Journal Club Resources

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AOA Journal Club Project

Each month, the AOA posts suggested articles and relevant discussion points to be used for journal club activities. The topics of the articles specifically address issues related to leadership and practice of medicine.

June 2018

Out of the Straitjacket

Michael S. Weinstein, MD, MBE

Review written by Jeffrey M. Smith, MD, FACS, Director of San Diego Orthopaedic Trauma Fellowship, and founder of SurgeonMastersSM

To start, Dr. Weinstein’s story is relayed in the third person, making the reader think he is describing a colleague. Then Dr. Weinstein reveals to the reader that the very dramatic events are in fact about HIM! 

He explains the context of his situation going through residency that ultimately resulted in his profound depression and burnout:

“My training occurred before work-hour regulations were created. Every-third-night call was the norm; every-other-night was common. On one rotation, we were ‘rewarded’ with being the operative resident on post-call days, which extended our shift to nearly 36 hours. On my trauma rotation, we took 48-hour shifts alternating with 48 hours off, to maximize the consecutive hours we could spend with family or friends.”

In general, research has shown that resiliency is a significant contributor to wellness and burnout prevention. The “old school” strategies for surgical training often centered on the methods of negative resilience training, such as long hours, sleep deprivation, pimping, and shaming. The evidence on risk factors for burnout is limited, and we should be careful in evaluating these factors, especially as it pertains to in-training or in practice.

Interestingly, burnout rates in residents have increased even after the implementation of work-hour restrictions. In a discussion paper for the National Academy of Medicine from June 2017, we can learn some of the current best available evidence. Much is still unknown, and the authors of the discussion paper encourage ongoing research in this area. 

  • Discussion Point:
    My theory is that negative and positive resilience training each play a role, and that many more positive strategies need to be utilized to create sustainable success as a surgeon.

A Stark Description of Burnout
In describing his experience, Dr. Weinstein offers a stark description of the burnout he faced:

“My work lost meaning; I was just going through the motions. I thought everything I tried to accomplish was a failure. I had trouble relating to patients and felt the urge to avoid encounters altogether. I cared less and less about anything I was doing. I didn’t know it then, but I had long experienced classic signs of burnout: emotional exhaustion, depersonalization, and low perceived personal achievement. But the burnout had been waxing and waning for 22 years; now I was in the worst episode of major depression of my life.”

First of all, burnout is not a bad thing nor a sign of weakness. Burnout is an occupational hazard secondary to emotional, mental and even physical injury. Some aspects of burnout are preventable through methods that address injury prevention or through full healing and recovery. Other aspects of burnout are not preventable, and proper management is needed to minimize permanent injury and maximize recovery. 

  • Discussion point:
    My recommendation for addressing burnout is to start somewhere. Find one or two healthy habits to implement and start now. Commonly, burnout is the result of too many or unrealistic expectations; adding also requires removing one or two unhealthy habits.

Mental Health and Illness
Between 300 and 400 physicians commit suicide every year. Personally, I know of too many in my career. While these rare events are the most tragic, burnout is independently associated with a 200% increased likelihood of suicidal ideation. Dr. Weinstein recounts:

“I remember the pain, early in residency, of witnessing a young man who had lost both his arms in an electrical incident, but my recollection of the countless limbs I subsequently removed is vague or nonexistent.” At another point in his story, he states, “I didn’t know what to do with these feelings. I didn’t believe anyone around me had similar thoughts. I didn’t know how to talk to my co-residents or faculty about medical mistakes and the accompanying self-flagellation. I don’t remember anyone talking about such issues back then.”

  • Discussion point:
    Beyond the fact that physicians are human and can be vulnerable to any physical and mental illness as well as alcohol and substance abuse, the factors that contribute to this increased risk include: 
    • post-traumatic stress
    • secrecy or culture of silence
    • stigma or shaming
    • punishment or fear of loss of licensure, privileges or the ability to practice

Recovery is Probable
Although awareness is growing, our current training and practice culture has made very little progress. Dr. Weinstein has taken the steps in the right direction to break the silence and invite others to talk about the subject, to decrease the stigma or shame, and to demonstrate that we can return to provide excellent, safe and compassionate care to our patients:

“I have been back at work in the same capacities as before. I find daily joy in interactions with patients, their families, colleagues, trainees, and our health care team. ... I am concerned for future generations of clinicians unless we change how we teach and practice medicine. We need to devote time and resources to promoting self-care. Too many physicians leave practice prematurely. Too many physicians take their own lives.”

This is an unfortunately all too common situation in which many over-burdened physicians find themselves. Dr. Weinstein found recovery from depression through the support of his family, expert-guided trial and error drug therapies, and cognitive behavioral therapy including mindfulness practices. 

  • Discussion point:
    A list of best practices and resources are growing for the treatment and prevention of burnout as well. Recovery from repetitive physical injury or overuse requires time, energy, focus, unloading and specific exercises. Recovery from repetitive mental and emotional injury and overuse does as well. Here are three resources dedicated to combating burnout: 
    • AMA STEPS Forward - AMA Practice Improvement Strategies
    • National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience
    • SurgeonMasters - Wellness and Burnout Prevention Education and Coaching

Helping a Colleague or Team Member
The Reciprocity of Roles and Relationships, one of my 8 PRACTICEs methodology, is consistent with Dr. Weinstein’s story, where even the provision of assistance requires a give and take.

“I’ve subsequently learned that my colleagues were quite concerned about me but found me unreceptive to attempts to help. I was trying to get help in many ways, but nothing seemed to work.”

Many programs are evolving that address managing potentially traumatic events with teams that offer as much support to the healthcare teams including the surgeons to minimize the injuries that can lead to post-traumatic stress disorder. While others may disagree, my impression is that providing voluntary options that avoid the perception of punishment allows the surgeon to maintain as much control as possible and minimize the mental and emotional injury.

  • Discussion point:
    As far as I know, all of us experience phases of burnout or at least emotional and mental stress or injury. Thoughts and emotions such as stress, anxiety, and anger are normal, and when they should raise concern is not necessarily easy to determine.

    In most cases, earlier intervention or assistance is better. Each of us can be aware that we are ALL at risk. The responsibility falls on ALL of us as colleagues to take the following steps: 
    • Notice the potentially concerning event or behavior
    • Interpret the event as an opportunity to show compassion
    • Assume personal responsibility
    • Know or learn how to assist yourself and others
    • Implement assistance without punishment
February 2018

See More, Do More, Teach More: Surgical Resident Autonomy and the Transition to Independent Practice
Hashimoto, Daniel A. MD, MS; Bynum, William E. IV MD; Lillemoe, Keith D. MD; Sachdeva, Ajit K. MD

Discussion Points:
  • The authors discuss the graduate medical education system’s challenges in providing appropriate resident autonomy and preparation for independent practice while also improving patient safety and cutting costs. With the increasing legal and societal expectations in healthcare, the surgical specialties, in particular, face a unique set of challenges. Hashimoto et al, describe specific threats to the classic Halsted model of surgical education, which involves progressive autonomy over the course of residency training. These threats include duty hour regulations, financial forces, and medical-legal issues.
  • Of note, almost a quarter of graduating surgical residents surveyed stated they did not feel fully prepared for independent practice as an independent surgeon. The latter portion of this article reviews the “Fix the Five” initiative developed by the American College of Surgeons, American Board of Surgery, the Residency Review Committee for Surgery, and the Association of Program Directors in Surgery.
  • The initiative seeks to preserve and promote resident autonomy through improvements in seven key focus areas. By identifying the unique challenges faced by surgical training programs in our current society, this article highlights the importance of collaborative change needed to adequately train the next generation of surgeons.

Understanding the Transition From Resident to Attending Physician: A Transdisciplinary, Qualitative Study
Westerman, Michiel MD; Teunissen, Pim W. MD, PhD; van der Vleuten, Cees P.M. PhD; Scherpbier, Albert J.J.A. MD, PhD; Siegert, Carl E.H. MD, PhD; van der Lee, Nadine MD; Scheele, Fedde MD, PhD

Discussion Points:
  • The authors seek to formulate a conceptual framework that illustrates the challenges of transition between residency training and attending practice.
  • By individually interviewing 14 internal medicine or obstetrics-gynecology physicians in the Netherlands who had recently transitioned to an attending position, the authors discovered three consistent themes underlying this transition: (1) disruptive novel elements; (2) perception and coping; and (3) personal development and outcome. The article goes on to describe these three themes in detail.
  • Results also showed no significant differences between internal medicine and obstetrics-gynecology attendings, illustrating that no discipline-specific factors were present. By retrospectively studying the transition from residency to independent practice and identifying a conceptual psychological framework, this article serves as a strong foundation for future measures that can be implemented to smooth this transition.

Discordance Between Resident and Faculty Perceptions of Resident Autonomy: Can Self-Determination Theory Help Interpret Differences and Guide Strategies for Bridging the Divide?
Biondi, Eric A. MD; Varade, William S. MD; Garfunkel, Lynn C. MD; Lynn, Justin F. MD, MPH; Craig, Mark S. MD, MPH; Cellini, Melissa M. MD, MSEd; Shone, Laura P. DrPH, MSW; Harris, J. Peter MD; Baldwin, Constance D. PhD

Discussion Points:
  • The authors investigate the dissonance between teacher and learner perceptions of autonomy in the medical training environment.
  • Self-determination theory – a concept widely used in business, education, and healthcare – states that individuals who receive autonomy support are more motivated to pursue their goals through the pillars of autonomy, competence, and relatedness. By examining the University of Rochester’s Pediatric Residency Program through parallel questionnaires sent to both faculty and residents, Biondi et al identified strikingly different perceptions of resident autonomy and faculty support.
  • This study revealed multiple underlying themes driving this discordance, including generational differences, inaccurate self-assessments by both parties, and challenges to self-determination. Strategies that could be implemented to prevent this dissonance using the concepts behind self-determination theory are discussed in the latter portion of the article. By critically assessing the discrepancies among trainer and trainee perceptions of autonomy, this article brings to light an issue highly relevant in all fields of academic medicine.

December 2017

Success in Orthopaedic Training: Resident Selection and Predictors of Quality Performance
Egol, Kenneth A. MD; Collins, Jason MD; Zuckerman, Joseph D. MD

Discussion points:
  • Longer days and colder weather mean only one thing: Interview season is in full swing. The resident interview process is a vital part of Orthopaedic residency programs. Failure to match the “right” candidate can create undo stress on the program and the applicant. Egol et al. reviewed research regarding specific attributes indicative of success during residency training. After a review of the literature they concluded that performance on an Orthopaedic rotation, USMLE Step 1 scores, medical school class rank, interview performance, and letters of recommendation all were ranked as important in matching.
  • They also found that higher standardized test scores are most predictive of cognitive ability. Three areas that may be predictive of resident performance are motor abilities, cognitive skills, and affective domain. However, objective tools for measuring performance in the affective domain are still lacking.
  • Direct observation of applicant performance on orthopedic rotations may still be the best way to measure interpersonal skills and possible affective domain issues. Proper emphasis should be placed on these rotations in addition to the remainder of the application.

November 2017

The Emerging Case for Shared Decision Making in Orthopaedics
Youm, Jiwon MS; Chenok, Kate MBA; Belkora, Jeff PhD; Chan, Vanessa MPH; Bozic, Kevin MD, MBA

Discussion points:
  • The authors examine the concept of shared decision making as it applies to orthopaedic practice. Despite the established utility of this philosophy, as well as its relevance to orthopaedics, it has not been commonly adopted among orthopaedic surgeons. The idea of shared decision making has been refined since its inception in 1982, and is supported by decades of evidence suggesting improved outcomes and benefits.
  • The authors of this 2013 Instructional Course Lecture discuss these potential benefits, as well as barriers to implementation of this ideology and methods of promoting its widespread adoption. The latter portion of the article details recent federal and statewide legislative initiatives incentivizing the adoption of shared decision making strategies in clinical practice.
  • The article ends with a call-to-action for orthopaedic surgeons to lead this shift in clinical paradigm. This paper provides a comprehensive overview of a contemporary topic pertinent to all physicians, and particularly those in orthopaedics who may have been slower to adopt this important philosophy.

October 2017

An Observational Study of Orthopaedic Abstracts and Subsequent Full-Text Publications
Bhandari, Mohit MD, MSc; Devereaux, P. J. MD; Guyatt, Gordon H. MD, MSc; Cook, Deborah J. MD, MSc; Swiontkowski, Marc F. MD; Sprague, Sheila BSc; Schemitsch, Emil H. MD

Discussion points:
  • The authors investigate the quality and validity of information presented in orthopaedic research abstracts, which are commonly used as sources in major orthopaedic textbooks. By examining the quality and completeness of abstracts presented at the 1996 Annual Meeting of the American Academy of Orthopaedic Surgeons, Bhandari et al. identified factors predictive of the ultimate publication of a complete manuscript following abstract presentation.
  • This study revealed that only one-third of abstracts were followed by publication of a full-text article. The authors go on to describe the many inconsistencies in primary outcome measures and results between the original abstracts and final publications.
  • Methods that could be implemented to prevent these discrepancies are discussed in the latter portion of the article. By critically assessing the quality and validity of information published in major orthopaedic textbooks and used to guide orthopaedic practice, this article brings to light an issue highly relevant to all orthopaedic surgeons, and particularly those closely involved with research and education.

Measuring Patient Satisfaction in Orthopaedic Surgery
Graham, Brent MD, FRCSC; Green, Andrew MD; James, Michelle MD; Katz, Jeffrey MD; Swiontkowski, Marc MD

Discussion points:
  • Clinical researchers have increasingly acknowledged the importance of understanding and documenting patient reported outcomes. Patient satisfaction has been identified as a component when reporting these outcomes. On the surface, this seems an easy task. The reality is that patient satisfaction is very complex. Patient satisfaction is dependent not only on the outcome of care, but on the process of the care. Multiple factors can influence whether patients are satisfied with their care.
  • The authors go on to discuss some of the difficulties and discussions of whether patient satisfaction can be measured and if it is a valid measure of overall quality of care. Several examples of patient satisfaction measures are then discussed. The characteristics that make each of these examples reliable and valid are explored in detail.
  • The last portion of the article discusses how and when patient satisfaction is important to be reported.  The article provides a detailed and concise discussion of a topic most orthopaedic surgeons feel is relatively simple to understand, but when you truly dig deeper, the topic is complicated and often confusing.
September 2017

Orthopaedic Surgeon Burnout: Diagnosis, Treatment, and Prevention
Daniels, Alan H. MD; DePasse, J. Mason MD; Kamal, Robin N. MD

Discussion points:
  • Are you feeling emotionally exhausted? Do you have a cynical view around the workplace? Do you have a perceived lack of personal accomplishment? If so, you may be experiencing occupational burnout. But you aren’t alone. The rate of burnout symptoms in practicing surgeons, academic leaders, and trainees has been reported to be as high as 40% to 60%.
  • Burnout can lead to adverse outcomes for surgeons and residents. Symptoms of burnout can lead to a reduced quality of life and interfere with personal relationships at home and at work. The emotional toll can lead to physical exhaustion and affect judgement and decision making skills. Ultimately, it may lead to depression, substance abuse, and physical illness. All these can lead to poor performance and medical error.
  • Prevention and treatment of burnout is a challenge with minimal interventions described. Some interventions include didactic sessions and mindfulness based training programs. Prevention programs that include meditation, making time for exercise, and spending quality time with a spouse can also decrease burnout.

Mentorship in Orthopaedic Surgery—Road Map to Success for the Mentor and the Mentee
Levine, William N. MD; Braman, Jonathan P. MD; Gelberman, Richard H. MD; Black, Kevin P. MD

Discussion points:
  • One factor shown to decrease the risk of burnout, particularly in academic surgeons, is simply having a mentor.
  • The relationship of the mentor and mentee differs based on the level of the mentee's responsibilities as a resident, fellow, or attending physician.
  • This article describes the conditions and responsibilities of each of the participants in the mentor/mentee relationship. 

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