Surgeon personality is associated with recommendation for operative treatment

Dissecting the surgeon's personality: cross-cultural comparisons in Western Europe

AIM

The surgeon's personality contributes to variation in surgical decision-making. Previous work on surgeon personality has largely been reserved to Anglo-Saxon studies, with limited international comparisons. In this work we built upon recent work on gastrointestinal surgeon personality and aimed to detect international variations.

METHOD

Gastrointestinal surgeons from the UK and the Netherlands were invited to participate in validated personality assessments (44-item, 60-item Big Five Inventory; BFI). These encompass personality using five domains (open-mindedness, conscientiousness, extraversion, agreeableness and negative emotionality) with three subtraits each. Mean differences in domain factors were calculated between surgeon and nonsurgeon populations from normative data using independent-samples t-tests, adjusted for multiple testing. The items from the 44-item and 60-item BFI were compared between UK and Dutch surgeons and classified accordingly: identical (n = 16), analogous (n = 3), comparable (n = 12).

RESULTS

UK (n = 78, 61.5% male) and Dutch (n = 280, 65% male) gastrointestinal surgeons had marked differences in the domains of open-mindedness, extraversion and agreeableness compared with national normative datasets. Moreover, although surgeons had similar levels of emotional stability, country of work influenced differences in specific BFI items. For example, Netherlands-based surgeons scored highly on questions related to sociability and organization versus UK-based surgeons who scored highly on creative imagination (p < 0.0001).

CONCLUSION

In a first cross-cultural setting, we identified country-specific personality differences in gastrointestinal surgeon cohorts across domain and facet levels. Given the variation between Dutch and UK surgeons, understanding country-specific data could be useful in guiding personality research in healthcare. Furthermore, we advocate that future work adopts consensus usage of the five factor model.

How do surgeons decide when to treat proximal humerus fractures with operative versus nonoperative management?

PURPOSE

The objective of this study was to determine the underlying factors that drive the decision for surgeons to pursue operative versus nonoperative management for proximal humerus fractures (PHF) and if fellowship training had an impact on these decisions.

METHODS

An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons Society to assess differences in patient selection for operative versus nonoperative management of PHF. Descriptive statistics were reported for all respondents.

RESULTS

A total of 250 fellowship trained Orthopaedic Surgeons responded to the online survey. A greater proportion of trauma surgeons preferred nonoperative management for displaced PHF fractures in patients over the age of 70. Operative management was preferred for older patients with fracture dislocations (98%), limited humeral head bone subchondral bone (78%), and intraarticular head split (79%). Similar proportions of trauma surgeons and shoulder surgeons cited that acquiring a CT was crucial to distinguish between operative and nonoperative management.

CONCLUSION

We found that surgeons base their decisions on when to operate primarily on patient's comorbidities, age, and the amount of fracture displacement when treating younger patients. Further, we found a greater proportion of trauma surgeons elected to proceed with nonoperative management in patients older than the age of 70 years old as compared to shoulder surgeons.

Upper Extremity Surgeon Recommendations for Imaging Do Not Correspond with Imaging Appropriateness Guidelines

Background Utilization of magnetic resonance imaging (MRI) and computed tomography (CT) increases annually, raising concerns about overuse. Imaging appropriateness guidelines have the potential to standardize decisions regarding imaging based on best evidence, which might reduce unhelpful or potentially misleading imaging. We studied expert use of advanced imaging for musculoskeletal illness compared to published appropriateness recommendations.

Methods First, 15 imaging guidelines with recommendations for advanced imaging of the upper extremity were collated. Next, members of the Science of Variation Group (SOVG) were invited to participate in a survey of 11 patient scenarios of common upper extremity illnesses and asked whether they would recommend MRI or CT. Guideline recommendations for imaging were compared with surgeon recommendations using Fisher's exact tests. We used Fleiss' kappa to measure the interobserver agreement among surgeons.

Results For the 11 scenarios, most imaging appropriateness guidelines suggested that MRI or CT is useful, while most surgeons (n = 108) felt it was not. There was no correlation between surgeons and guidelines recommendations for imaging (ρ = 0.28; p = 0.40). There was slight agreement among surgeons regarding imaging recommendations (kappa: 0.17; 95% confidence interval: 0.023–0.32).

Conclusion The available imaging appropriateness guidelines appear to be too permissive and therefore seem to have limited clinical utility for upper extremity surgeons. The notable surgeon-to-surgeon variation (unreliability) in recommendations for advanced imaging in this and other studies suggests a role for strategies to ensure that patient decisions about imaging are consistent with their values (what matters most to them) and not unduly influenced by patient misconceptions about imaging or by surgeon beliefs and habits.

Level Of Evidence II, diagnostic

Recovery After Musculoskeletal Injury: Mental and Social Health

Recovery from injury involves painful movement and activity, painful stretches and muscle strengthening, and adjustment to permanent impairment. Recovery is facilitated by embracing the concept that painful movement can be healthy, which is easier when one has more hope, less worry, and greater social supports and security. Evolution of one's identity to match the new physical status is a hallmark of a healthy outcome and is largely determined by mental and social health factors. When infection, loss of alignment or fixation, and nerve issues or compartment syndrome are unlikely, greater discomfort and incapability that usual for a given pathology or stage of recovery signal opportunities for improved mental and social health. Surgeons may be the clinicians most qualified to make this discernment. A surgeon who has gained a patient's trust can start to noticed despair, worry, and unhelpful thinking such as fear of painful movement. Reorienting people to greater hope and security and a healthier interpretation of the pains associated with the body's recovery can be initiated by the surgeon and facilitated by social workers, psychologist, and physical, occupational and hand therapists trained in treatments that combine mental and physical therapies.

Factors Associated With Surgical Treatment of Isolated, Displaced Midshaft Clavicle Fractures

Given the current available evidence, surgical treatment of isolated, displaced midshaft clavicle fractures is discretionary. The aim of this study was to determine whether there are identifiable factors associated with the surgical treatment of isolated, displaced midshaft clavicle fractures. A retrospective cohort study of 150 patients who underwent nonoperative treatment and 290 patients who underwent surgical treatment of isolated, displaced midshaft clavicle fractures from January 2010 to March 2019 at 2 level I trauma centers was performed. Multivariable regression analysis demonstrated that younger age (odds ratio [OR], 0.97; 95% CI, 0.95-0.99), absence of diabetes mellitus (OR, 0.045; 95% CI, 0.003-0.79), nonsmoking status (OR, 0.31; 95% CI, 0.13-0.75), higher American Society of Anesthesiologists classification (OR, 5.0; 95% CI, 2.7-9.2), fracture comminution (OR, 2.3; 95% CI, 1.3-3.9), and fracture displacement (OR, 1.1; 95% CI, 1.0-1.1) were associated with surgical treatment of an isolated, displaced midshaft clavicle fracture. Furthermore, lower social deprivation (OR, 0.99; 95% CI, 0.97-0.99) and private insurance compared with Medicare (OR, 6.6; 95% CI, 1.6-27) were associated with surgical treatment. The authors conclude that surgical treatment of discretionary midshaft clavicle fractures is influenced by patient factors, fracture characteristics, and socioeconomic factors. Further study is needed to understand the etiology of social disparities in clavicle surgery and rectify unintended trends in treatment. [Orthopedics. 2021;44(4):e515-e520.].

Factors influencing management of bilateral femur fractures: A multicenter retrospective cohort of early versus delayed definitive Fixation

INTRODUCTION

The purpose of our study was to evaluate the factors that influence the timing of definitive fixation in the management of bilateral femoral shaft fractures and the outcomes for patients with these injuries.

METHODS

Patients with bilateral femur fractures treated between 1998 to 2019 at ten level-1 trauma centers were retrospectively reviewed. Patients were grouped into early or delayed fixation, which was defined as definitive fixation of both femurs within or greater than 24 hours from injury, respectively. Statistical analysis included reversed logistic odds regression to predict which variable(s) was most likely to determine timing to definitive fixation. The outcomes included age, sex, high-volume institution, ISS, GCS, admission lactate, and admission base deficit.

RESULTS

Three hundred twenty-eight patients were included; 164 patients were included in the early fixation group and 164 patients in the delayed fixation group. Patients managed with delayed fixation had a higher Injury Severity Score (26.8 vs 22.4; p<0.01), higher admission lactate (4.4 and 3.0; p<0.01), and a lower Glasgow Coma Scale (10.7 vs 13; p<0.01). High-volume institution was the most reliable influencer for time to definitive fixation, successfully determining 78.6% of patients, followed by admission lactate, 64.4%. When all variables were evaluated in conjunction, high-volume institution remained the strongest contributor (X² statistic: institution: 45.6, ISS: 8.83, lactate: 6.77, GCS: 0.94).

CONCLUSION

In this study, high-volume institution was the strongest predictor of timing to definitive fixation in patients with bilateral femur fractures. This study demonstrates an opportunity to create a standardized care pathway for patients with these injuries.

LEVEL OF EVIDENCE

Level III.

Factors Associated with a Recommendation for Operative Treatment for Fracture of the Distal Radius

Background  Evidence suggests that there is substantial and unexplained surgeon-to-surgeon variation in recommendation of operative treatment for fractures of the distal radius. We studied (1) what factors are associated with recommendation for operative treatment of a fracture of the distal radius and (2) which factors are rated as the most influential on recommendation of operative treatment. Methods  One-hundred thirty-one upper extremity and fracture surgeons evaluated 20 fictitious patient scenarios with randomly assigned factors (e.g., personal, clinical, and radiologic factors) for patients with a fracture of the distal radius. They addressed the following questions: (1) Do you recommend operative treatment for this patient (yes/no)? We determined the influence of each factor on this recommendation using random forest algorithms. Also, participants rated the influence of each factor-excluding age and sex- on a scale from 0 (not at all important) to 10 (extremely important). Results  Random forest algorithms determined that age and angulation were having the most influence on recommendation for operative treatment of a fracture of the distal radius. Angulation on the lateral radiograph and presence or absence of lunate subluxation were rated as having the greatest influence and smoking status and stress levels the lowest influence on advice to patients. Conclusions  The observation that-other than age-personal factors have limited influence on surgeon recommendations for surgery may reflect how surgeon cognitive biases, personal preferences, different perspectives, and incentives may contribute to variations in care. Future research can determine whether decision aids-those that use patient-specific probabilities based on predictive analytics in particular-might help match patient treatment choices to what matters most to them, in part by helping to neutralize the influence of common misconceptions as well as surgeon bias and incentives. Level of Evidence  There is no level of evidence for the study.

Reliability of recommendations to reduce a fracture of the distal radius

Background and purpose - It is unclear what degree of malalignment of a fracture of the distal radius benefits from reduction. This study addressed the following questions: (1) What is the interobserver reliability of surgeons concerning the recommendation for a reduction for dorsally displaced distal radius fractures? (2) Do expert-based criteria for reduction improve reliability or not?Methods - We sent out 2 surveys to a group of international hand and fracture surgeons. On the first survey, 80 surgeons viewed radiographs of 95 dorsally displaced (0° to 25°) fractures of the distal radius. The second survey randomized 68 participants to either receive or not receive expert-based criteria for when to reduce a fracture and then viewed 20 radiographs of fractures with dorsal angulation between 5° and 15°. All participants needed to indicate whether they would advise a reduction or not.Results - In the 1st study, the interrater reliability of advising a reduction was fair (kappa 0.31). Multivariable linear regression analyses indicated that each additional degree of dorsal angulation increased the chance of recommending a reduction by 3%. In the 2nd study, reading criteria for reduction did not increase interobserver reliability for recommending a reduction.Interpretation - There is notable variation in recommendations for reduction that is not accounted for by surgeon or patient factors and is not diminished by exposure to expert criteria. Surgeons should be aware of their biases and develop strategies to inform patients and share the decision regarding whether to reduce a fracture of the distal radius.

Factors Associated With Surgical Treatment of Nondisplaced or Minimally Displaced Scaphoid Waist Fractures

PURPOSE

To determine whether there are identifiable factors associated with the surgical treatment of nondisplaced or minimally displaced scaphoid waist fractures.

METHODS

We identified 50 patients who underwent nonsurgical treatment and 67 patients who underwent surgical treatment of nondisplaced or minimally displaced scaphoid waist fractures at 2 tertiary care referral centers in a single metropolitan area in the United States between January 2010 and March 2019. Bivariate analysis was used to screen for factors associated with surgical treatment. Multivariable stepwise logistic regression was used to determine factors associated with surgical treatment of a nondisplaced or minimally displaced scaphoid fracture.

RESULTS

Multivariable logistic regression analysis showed that male sex (odds ratio = 2.80; 95% confidence interval, 1.20-6.52) and employed status (odds ratio = 3.12, 95% confidence interval, 1.24-7.85) were associated with surgical treatment of nondisplaced or minimally displaced scaphoid waist fractures.

CONCLUSIONS

Male and employed patients have increased odds of undergoing scaphoid surgery for nondisplaced or minimally displaced waist fractures compared with female and unemployed patients. These differences may represent patient preference, surgeon counseling, or a combination. Further study is needed to understand the etiology of this sex difference.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Radiographs and Corticosteroid Injections at a New Patient Visit for Care of Carpal Tunnel Syndrome and Ulnar Neuropathy at the Elbow

Introduction The benefit of radiographs or steroid injection for idiopathic carpal tunnel syndrome (CTS) or ulnar neuropathy at the elbow (UNE) is open to debate. We assessed: (1) Radiographs ordered and injections performed at a new patient visit for patients presenting with either idiopathic CTS or UNE; (2) The estimated payment reduction if we omit these interventions; and (3) Patient age, sex, geographic region, and work status associated with radiographs or injections at a new patient visit for patients presenting with either idiopathic CTS or UNE.

Materials and Methods Using a large database of commercial insurance claims, we identified patients with a new visit for either CTS (N = 9,522), UNE (N = 2,507), or both (N = 962; 8.7%). We identified injections and radiographs, and estimated total payments for these interventions. We created three multivariable logistic regression models for each diagnosis to identify factors associated with the interventions.

Results Nearly one third of patients had radiographs at a new patient visit (30% and 32% for idiopathic CTS and UNE, respectively). Nearly 10% of patients with CTS and 2.6% with UNE received an injection. Both radiographs and injections representing annual minimum payments of over $345,000 and $294,000, respectively. Among people with CTS, radiographs were independently more common in the South and less common in the West. Injection for CTS was associated with younger age; North, Central, and South regions; and retired employment status. For people with UNE, radiographs were independently associated with younger age; South or West region; and retired or working employment status. Injection for UNE was associated with retired employment status.

Conclusion The prevalence of radiographs and injections suggests opportunities for savings, which might benefit clinicians with bundled or capitated payments and patients with large copayments or deductibles. The observed variation may reflect debate about whether these interventions are worthwhile.

Level of Evidence Diagnostic; Retrospective Database Level III study.

The influence of arthroscopy on the classification and treatment of tibial plateau fractures

Introduction

Arthroscopically-assisted reduction and percutaneous fixation of tibial plateau fractures is associated with fewer adverse events, better knee motion, and better Rasmussen functional scores compared to open reduction internal fixation in a number of non-randomized studies. The purpose of this study was to measure the influence of arthroscopy on the interobserver reliability in classification, treatment, and evaluation of intra-articular pathology and fracture reduction for fractures of the tibial plateau.

Methods

Surgeons were invited to participate in this online survey study. Surgeons were randomized at a 1:1 ratio to review eight cases of patients with tibial plateau fractures with either 1) knee radiographs alone or 2) radiographs and arthroscopic images. Multirater kappa was used to assess chance-corrected interobserver agreement.

Results

There was no difference in interobserver agreement between groups for classification, treatment choice, determination of intra-articular pathology, or evaluation of fracture reduction.

Conclusions

Arthroscopy may not influence classification, treatment choice, diagnosis of intra-articular pathology, or quality of fracture reduction. Future studies will be necessary to determine if arthroscopic-assisted fixation of tibial plateau fractures is generalizable to surgeons of different training backgrounds.

Variability in clinicians' understanding and reported methods of identifying high-risk surgical patients: a qualitative study

Background

High-risk patients presenting for surgery require complex decision-making and perioperative management. However, given there is no gold standard for identifying high-risk patients, doing so may be challenging for clinicians in practice. Before a gold standard can be established, the state of current practice must be determined. This study aimed to understand how working clinicians define and identify high-risk surgical patients.

Methods

Clinicians involved in the care of high-risk surgical patients at a public hospital in regional Australia were interviewed as part of an ongoing study evaluating a new shared decision-making process for high-risk patients. The new process, Patient-Centred Advanced Care Planning (PC-ACP) engages patients, families, and clinicians from all relevant specialties in shared decision-making in line with the patient’s goals and values. The semi-structured interviews were conducted before the implementation of the new process and were coded using a modified form of the ‘constant comparative method’ to reveal key themes. Themes concerning patient risk, clinician’s understanding of high risk, and methods for identifying high-risk surgical patients were extricated for close examination.

Results

Thirteen staff involved in high-risk surgery at the hospital at which PC-ACP was to be implemented were interviewed. Analysis revealed six sub-themes within the major theme of factors related to patient risk: (1) increase in high-risk patients, (2) recognising frailty, (3) risk-benefit balance, (4) suitability and readiness for surgery, (5) avoiding negative outcomes, and (6) methods in use for identifying high-risk patients. There was considerable variability in clinicians’ methods of identifying high-risk patients and regarding their definition of high risk. This variability occurred even among clinicians within the same disciplines and specialties.

Conclusions

Although clinicians were confident in their own ability to identify high-risk patients, they acknowledged limitations in recognising frail, high-risk patients and predicting and articulating possible outcomes when consenting these patients. Importantly, little consistency in clinicians’ reported methods for identifying high-risk patients was found. Consensus regarding the definition of high-risk surgical patients is necessary to ensure rigorous decision-making.

Variation in Offer of Operative Treatment to Patients With Trapeziometacarpal Osteoarthritis

PURPOSE

Operative treatment of trapeziometacarpal osteoarthritis (TMC OA) is discretionary. There is substantial surgeon-to-surgeon variation in offers of surgery. This study assessed factors associated with variation in recommendation of operative treatment to patients with TMC OA. Secondarily, we studied factors associated with preferred operative technique and surgeon demographic factors variability in recommendation for operative treatment.

METHODS

We invited all hand surgeon members of the Science of Variation Group to review 16 scenarios of patients with TMC OA and asked the surgeons whether they would recommend surgical treatment for each patient and, if yes, which surgical technique they would offer (trapeziectomy, trapeziectomy with ligament reconstruction and/or tendon interposition, joint replacement, or arthrodesis). Scenarios varied in pain intensity, relief after injection, radiographic severity, and psychosocial symptoms.

RESULTS

Patient characteristics associated with greater likelihood to recommend surgical treatment were substantial pain, a previous injection that did not relieve pain, radiograph with severe TMC OA, and few symptoms of depression. Practice region was the only factor associated with preferred surgical technique and trapeziectomy with ligament reconstruction and/or tendon interposition the most commonly recommended treatment. There was low agreement among surgeons regarding treatment recommendations.

CONCLUSIONS

The notable variation in offers of operative treatment for TMC OA is largely associated with variable attention to subjective factors. Future studies might address the relative influence of surgeon incentives and beliefs, objective pathophysiology, and subjective patient factors on variation in surgeon recommendations.

CLINICAL RELEVANCE

Surgeons' awareness of the potential influence of subjective factors on their recommendations might contribute to efforts to ensure that patient choices reflect what matters most to them and are not based on misconceptions.

Surgical Decision-Making in Median Neuropathy Associated with Distal Radius Fractures

Objectives  A lack of conclusive evidence on the treatment of acute median neuropathy (AMN) in patients with distal radius fractures has led to inconsistent surgical guidelines and recommendations regarding AMN in distal radius fractures. There is a wide variation in surgical decision-making. We aimed to evaluate international differences between surgical considerations and practices related to carpal tunnel release (CTR) in the setting of distal radius fractures. Methods  We approached surgeons who were a member of the Orthopaedic Trauma Association (United States) or of the Dutch Trauma Society (the Netherlands) and asked them to provide sociodemographic information and information on their surgical practice regarding CTR in the setting of distal radius fractures. After applying our exclusion criteria, our final cohort consisted of 127 respondents. Results  Compared with Dutch surgeons, surgeons from the United States are more of the opinion that displaced distal radius fractures are at risk of developing acute carpal tunnel syndrome (ACTS), consider persistent paresthesia in the median nerve distribution after closed reduction to be a surgical emergency less often, and are more likely to perform a CTR if there are signs of ACTS in the setting of a distal radius fracture. Conclusion  A lack of conclusive evidence has led to international differences in surgical practice regarding the treatment of ACTS in the setting of distal radius fractures. Future research should guide surgeons in making appropriate evidence-based decisions when performing CTR in the setting of distal radius fractures. Level of Evidence  This is a Level V study.

Factors associated with the decision for operative versus conservative treatment of displaced distal radius fractures in the elderly

BACKGROUND

The treatment of senile distal radius fractures had not been clearly defined. The objective of this study was to identify the factors associated with the decision for operative treatment of displaced distal radius fractures in patients aged over 55 years.

METHODS

Data of 318 patients with displaced distal radius fractures were collected on patient-, fracture- and surgeon-related characteristics that were plausibly related to the decision for operation. Mean comparisons or chi-squared test were used for univariate analysis of the above-mentioned factors, and then multiple logistic regression was used to identify factors associated with the decision for operation.

RESULTS

Univariate analysis showed that age, osteoporosis, Charlson score, associated orthopaedic injuries requiring surgery, Orthopaedic Trauma Association (AO) and Fernandez classification, radial height, volar tilt, volar/dorsal comminution, ulnar variance, intra-articular displacement/step-off, associated distal radioulnar joint instability or radiocarpal joint dislocation and subspecialty of treating surgeons had statistically significant association with operative intervention. In the multivariate analysis, the predictors of operative intervention were younger patient age (P = 0.028), associated orthopaedic injuries requiring surgery (P = 0.020), higher AO classification (P = 0.037), higher Fernandez classification (P = 0.041), radial shortening >5 mm (P = 0.020), volar tilt > -10° (P = 0.020), volar/dorsal comminution (P = 0.020), ulnar variance >5 mm (P = 0.023), intra-articular displacement/step-off >2 mm (P = 0.004), associated distal radioulnar joint instability or radiocarpal joint dislocation (P = 0.047) and treatment by an upper extremity specialist (P = 0.038).

CONCLUSION

The decision for surgery was predominantly influenced by the characteristics and severity of the fracture. Patients' age and treatment by an upper extremity specialist were also significant factors associated with a higher likelihood of operative intervention.

Perceptions and experiences of wrist surgeons on the management of triangular fibrocartilage complex tears: a qualitative study

There is lack of consensus on the management of triangular fibrocartilage injuries. The aim of this study was to investigate wrist surgeons' experiences and perceptions regarding treatment of triangular fibrocartilage complex injuries and to explore the rationale behind clinical decision-making. A purposive sample of consultant wrist surgeons (n = 10) was recruited through 'snow-balling' until data saturation was reached. Semi-structured interviews were conducted, digitally recorded and transcribed verbatim. Two researchers independently analysed data using an iterative/thematic approach. Findings suggest that surgeons rely more on their own training and experience, and patient-related factors such as individual expectations, to inform their decision-making, rather than on published material. Current classification systems are largely considered to be unhelpful. Level of evidence: V.

Do Patient Preferences Influence Surgeon Recommendations for Treatment?

BACKGROUND

When the best treatment option is uncertain, a patient's preference based on personal values should be the source of most variation in diagnostic and therapeutic interventions. Unexplained surgeon-to-surgeon variation in treatment for hand and upper extremity conditions suggests that surgeon preferences have more influence than patient preferences.

METHODS

A total of 184 surgeons reviewed 18 fictional scenarios of upper extremity conditions for which operative treatment is discretionary and preference sensitive, and recommended either operative or non-operative treatment. To test the influence of six specific patient preferences the preference was randomly assigned to each scenario in an affirmative or negative manner. Surgeon characteristics were collected for each participant.

RESULTS

Of the six preferences studied, four influenced surgeon recommendations. Surgeons were more likely to recommend non-operative treatment when patients; preferred the least expensive treatment (adjusted OR, 0.82; 95% CI, 0.71 - 0.94; P=0.005), preferred non-operative treatment (adjusted OR, 0.82; 95% CI, 0.72 - 0.95; P=0.006), were not concerned about aesthetics (adjusted OR, 1.15; 95% CI, 1.0 - 1.3; P=0.046), and when patients only preferred operative treatment if there is consensus among surgeons that operative treatment is a useful option (adjusted OR, 0.78; 95% CI, 0.68 - 0.89; P<0.001).

CONCLUSION

Patient preferences were found to have a measurable influence on surgeon treatment recommendations though not as much as we expected-and surgeons on average interpreted surgery as more aesthetic. This emphasizes the importance of strategies to help patients reflect on their values and ensure their preferences are consistent with those values (e.g. use of decision-aids).

Resident-Sensitive Processes of Care: Impact of Surgical Residents on Inpatient Testing

BACKGROUND

Health care value is a national priority, and there are substantial efforts to reduce overuse of low-value testing. Residency training programs and teaching hospitals have been implicated in excessive testing. We evaluated the impact of surgery residents on the frequency of inpatient testing and investigated potential inter-resident variation.

STUDY DESIGN

Inpatient laboratory and imaging orders placed on general surgery services were extracted from an academic institution from 2014 to 2016 and linked to National Surgical Quality Improvement Program data. Using negative binomial mixed effects regression with unstructured covariance, we evaluated the frequency of testing orders compared with median use, accounting for case, patient, and attending-level variables.

RESULTS

There were 111,055 laboratory orders and 7,360 imaging orders linked with 2,357 patients. Multivariable analysis demonstrated multiple significant predictors of increased testing including: postoperative complications, medical comorbidities, length of stay, relative value units, attending surgeon, and resident surgeon (95% CIs > 1, p < 0.05). Compared with the median resident physician, 47 residents (37.9%) placed significantly more laboratory orders, and 2 residents (1.6%) placed significantly more imaging orders (95% CI >1, p < 0.05). Resident identification explained 3.5% of the total variation in laboratory ordering and 4.9% in imaging orders.

CONCLUSIONS

Individual surgical residents had a significant association with the frequency of inpatient testing after adjusting for attending, case, and patient-level variables. There was greater resident variation in laboratory testing compared with imaging, yet surgical residents had small contributions to the total variation in both laboratory and imaging testing. Our models provide a means of identifying high users and could be used to educate residents on their ordering patterns.

How do Orthopaedic Surgeons Address Psychological Aspects of Illness?

BACKGROUND

Orthopaedic surgeons have a pivotal role in transitioning the care of orthopedic patients from a biomedical to a biopsychosocial model. In an effort to foster this transition, we designed a study aimed to determine surgeons' attitudes and practice of noticing, screening, discussing psychological illness with patients, as well as making referrals to address psychosocial issues in patients in need. Additionally, we asked surgeons to rank order potential barriers to and reasons for referrals to psychosocial treatment.

METHODS

Orthopaedic surgeons members of the Science and Variation Group and Ankle Platform (N =350) completed demographics, and a 4-part survey assessing the degree to which surgeons notice, assess, screen and refer for psychological treatments, as well ranked ordered barriers to engaging in these processes.

RESULTS

As a group surgeons were neutral to referral for psychological treatment and formal screening of psychological factors, and somewhat likely to notice and discuss psychological factors. Surgeons were more likely to refer for psychological treatment if they engaged in research, or if they reside in South America as opposed to North America. The highest ranked barriers to screening, noticing, discussing and referring for psychological treatment were lack of time, stigma and feeling uncomfortable.

CONCLUSION

Overall surgeons are likely to notice and discuss psychological factors, but less likely to formally screen or refer for psychological treatment. Transition to biopsychosocial models should focus on problem solving these barriers by teaching surgeons communication skills to increase comfort with discussing psychoemotional factors associated with orthopedic problems. The use of empathic communication can be very helpful in normalizing the difficulty of coping with an orthopedic condition, and may facilitate referral.