Medicine is a field that is simultaneously factual and ambiguous. Medical students have their first exposure to full time clinical practice during clerkship. While studies have examined medical ...trainees' tolerance of ambiguity (TOA), the extent to which TOA is affected by clinical experiences and its association with perfectionism is unknown. The aim of this study was to evaluate the effect of clerkship experience on TOA and perfectionism in medical students.
This was a multiple sampling, single cohort study of students in their first year of clinical clerkship which is comprised of 6 core rotations. Consenting students completed an online anonymous survey assessing their tolerance of ambiguity (TOA) and perfectionism in their first (pre) and last (post) 12 weeks of their clinical clerkship year. Tolerance of Ambiguity in Medical Students and Doctors (TAMSAD) and The Big Three perfectionism scale-short form (BTPS-SF) were used to assess TOA and perfectionism respectively. Pre-Post mean comparisons of TOA and perfectionism were assessed via t-tests.
From a cohort of 174 clinical clerkship students, 51 students responded to pre-survey, 62 responded to post-survey. Clerkship was associated with a significant decrease in TOA (p < 0.00) with mean pre-TOA scores of 59.57 and post TOA of 43.8. Perfectionism scores were not significantly different over time (p > 0.05). There was a moderate inverse correlation between TOA and perfectionism before clerkship (r = 0.32) that increased slightly after clerkship (r = 0.39). Those preferring primary care specialties had significantly lower rigid and total perfectionism scores in pre-clerkship than those choosing other specialties, but this difference was not found post-clerkship.
Exposure to clerkship decreased TOA while perfectionism remained stable in medical students. These results were not expected as exposure has been previously shown to increase TOA. The frequency of rotation changes maintaining a cycle of anxiety may be an underlying factor accounting for these results. Overall these results require further investigation to better characterize the role of clinical exposure on TOA.
Introduction: Previous work suggests that patients do not understand the extent of trainee involvement in their care and are uncomfortable with trainee involvement.
Methods: We recruited 202 English ...speaking patients with previous or planned total joint arthroplasty of the lower limb for a prospective survey trial. We assessed participant’s knowledge of trainee level of education and confidence of trainee involvement in their surgery as a function of supervision.
Results: Participants’ mean level of confidence in the consultant surgeon was 4.30 (SD±1.13) on a 5-point Likert scale. Confidence in residents was significantly less, regardless of resident experience (p < 0.05). 11.1% of participants did not want trainees involved in their treatment. 60.6% would like to know more about the education level of the trainee. Less than half of participants correctly identified the education level of residents and fellows.
Conclusion: Patient confidence in trainees performing part or all of their surgery increases with resident experience and supervision. Most patients do not understand the hierarchy in education of medical trainees and would like to know more about the education level of the trainee involved in their care. Further work should explore how we can help patients better understand trainee involvement in their surgical care.
The number of unmatched Canadian Medical Graduates (CMGs) has risen dramatically over the last decade. To identify long-term solutions to this problem, an understanding of the factors contributing to ...these rising unmatched rates is critical.
Using match and electives data from 2009-2019, we employed machine learning algorithms to identify three clusters of disciplines with distinct trends in match and electives behaviours. We assessed the relationships between unmatched rates, competitiveness, rates of parallel planning, and program selection practices at a discipline level.
Across Canada, growth in CMGs has outpaced growth in residency seats, narrowing the seat-to-applicant ratio. Yet not all disciplines have been affected equally: a subset of surgical disciplines experienced a consistent decline in residency seats over time. Applicants to these disciplines are also at disproportionate risk of becoming unmatched, and this is associated with lower rates of parallel planning as quantified through clinical electives and match applications. This, in turn, is associated with the program selection practices of these disciplines.
Long-term solutions to the unmatched CMG crisis require more nuance than indiscriminately increasing residency seats and should consider cluster specific match ratios as well as regulations around clinical electives and program selection practices.
Orthopedic surgery is a field which has often been talked about with regards to surgeon underemployment. This is particularly important given the paradoxical increasing demand for orthopedic care. ...There has not been well studied literature understanding the state of orthopedic surgery training in Ontario, Canada. Using a combination of various databases and surveying surgeons trained in Ontario we sought to provide some insight.We demonstrated multiple important findings. More recent graduates are feeling less ready to enter practice and almost all graduates do at least 1 fellowship, with equal amount of 1 versus 2 fellowships. We showed an effect of school of graduation on likelihood of emigrating out of Ontario. More recent graduates are more likely to emigrate out of necessity, and less likely to pursue a graduate degree out of interest. Despite all the challenges, however, orthopedic surgeons remain satisfied with their work.
There is controversy regarding the superiority of posterior-stabilizing (PS) total knee arthroplasty (TKA) and cruciate-retaining (CR) TKA. Substantial work has made comparisons between PS and CR TKA ...at follow-ups of less than 5 years. It was the goal of the present study to compare the kinematics at greater than 5 years postoperatively between CR and PS TKA, with a secondary goal of comparing patient function.
A total of 42 knees were investigated, with equal representation in the PS and CR TKA groups. Patients underwent radiostereometric analysis imaging at 0°, 20°, 40°, 60° 80°, and 100° of flexion. Contact position, magnitude of excursion, and condylar separation on each condyle were measured. A Timed-Up-and-Go functional test was also performed by patients, with the total test time being measured. Preoperative and postoperative clinical outcome scores were also collected.
There were differences in contact position on both the medial and lateral condyles at multiple angles of flexion (P < .05). There was no difference (P = .89) in medial excursion; however, PS TKA had greater lateral excursion than CR TKA (P < .01). No difference (P > .99) was found in frequency of condylar separation. PS TKA was associated with faster (P = .03) total Timed-Up-and-Go test times. There were no differences in clinical outcome scores between the groups preoperatively or postoperatively.
We found kinematic and functional differences that favor PS TKA. Our results suggest posterior cruciate ligament insufficiency in CR TKA, indicating that perhaps the cam/post systems in PS TKA better maintain knee kinematics and function long term.
Underemployment is a reality for many new graduates, who accept locum or part-time work as an alternative to unemployment because of lack of opportunities. We sought to analyze orthopedic surgeons' ...Ontario Health Insurance Program (OHIP) billing data over a 20-year period as a proxy of practice patterns and hypothesized that billing in the first 6 years of practice would be affected by underemployment and locum.
We analyzed the annual average billing totals of orthopedic surgeons, broken down by year of graduation, year of billings, and number of surgeons billing in that year. We analyzed public census data of the Ontario population size as a proxy of orthopedic demand.
A 2019 cross-sectional analysis showed that around 15 surgeons per graduating year were billing in Ontario from the 1995 to 2016 cohorts, while 2017 and 2018 saw an increase to 30 and 36 actively billing surgeons, respectively. The number returned to more historical numbers in 2019, with 20 actively billing surgeons. For those surgeons billing in Ontario, billing trends have been roughly stable, with average billings increasing each year for the first 6 years in practice (
< 0.001). Year of graduation did not have an effect on the first 6 years of billings (
> 0.5). Billings were stable after 6 years in practice (
> 0.09).
The Ontario health care system has not expanded to support more orthopedic surgeons despite the aging and growing population; despite our growing population, the number of surgeons being trained and retained has not matched this growth. Further research needs to be done to guide optimal health human resource decision-making.
Abstract As North America is largely industrialized with a variety of available private transportation options, trauma is a common occurrence, resulting in significant burdens of disability and costs ...to the health care system. To meet increasing trauma care needs, there is a robust organization of trauma and rehabilitation systems, particularly within the United States and Canada. The American and Canadian health care systems share multiple similarities, including well-equipped Level I trauma centers, specialized inpatient rehabilitation units for polytrauma patients, and thorough evaluations for recovery and post-discharge placement. However, they also have several key differences. In Canada, the criteria for admission to inpatient rehabilitation vary by location, and inpatient rehabilitation is universally accessible, whereas outpatient rehabilitation services are generally not covered by insurance. In the United States, these admission criteria for post-acute inpatient rehabilitation are standardized, and both inpatient and outpatient services are covered by private and government-funded insurance with varying durations. Overall, both health care systems face challenges in post-acute rehabilitation, including benefit limitations and limited provider access in rural areas, and must continue to evolve to meet the rehabilitation needs of injured patients as they reintegrate into their communities.
As health care shifts to value-based models, one strategy within orthopedics has been to transition appropriate cases to outpatient or ambulatory settings to reduce costs; however, there are limited ...data on the efficacy and safety of this practice for isolated ankle fractures. The purpose of this study was to compare the cost and safety associated with inpatient versus outpatient ankle open reduction internal fixation (ORIF).
All patients who underwent ORIF of isolated closed ankle fractures at 2 affiliated hospitals between April 2016 and March 2017 were identified retrospectively. Demographic characteristics, including age, gender, comorbidities and injuryspecific variables, were collected. We grouped patients based on whether they underwent ankle ORIF as an inpatient or outpatient. We determined case costing for all patients and analyzed it using multivariate regression analysis.
A total of 196 patients (125 inpatient, 71 outpatient) were included for analysis. Inpatients had a significantly longer mean length of stay than outpatients (54.3 h standard deviation (SD) 36.3 h v. 7.5 h SD 1.7 h,
< 0.001). The average cost was significantly higher for the inpatient cohort than the outpatient cohort ($4137 SD $2285 v. $1834 SD $421,
< 0.001). There were more unimalleolar ankle fractures in the outpatient group than in the inpatient group (42 59.2% v. 41 32.8%,
< 0.001). Outpatients waited longer for surgery than inpatients (9.6 d SD 5.6 d v. 2.0 d SD 3.3 d,
< 0.001). Fourteen patients (11.2%) in the inpatient group presented to the emergency department or were readmitted to hospital within 30 days of discharge, compared to 5 (7.0%) in the outpatient group (
= 0.3).
In the treatment of isolated closed ankle fractures, outpatient surgery was associated with a significant reduction in length of hospital stay and overall case cost compared to inpatient surgery, with no significant difference in readmission or reoperation rates. In medically appropriate patients, isolated ankle ORIF can be performed safely in an ambulatory setting and is associated with significant cost savings.
Previous work suggests that patients do not understand the extent of resident involvement in their care and are also uncomfortable with resident involvement.
We recruited 202 English speaking ...patients with previous or planned total joint arthroplasty of the lower limb for a prospective survey trial. We assessed participant's knowledge of resident level of education and confidence of resident involvement in their surgery as a function of supervision.
Participants' mean level of confidence in the consultant surgeon was 4.30 (SD±1.13) on a 5-point Likert scale. Confidence in residents was significantly less, regardless of experience (
< 0.05). 11.1% of participants did not want residents involved in their treatment. 60.6% would like to know more about the education level of the trainee. Less than half of participants correctly identified the education level of residents and fellows.
Patient confidence in residents performing part or all of their surgery increases with resident experience and supervision. Compared with attending surgeons, patients have significantly less confidence in residents performing their surgery, including while supervised. Most patients do not understand the educational progression of medical trainees and would like to know more about the education level of the resident involved in their care. Further work should explore how we can help patients better understand resident involvement in their surgical care.
Tests are shown to enhance learning: this is known as the “testing effect”. The benefit of testing is theorized to be through “active retrieval”, which is the effortful process of recalling stored ...knowledge. This differs from “passive studying”, such as reading, which is a low effort process relying on recognition. The testing effect is commonly studied in random word list scenarios and is thought to disappear as complexity of material increases. Little is known about the testing effect in complex situations such as procedural learning. Therefore, we investigated if testing improves procedural learning of fracture fixation as compared to “passive studying”.
Fifty participants watched an instructional video of an open reduction internal fixation of a Sawbones™ femur. Participants then performed the procedure under guided supervision (pretest). After randomization, they either read the steps (passive studying group), or wrote down the steps from memory (active retrieval group) for a period of 15 minutes. After a washout period, all participants performed the procedure without guidance (posttest) and then once more, 1 week after the initial testing (retention test). The participants were assessed using the Objective Structured Assessment of Technical Skill. Each performance was video recorded for data analysis purposes.
Participants in the passive studying group had significantly higher Objective Structured Assessment of Technical Skill scores during immediate assessment compared to the active retrieval group (p = 0.001), especially with respect to remembering the correct order of the steps (p = 0.002). The percentage of information forgotten was significantly less in the active retrieval group (p = 0.02) at the retention test.
We demonstrated that, compared to passive studying, testing with active retrieval through writing resulted in better retention of fracture fixation knowledge (i.e., less forgetting). These findings can easily be applied and incorporated in existing curricula. Future studies are needed to determine the effects of different kinds of active retrieval methods such as verbal retrieval (e.g., dictating) in surgical practice.
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