need to consider its financial implications and demands on faculty time. QUESTIONS/PURPOSES: This study presents a cost and faculty work-hours analysis of implementing simulation as a teaching and evaluation tool in the University of Toronto's novel competency-based curriculum program compared with the historic costs of using simulation in the residency training program. METHODS: All invoices for simulation training were reviewed to determine the financial costs before and after implementation of the competency-based curriculum. Invoice items included costs for cadavers, artificial models, skills laboratory labor, associated materials, and standardized patients. Costs related to the surgical skills laboratory rental fees and orthopaedic implants were waived as a result of special arrangements with the skills laboratory and implant vendors. Although faculty time was not reimbursed, faculty hours dedicated to simulation were also evaluated. The academic year of 2008 to 2009 was chosen to represent an academic year that preceded the introduction of the competency-based curriculum. During this year, 12 residents used simulation for teaching. The academic year of 2010 to 2011 was chosen to represent an academic year when the competency-based curriculum training program was functioning parallel but separate from the regular stream of training. In this year, six residents used simulation for teaching and assessment. The academic year of 2012 to 2013 was chosen to represent an academic year when simulation was used equally among the competency-based curriculum and regular stream residents for teaching (60 residents) and among 14 competency-based curriculum residents and 21 regular stream residents for assessment. RESULTS: The total costs of using simulation to teach and assess all residents in the competency-based curriculum and regular stream programs (academic year 2012-2013) (CDN 155,750, USD 158,050) were approximately 15 times higher than the cost of using simulation to teach residents before the implementation of the competency-based curriculum (academic year 2008-2009) (CDN 10,090, USD 11,140). The number of hours spent teaching and assessing trainees increased from 96 to 317 hours during this period, representing a threefold increase. CONCLUSIONS: Although the financial costs and time demands on faculty in running the simulation program in the new competency-based curriculum at the University of Toronto have been substantial, augmented learner and trainer satisfaction has been accompanied by direct evidence of improved and more efficient learning outcomes. CLINICAL RELEVANCE: The higher costs and demands on faculty time associated with implementing simulation for teaching and assessment must be considered when it is used to enhance surgical training.

Training Distal Locking Screw Insertion Skills to Novice Trainees: A Comparison Between Fluoroscopic- and Electromagnetic-Guided Techniques.

OBJECTIVES: To compare the effect fluoroscopy or electromagnetic (EM) guidance has on the learning of locking screw insertion in tibial nails in surgical novices. METHODS: A randomized, prospective, controlled trial was conducted involving 18 surgical trainees with no prior experience inserting locking screws in intramedullary nails. After a training session using fluoroscopy, participants underwent a pretest using fluoroscopic guidance. Participants were then randomized into either the fluoroscopy or EM group and were further trained using their respective technique. Post, retention, and transfer tests were conducted. Outcomes included task completion, drill attempts, screw changes, and radiation time. RESULTS: Intragroup comparisons revealed that the EM group used significantly less drill attempts during the post and retention tests compared with the pretest (P = 0.016 and P = 0.016, respectively). Intergroup comparisons revealed that the EM group was (1) more likely to complete the task during the retention test (P = 0.043) and (2) had significantly less radiation time during the post and retention tests (P = 0.002 and P = 0.003, respectively). Radiation time in the EM group during the transfer test increased to a level equal to what the fluoroscopy group used during the post and retention tests (P = 0.71 and P = 0.92, respectively). No other significant between-group differences occurred. CONCLUSIONS: EM guidance may be safely used to assist in the training of surgical novices in the skill of distal locking screw insertion. Not only does this technology significantly improve the ability to complete the task and decrease radiation use but also it does so without compromising skill acquisition. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The treatment of periprosthetic fractures.

The management of periprosthetic fractures is an issue of increasing importance for orthopaedic surgeons. Because of the expanding indications for total joint arthroplasty (TJA) and an aging population with increasingly active lifestyles, the incidence of primary and revision TJA is increasing, and there is a corresponding increase in the prevalence of periprosthetic fractures about a TJA. The management of these fractures is often complex because of issues with obtaining fixation around implants, dealing with osteopenic bone or compromised bone stock, and the potential need for revising loose TJA components. In addition, these injuries frequently occur in frail, elderly patients, and the literature has demonstrated that both morbidity and mortality in these patients is similar to that of the geriatric hip fracture population. As such, the early restoration of function and ambulation is critical in patients with these injuries, and effective surgical strategies to achieve these goals are essential.

Radiotherapy for the prophylaxis of heterotopic ossification: a systematic review and meta-analysis of published data.

INTRODUCTION: Following surgery, the formation of heterotopic ossification (HTO) can limit mobility and impair quality of life. Radiotherapy has been proven to provide efficacious prophylaxis against HTO, especially in high-risk settings. PURPOSE: The current review aims to determine the factors influencing HTO formation in patients receiving prophylactic radiotherapy. METHODS: A systematic search of the literature was conducted on Ovid Medline, Embase and the Cochrane Central Register of Controlled Trials. Studies were included if they reported the percentage of sites developing heterotopic ossification after receiving a specified dose of prophylactic radiotherapy. Weighted linear regression analysis was conducted for continuous or categorical predictors. RESULTS: Extracted from 61 articles, a total of 5464 treatment sites were included, spanning 85 separate study arms. Most sites were from the hip (97.7%), from United States patients (55.2%), and had radiation prescribed postoperatively (61.6%) at a dose of 700cGy (61.0%). After adjusting for radiation site, there was no statistically significant relationship between the percentage of sites developing HTO and radiation dose (p=0.1) or whether radiation was administered preoperatively or postoperatively (p=0.1). Sites with previous HTO formation were more likely to develop recurrent HTO than those without previous HTO formation (p=0.04). There was a statistically significant negative relationship between the HTO development and the cohort mean year of treatment (p=0.007). CONCLUSION: Decreases in rates of HTO over time in this patient population may be a function of more efficacious surgical regimens and prophylactic radiotherapy.

Competency-based education: a new model for teaching orthopaedics.

The current methods used to train residents to become orthopaedic surgeons are based on tradition, not evidence-based models. Educators have only a limited ability to assess trainees for competency using validated tests in various domains. The reduction in resident work hours limits the time available for clinical training, which has resulted in some calls for lengthening the training process. Another approach to address limited training hours is to focus training in a program that allows residents to graduate from a rotation based on demonstrated competency rather than on time on a service. A pilot orthopaedic residency curriculum, which uses a competency-based framework of resident training and maximizes the use of available training hours, has been designed and is being implemented.

Patients' views on surgeons' financial conflicts of interest.

BACKGROUND: The U.S. Department of Justice's investigations into financial relationships between surgical device manufacturers and orthopaedic surgeons have raised the question as to whether surgeons can continue to collaborate with industry and maintain public trust. We explored postoperative patients' views on financial relationships between surgeons and surgical device manufacturers, their views on disclosure as a method to manage these relationships, and their opinions on oversight. METHODS: From November 2010 to March 2011, we surveyed 251 postoperative patients in the U.S. (an 88% response rate) and 252 postoperative patients in Canada (a 92% response rate) in follow-up hip and knee arthroplasty clinics with use of self-administered questionnaires. Patients were eligible to complete the questionnaire if their surgery (primary or revision hip or knee arthroplasty) had occurred at least three months earlier. RESULTS: Few patients are worried about possible financial relationships between their surgeon and industry (6% of surveyed patients in the U.S. and 6% of surveyed patients in Canada). Most patients thought that it is appropriate for surgeons to receive payments from manufacturers for activities that can benefit patients, such as royalties for inventions (U.S., 69%; Canada, 66%) and consultancy (U.S., 48%; Canada, 53%). Most patients felt that it is not appropriate for their surgeon to receive gifts from industry (U.S., 63%; Canada, 59%). A majority felt that their surgeon would hold patients' interests paramount, regardless of any financial relationship with a manufacturer (U.S., 76%; Canada, 74%). A majority of patients wanted their surgeon's professional organization to ensure that financial relationships are appropriate (U.S., 83%; Canada, 83%); a minority endorsed government oversight of these relationships (U.S., 26%; Canada, 35%). CONCLUSIONS: Most patients are not worried about possible financial relationships between their surgeon and industry. They clearly distinguish financial relationships that benefit current or future patients from those that benefit the surgeon or device manufacturer. They favor disclosure with professional oversight as a method of managing financial relationships between surgeons and manufacturers.