What are the Trends in Racial Diversity Among Orthopaedic Applicants, Residents, and Faculty?
Orthopaedic surgery has recruited fewer applicants from underrepresented in medicine (UIM) racial groups than many other specialties, and recent studies have shown that although applicants from UIM racial groups are competitive for orthopaedic surgery, they enter the specialty at lower rates. Although previous studies have measured trends in orthopaedic surgery applicant, resident, or attending diversity in isolation, these populations are interdependent and therefore should be analyzed together. It is unclear how racial diversity among orthopaedic applicants, residents, and faculty has changed over time and how it compares with other surgical and medical specialties.
(1) How has the proportion of orthopaedic applicants, residents, and faculty from UIM and White racial groups changed between 2016 and 2020? (2) How does representation of orthopaedic applicants from UIM and White racial groups compare with that of other surgical and medical specialties? (3) How does representation of orthopaedic residents from UIM and White racial groups compare with that of other surgical and medical specialties? (4) How does representation of orthopaedic faculty from UIM and White racial groups compare with that of other surgical and medical specialties?
We drew racial representation data for applicants, residents, and faculty between 2016 and 2020. Applicant data on racial groups was obtained for 10 surgical and 13 medical specialties from the Association of American Medical Colleges Electronic Residency Application Services report, which annually publishes demographic data on all medical students applying to residency through Electronic Residency Application Services. Resident data on racial groups were obtained for the same 10 surgical and 13 medical specialties from the Journal of the American Medical Association Graduate Medical Education report, which annually publishes demographic data on residents in residency training programs accredited by the Accreditation Council for Graduate Medical Education. Faculty data on racial groups were obtained for four surgical and 12 medical specialties from the Association of American Medical Colleges Faculty Roster United States Medical School Faculty report, which annually publishes demographic data of active faculty at United States allopathic medical schools. UIM racial groups include American Indian or Alaska Native, Black or African American, Hispanic or Latino, and Native American or Other Pacific Islander. Chi-square tests were performed to compare representation of UIM and White groups among orthopaedic applicants, residents, and faculty between 2016 and 2020. Further, chi-square tests were performed to compare aggregate representation of applicants, residents, and faculty from UIM and White racial groups in orthopaedic surgery to aggregate representation among other surgical and medical specialties with available data.
The proportion of orthopaedic applicants from UIM racial groups increased between 2016 to 2020 from 13% (174 of 1309) to 18% (313 of 1699, absolute difference 0.051 [95% CI 0.025 to 0.078]; p < 0.001). The proportion of orthopaedic residents (9.6% [347 of 3617] to 10% [427 of 4242]; p = 0.48) and faculty (4.7% [186 of 3934] to 4.7% [198 of 4234]; p = 0.91) from UIM racial groups did not change from 2016 to 2020. There were more orthopaedic applicants from UIM racial groups (15% [1151 of 7446]) than orthopaedic residents from UIM racial groups (9.8% [1918 of 19,476]; p < 0.001). There were also more orthopaedic residents from UIM groups (9.8% [1918 of 19,476]) than orthopaedic faculty from UIM groups (4.7% [992 of 20,916], absolute difference 0.051 [95% CI 0.046 to 0.056]; p < 0.001). The proportion of orthopaedic applicants from UIM groups (15% [1151 of 7446]) was greater than that of applicants to otolaryngology (14% [446 of 3284], absolute difference 0.019 [95% CI 0.004 to 0.033]; p = 0.01), urology (13% [319 of 2435], absolute difference 0.024 [95% CI 0.007 to 0.039]; p = 0.005), neurology (12% [1519 of 12,862], absolute difference 0.036 [95% CI 0.027 to 0.047]; p < 0.001), pathology (13% [1355 of 10,792], absolute difference 0.029 [95% CI 0.019 to 0.039]; p < 0.001), and diagnostic radiology (14% [1635 of 12,055], absolute difference 0.019 [95% CI 0.009 to 0.029]; p < 0.001), and it was not different from that of applicants to neurosurgery (16% [395 of 2495]; p = 0.66), plastic surgery (15% [346 of 2259]; p = 0.87), interventional radiology (15% [419 of 2868]; p = 0.28), vascular surgery (17% [324 of 1887]; p = 0.07), thoracic surgery (15% [199 of 1294]; p = 0.94), dermatology (15% [901 of 5927]; p = 0.68), internal medicine (15% [18,182 of 124,214]; p = 0.05), pediatrics (16% [5406 of 33,187]; p = 0.08), and radiation oncology (14% [383 of 2744]; p = 0.06). The proportion of orthopaedic residents from UIM groups (9.8% [1918 of 19,476]) was greater than UIM representation among residents in otolaryngology (8.7% [693 of 7968], absolute difference 0.012 [95% CI 0.004 to 0.019]; p = 0.003), interventional radiology (7.4% [51 of 693], absolute difference 0.025 [95% CI 0.002 to 0.043]; p = 0.03), and radiation oncology (7.9% [289 of 3659], absolute difference 0.020 [95% CI 0.009 to 0.029]; p < 0.001), and it was not different from UIM representation among residents in plastic surgery (9.3% [386 of 4129]; p = 0.33), urology (9.7% [670 of 6877]; p = 0.80), dermatology (9.9% [679 of 6879]; p = 0.96), and diagnostic radiology (10% [2215 of 22,076]; p = 0.53). The proportion of orthopaedic faculty from UIM groups (4.7% [992 of 20,916]) was not different from UIM representation among faculty in otolaryngology (4.8% [553 of 11,413]; p = 0.68), neurology (5.0% [1533 of 30,871]; p = 0.25), pathology (4.9% [1129 of 23,206]; p = 0.55), and diagnostic radiology (4.9% [2418 of 49,775]; p = 0.51). Compared with other surgical and medical specialties with available data, orthopaedic surgery had the highest proportion of White applicants (62% [4613 of 7446]), residents (75% [14,571 of 19,476]), and faculty (75% [15,785 of 20,916]).
Orthopaedic applicant representation from UIM groups has increased over time and is similar to that of several surgical and medical specialties, suggesting relative success with efforts to recruit more students from UIM groups. However, the proportion of orthopaedic residents and UIM groups has not increased accordingly, and this is not because of a lack of applicants from UIM groups. In addition, UIM representation among orthopaedic faculty has not changed and may be partially explained by the lead time effect, but increased attrition among orthopaedic residents from UIM groups and racial bias likely also play a role. Further interventions and research into the potential difficulties faced by orthopaedic applicants, residents, and faculty from UIM groups are necessary to continue making progress.
A diverse physician workforce is better suited to address healthcare disparities and provide culturally competent patient care. Representation of orthopaedic applicants from UIM groups has improved over time, but further research and interventions are necessary to diversify orthopaedic surgery to ultimately provide better care for all orthopaedic patients.
Kalyanasundaram G
，Mener A
，DiCaprio MR
《-》
Implementation of Entrustable Professional Activities in General Surgery: Results of a National Pilot Study.
The ongoing complexity of general surgery training has led to an increased focus on ensuring the competence of graduating residents. Entrustable professional activities (EPAs) are units of professional practice that provide an assessment framework to drive competency-based education. The American Board of Surgery convened a group from the American College of Surgeons, Accreditation Council for Graduate Medical Education (ACGME) Surgery Review Committee, and Association of Program Directors in Surgery to develop and implement EPAs in a pilot group of residency programs across the country. The objective of this pilot study was to determine the feasibility and utility of EPAs in general surgery resident training.
5 EPAs were chosen based on the most common procedures reported in ACGME case logs and by practicing general surgeons (right lower quadrant pain, biliary disease, inguinal hernia), along with common activities covering additional ACGME milestones (performing a consult, care of a trauma patient). Levels of entrustment assigned (1 to 5) were observation only, direct supervision, indirect supervision, unsupervised, and teaching others. Participating in site recruitment and faculty development occurred from 2017 to 2018. EPA implementation at individual residency programs began on July 1, 2018, and was completed on June 30, 2020. Each site was assigned 2 EPAs to implement and collected EPA microassessments on residents for those EPAs. The site clinical competency committees (CCC) used these microassessments to make summative entrustment decisions. Data submitted to the independent deidentified data repository every 6 months included the number of microassessments collected per resident per EPA and CCC summative entrustment decisions.
Twenty-eight sites were selected to participate in the program and represented geographic and size variability, community, and university-based programs. Over the course of the 2-year pilot programs reported on 14 to 180 residents. Overall, 6,272 formative microassessments were collected (range, 0 to 1144 per site). Each resident had between 0 and 184 microassessments. The mean number of microassessments per resident was 5.6 (SD = 13.4) with a median of 1 [interquartile range (IQR) = 6]. There were 1,763 summative entrustment ratings assigned to 497 unique residents. The average number of observations for entrustment was 3.24 (SD 3.61) with a median of 2 (IQR 3). In general, PGY1 residents were entrusted at the level of direct supervision and PGY5 residents were entrusted at unsupervised practice or teaching others. For each EPA other than the consult EPA, the degree of entrustment reported by the CCC increased by resident level.
These data provide evidence that widespread implementation of EPAs across general surgery programs is possible, but variable. They provide meaningful data that graduating chief residents are entrusted by their faculty to perform without supervision for several common general surgical procedures and highlight areas to target for the successful widespread implementation of EPAs.
Brasel KJ
，Lindeman B
，Jones A
，Sarosi GA
，Minter R
，Klingensmith ME
，Whiting J
，Borgstrom D
，Buyske J
，Mellinger JD
... -
《-》
Falls prevention interventions for community-dwelling older adults: systematic review and meta-analysis of benefits, harms, and patient values and preferences.
About 20-30% of older adults (≥ 65 years old) experience one or more falls each year, and falls are associated with substantial burden to the health care system, individuals, and families from resulting injuries, fractures, and reduced functioning and quality of life. Many interventions for preventing falls have been studied, and their effectiveness, factors relevant to their implementation, and patient preferences may determine which interventions to use in primary care. The aim of this set of reviews was to inform recommendations by the Canadian Task Force on Preventive Health Care (task force) on fall prevention interventions. We undertook three systematic reviews to address questions about the following: (i) the benefits and harms of interventions, (ii) how patients weigh the potential outcomes (outcome valuation), and (iii) patient preferences for different types of interventions, and their attributes, shown to offer benefit (intervention preferences).
We searched four databases for benefits and harms (MEDLINE, Embase, AgeLine, CENTRAL, to August 25, 2023) and three for outcome valuation and intervention preferences (MEDLINE, PsycINFO, CINAHL, to June 9, 2023). For benefits and harms, we relied heavily on a previous review for studies published until 2016. We also searched trial registries, references of included studies, and recent reviews. Two reviewers independently screened studies. The population of interest was community-dwelling adults ≥ 65 years old. We did not limit eligibility by participant fall history. The task force rated several outcomes, decided on their eligibility, and provided input on the effect thresholds to apply for each outcome (fallers, falls, injurious fallers, fractures, hip fractures, functional status, health-related quality of life, long-term care admissions, adverse effects, serious adverse effects). For benefits and harms, we included a broad range of non-pharmacological interventions relevant to primary care. Although usual care was the main comparator of interest, we included studies comparing interventions head-to-head and conducted a network meta-analysis (NMAs) for each outcome, enabling analysis of interventions lacking direct comparisons to usual care. For benefits and harms, we included randomized controlled trials with a minimum 3-month follow-up and reporting on one of our fall outcomes (fallers, falls, injurious fallers); for the other questions, we preferred quantitative data but considered qualitative findings to fill gaps in evidence. No date limits were applied for benefits and harms, whereas for outcome valuation and intervention preferences we included studies published in 2000 or later. All data were extracted by one trained reviewer and verified for accuracy and completeness. For benefits and harms, we relied on the previous review team's risk-of-bias assessments for benefit outcomes, but otherwise, two reviewers independently assessed the risk of bias (within and across study). For the other questions, one reviewer verified another's assessments. Consensus was used, with adjudication by a lead author when necessary. A coding framework, modified from the ProFANE taxonomy, classified interventions and their attributes (e.g., supervision, delivery format, duration/intensity). For benefit outcomes, we employed random-effects NMA using a frequentist approach and a consistency model. Transitivity and coherence were assessed using meta-regressions and global and local coherence tests, as well as through graphical display and descriptive data on the composition of the nodes with respect to major pre-planned effect modifiers. We assessed heterogeneity using prediction intervals. For intervention-related adverse effects, we pooled proportions except for vitamin D for which we considered data in the control groups and undertook random-effects pairwise meta-analysis using a relative risk (any adverse effects) or risk difference (serious adverse effects). For outcome valuation, we pooled disutilities (representing the impact of a negative event, e.g. fall, on one's usual quality of life, with 0 = no impact and 1 = death and ~ 0.05 indicating important disutility) from the EQ-5D utility measurement using the inverse variance method and a random-effects model and explored heterogeneity. When studies only reported other data, we compared the findings with our main analysis. For intervention preferences, we used a coding schema identifying whether there were strong, clear, no, or variable preferences within, and then across, studies. We assessed the certainty of evidence for each outcome using CINeMA for benefit outcomes and GRADE for all other outcomes.
A total of 290 studies were included across the reviews, with two studies included in multiple questions. For benefits and harms, we included 219 trials reporting on 167,864 participants and created 59 interventions (nodes). Transitivity and coherence were assessed as adequate. Across eight NMAs, the number of contributing trials ranged between 19 and 173, and the number of interventions ranged from 19 to 57. Approximately, half of the interventions in each network had at least low certainty for benefit. The fallers outcome had the highest number of interventions with moderate certainty for benefit (18/57). For the non-fall outcomes (fractures, hip fracture, long-term care [LTC] admission, functional status, health-related quality of life), many interventions had very low certainty evidence, often from lack of data. We prioritized findings from 21 interventions where there was moderate certainty for at least some benefit. Fourteen of these had a focus on exercise, the majority being supervised (for > 2 sessions) and of long duration (> 3 months), and with balance/resistance and group Tai Chi interventions generally having the most outcomes with at least low certainty for benefit. None of the interventions having moderate certainty evidence focused on walking. Whole-body vibration or home-hazard assessment (HHA) plus exercise provided to everyone showed moderate certainty for some benefit. No multifactorial intervention alone showed moderate certainty for any benefit. Six interventions only had very-low certainty evidence for the benefit outcomes. Two interventions had moderate certainty of harmful effects for at least one benefit outcome, though the populations across studies were at high risk for falls. Vitamin D and most single-component exercise interventions are probably associated with minimal adverse effects. Some uncertainty exists about possible adverse effects from other interventions. For outcome valuation, we included 44 studies of which 34 reported EQ-5D disutilities. Admission to long-term care had the highest disutility (1.0), but the evidence was rated as low certainty. Both fall-related hip (moderate certainty) and non-hip (low certainty) fracture may result in substantial disutility (0.53 and 0.57) in the first 3 months after injury. Disutility for both hip and non-hip fractures is probably lower 12 months after injury (0.16 and 0.19, with high and moderate certainty, respectively) compared to within the first 3 months. No study measured the disutility of an injurious fall. Fractures are probably more important than either falls (0.09 over 12 months) or functional status (0.12). Functional status may be somewhat more important than falls. For intervention preferences, 29 studies (9 qualitative) reported on 17 comparisons among single-component interventions showing benefit. Exercise interventions focusing on balance and/or resistance training appear to be clearly preferred over Tai Chi and other forms of exercise (e.g., yoga, aerobic). For exercise programs in general, there is probably variability among people in whether they prefer group or individual delivery, though there was high certainty that individual was preferred over group delivery of balance/resistance programs. Balance/resistance exercise may be preferred over education, though the evidence was low certainty. There was low certainty for a slight preference for education over cognitive-behavioral therapy, and group education may be preferred over individual education.
To prevent falls among community-dwelling older adults, evidence is most certain for benefit, at least over 1-2 years, from supervised, long-duration balance/resistance and group Tai Chi interventions, whole-body vibration, high-intensity/dose education or cognitive-behavioral therapy, and interventions of comprehensive multifactorial assessment with targeted treatment plus HHA, HHA plus exercise, or education provided to everyone. Adding other interventions to exercise does not appear to substantially increase benefits. Overall, effects appear most applicable to those with elevated fall risk. Choice among effective interventions that are available may best depend on individual patient preferences, though when implementing new balance/resistance programs delivering individual over group sessions when feasible may be most acceptable. Data on more patient-important outcomes including fall-related fractures and adverse effects would be beneficial, as would studies focusing on equity-deserving populations and on programs delivered virtually.
Not registered.
Pillay J
，Gaudet LA
，Saba S
，Vandermeer B
，Ashiq AR
，Wingert A
，Hartling L
... -
《Systematic Reviews》
ResearchGate
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