Symposium: Can We Align Conflicting Agendas: Medical Education and Value-Based Care

Moderator: Daniel B. Murrey, MD, MPP, FAOA
Panelists: Karl M. Koenig, MD, MS, FAOA ; Joseph A. Bosco, III, MD; Dave Jevsevar, MD, MBA, FAOA

Objectives:

1. What types of new contracting arrangements are being offered to or forced upon orthopaedic surgeons and what is required to perform on them?
2. What potential impact will these arrangements have on our ability to train residents and our willingness to let them learn?
3. What options can we consider to not only care for patients differently but organize our training programs and curriculum differently?

Summary:

Value-based contracts offer incentives to patients and providers for choosing caregivers who deliver better quality at a lower cost.  Academic and tertiary centers with higher cost structures are vulnerable to loss of market share to those who can do it more economically, such as community hospitals and ASCs. This could undermine profitability of the hospital system even though it may increase value to the patient. In some markets this may be an appropriate adjustment in pricing, but in others it will require better resource management within systems and may threaten the viability of necessary community resources.  

As medical educators working in these environments, this creates an additional challenge of two competing interests -- the need to train inexperienced new graduates to manage patients while working in a system that is trying to divert care to the most experienced and successful providers. How do we effectively train new physicians if their learning curve is counted against our bottom line? Or if market forces shift all routine care away from academic centers to ambulatory and community settings, how will we train residents in the full breadth of orthopaedic care?

Given that orthopaedics is on the cutting edge of value-based care for specialists, we must lead the way in creating models that train surgeons while succeeding in these new care models.
 
 

Symposium: How to Assess Quality in an Expanding Healthcare System?

Moderator: William Obremskey, MD, MPH, FAOA
Panelists: George V. Russell, Jr., MD, FAOA; Michael Suk, MD, JD, MPH, MBA, FAOA; Benjamin A. Alman, MD, FAOA; Thomas P. Vail, MD, FAOA

Objectives:

1. Understand what Quality metrics are available.
2. Learn options to assess surgeon quality
3. Explore how health systems merge and assess Quality metrics

Summary: 

Quality and value are buzz-words of modern healthcare systems. Healthcare systems are expanding by recruiting core clinical faculty as well as by absorbing community practice groups or entire health systems. Orthopaedic chairs are being asked to assist with evaluating and validating quality orthopaedic care.  Little data is available to help guide chairs through these challenging decisions and processes. This symposium will provide insight on different quality metrics in a variety of settings.

Can quality be defined? This is an imposing question for healthcare in general and orthopaedic chairs as healthcare systems continue to grow. Most things that we measure are a surrogate for quality. Once absorbed by the health care system, it is difficult for a chair to decide if a new recruit or faculty are of the same standard as other faculty members, for whom the chair is primarily responsible. Quality can be assessed by process measures, clinical measures, cost measures, patient reported outcomes, and patient satisfaction scores.
 
 

Symposium: Strategies for Recruiting and Retaining Women and Minorities in Orthopaedics

Moderator: Jonathan P. Braman, MD, FAOA
Panelists: Katherine Gerull, MD; Scott E. Porter, MD, MBA, FACS, FAOA; Arghavan Salles, MD, PhD

Objectives:
1. Understand the role that implicit bias plays in leadership decisions and evaluation.
2. Recognize and support the role that gender and minority identity play in the sense of belonging in medicine.
3. Demonstrate the ability to develop a plan on how to assemble and mentor diverse teams in the healthcare setting.

Summary:
The AOA has recognized the need to promote diversity within the orthopaedic community, calling the lack of diversity in orthopaedic surgery a “critical issue”. Recent data published in August of 2019 by the AAOS demonstrates that 5.8% orthopaedic surgeons identify as female and 84.7% identify as Caucasian. (AAOS 2019) These ratios have not undergone significant change recently. This has led to the AOA sponsoring community outreach projects, appointing several diversity liaisons, hosting an AOA/JBJS webinar on diversity, and hosting a 2018 and 2019 AOA conference symposia on diversity. It is important to recognize, however, that there is evidence from work in the legal profession that the programs which are most effective at increasing retention of women may not be as effective at retaining racial minority lawyers and vice versa. (Apfelbaum et al, 2016) This begs the question: how can we work to increase the diversity of our profession so that all groups are welcome, sponsored, successful, and satisfied with a career choice in orthopaedic surgery?

Now is the time for action since orthopaedics is the least gender and racially diverse specialty in medicine.

Women comprise only 17% of Orthopaedic Surgery faculty, compared to 23% of General Surgery faculty and 32% of Otolaryngology faculty. Even at the level of residency training, women are under-represented in orthopaedics. Van Heest found that of the 150 orthopaedic training programs in the United States, 30 programs (20%) had at least one residency class with no female trainees, and eight programs (5%) had no women trainees enrolled in any of the five classes. Demographic trends since 1968 show that the percentage of women entering General Surgery is increasing at a significantly faster rate than Orthopaedic Surgery (p < 0.0001). By the year 2015, 38% of General Surgery residents were women, compared to only 15% of orthopaedic Surgery residents.
Additionally, other facets of diversity including racial diversity has seen little improvement. More longitudinal data shows that minority representation in orthopaedic surgery residency programs averaged 25.6% from 2006-2015, with no significant change in the representation of African-American students over time, and a significant decrease in overall racial diversity amongst orthopaedic surgery residents over this time.

Taken together, these data points raise significant concern about the future gender and racial diversity of Orthopaedic Surgery and also suggest that current policies designed to increase diversity and improve inclusion within our specialty are failing women and under-represented minorities.
Much of the national conversation on this topic has been about defining the problem—citing numbers and statistics about the lack of diversity in orthopaedics—but very few of these conversations have moved into discussions of forward-looking strategies. Through implementation of our proposed symposium, the AOA could host a national conversation about gender and racial diversity in orthopaedics using a strategy-forward, data driven approach. As the premiere organization for orthopaedic educators, program directors, and academic orthopedists, the AOA has a unique and pivotal role to play in this conversation. This symposium will focus on the differences between recruiting and retaining women and recruiting and retaining under-represented minorities.     

 
 

Symposium: Own the Fall: The Role of the Orthopaedic Surgeon in Falls and Fall Prevention

Moderator: Paul A. Anderson, MD, FAOA
Panelists: Jay S. Magaziner, PhD, MSHyg; Daniel A. Mendelson, MS, MD; Julie A. Switzer, MD, FAOA

Objectives:
1. Participants will learn the morbidity and mortality associated with falls in orthopaedics (including elective surgery) patients
2. Attendees will Introduce falls assessment into orthopaedic practice
3. Participants will be able to provide evidence-based care for patients at risk of falling

Summary:
The goals of this critical issue symposium are to raise awareness among orthopaedic surgeons of the role they play in assessing the causes of falls. This is important not only at the time of injury but also as a component of preoperative optimization in elective surgery to improve outcomes and prevent complications. Falls and subsequent fractures are well known causes of morbidity and mortality. 

An initial fall is a major predictor of a subsequent fall and additional fractures, but is rarely evaluated in orthopaedic practices. Secondary fracture prevention services focus on diagnostic and pharmaceutical interventions while rehabilitation is mainly directed at recovery from injury. Fall prevention, although a key quality parameter for the AOA’s Own the Bone program, is subject to significant variation and is delayed until after fracture healing has occurred. 

Despite the relevance of falls to our patients’ health, orthopaedic educational curricula do not generally include information on this subject to train surgeons in assessing fall risk nor multidisciplinary options to prevent falls. The fact that falls occur commonly after elective orthopaedic surgery, such as joint replacement, is even less well-known, yet can be associated with complications such as loosening, periprosthetic fracture, and in the spine junctional segment fracture.  Similar to the concept of preoperative medical optimization, assessment of fall risk could lead to preoperative and postoperative rehabilitation strategies to improve outcomes and avoid complications. 

Symposium: COVID-19: Impact on Orthopaedic Graduate Medical Education in the US

Moderator:  Ann Van Heest, MD, FAOA

Panelists: Peter M. Murray, MD, FAOA; George Dyer, MD, FAOA; Aaron Brandt, MD

Objectives:
  1. To update participants on the impact of the restrictions caused by COVID-19 on orthopaedic surgical education in the United States.
  2. To review the ACGME guidelines for programs regarding requirements to demonstrate competence in learners, as well as alternatives to case volumes alone to evaluate learner readiness.
  3. To discuss/develop innovative tools that can be used to evaluate competence in residents and fellows.

Summary:
The COVID-19 crisis has challenged the US healthcare system in a variety of ways, including how we teach and train residents and fellows.  The reductions in elective patient care during this period, including surgical procedures and outpatient visits, will be reflected in case logs and other metrics used  by the ACGME to determine how well programs prepare learners to be competent in the independent  practice of their specialty/sub-specialty.  This symposium will assess the impact of restrictions related to the COVID-19 pandemic on residency and fellowship programs from the perspective of the ACGME, program directors and learners themselves.    The ACGME's recent guidelines to programs regarding how competence is assessed will be reviewed and discussed to ensure that all stakeholders involved in orthopaedic GME have a clear understanding of the options available to them, including alternate measures of competence, increased time for training and collaboration between organizations such as the ACGME and ABOS.