Is There Unconscious Bias in the Orthopaedic Residency Interview Selection Process?

OBJECTIVE: Orthopaedic surgery has historically been a white male-dominated field. Given the diverse patient population presenting to providers with musculoskeletal pathology, it is thought that it would be beneficial for the orthopaedic workforce to more closely mirror this patient population. This study aims to elucidate whether unconscious bias may have an effect on the scoring of applications for residency interview selection. DESIGN: Applications for the 2019-2020 residency match cycle were initially reviewed and scored by faculty members. Applications were then redacted of all information suggestive of race or gender and returned to evaluators for rescoring after at least 6 months. The pre and post-redaction data was compared using ANOVA and student's two-tailed t tests. SETTING: Department of Orthopaedic Surgery, Medical College of Georgia at Augusta University. PARTICIPANTS: Thirteen attending surgeons scored 320 2019-2020 Electronic Residency Application System (ERAS) applications, unblinded and blinded of applicant identifying information. RESULTS: Interviewed applicants were similar to the non-interviewed group in all measured variables except for higher pre-redaction scores (8.73-7.81; p = 0.02) which was expected (Table 2). Minority applicants had significant differences in Step 1 scores (243 vs 247; p < 0.01), Step 2 scores (251 vs 254; p = 0.01), articles (5.9 vs 3.8; p < 0.01), posters (5.9 vs 3.5; p < 0.01), and pre-redaction scores (7.44 vs 8.07; p = 0.01) compared to white applicants (Table 4). There was no relationship noted between step score and number or type of research items (Table 5). Pre-redaction and post-redaction scores were significantly different in white applicants who experienced a negative change (8.07-7.88; p = 0.03 (Table 6)). Males had statistically significant differences compared to females in Step 1 score (246 vs 243; p = 0.01) (Table 7). CONCLUSIONS: This study was unable to prove unconscious bias based on a lack of statistically significant change of score when blinded, however the direction in change of scores was unlikely to be accounted for exclusively by objective differences between applicants, suggesting a trend toward unconscious bias. It remains unclear how influential subjective portions of the ERAS application such as personal statements, Letters of Recommendation, hobbies, and activities are on the overall assessment of an applicant and whether or not unconscious bias manifests in these subjective portions. Further investigation is needed in this area. Until then, residency programs should take immediate measures to mitigate potential implicit bias in the residency interview selection process. Actions can include implicit bias training for all faculty members involved in resident selection, standardization of application scoring and possibly redacting all or portions of the ERAS application so that only objective academic markers are presented to evaluators. Gaining a better understanding of these barriers is not only essential for their removal, but also allows for better preparation of applicants for success in the match with the ultimate goal being to correct the persistent disparity in the field of orthopaedic surgery.

From Lateral Ankle Sprain to Above-Knee Amputation: A Unique Case Report of Group A Streptococcus Necrotizing Soft-tissue Infection.

INTRODUCTION: Necrotizing fasciitis, also referred to necrotizing soft-tissue infection (NSTI), is an infrequent entity that results in orthopedic consultation. It is a rapidly spreading typically associated with a contaminated wound that spreads rapidly along fascial planes resulting in significant morbidity and mortality. However, it is a rare occurrence that such pathology occurs in an atraumatic fashion, which is without a wound through the skin. CASE REPORT: A 33-year-old female with no significant medical history presented to a walk-in orthopedic clinic with increasing ankle pain after a lateral ankle sprain 2 days prior. Patient denies any fevers, chills, shortness of breath, numbness, tingling, paresthesia, or any additional trauma since the initial ankle sprain. The patient was afebrile, maintaining oxygenation, normotensive, but tachycardic to just over 100. Physical examination was only significant for moderate swelling and ecchymosis about the lateral malleolus. X-rays and venous ultrasound were negative for any associated pathology. After a period of observation, the patient acutely decompensated with a significant increase in pain in the lower leg on passive stretch, an increase in compartment firmness and a worsening tachycardia up to the 120's. The patient was taken emergently for fasciotomies for presumed compartment syndrome. The patient was hemodynamically unstable during the case and transferred to the intensive care unit where she continued to decompensate, requiring multiple vasopressors. The affected extremity became necrotic at the level of the foot and her hemodynamic instability continued, causing a return to the operating room for an emergent guillotine above-knee amputation. The patient progressively stabilized and underwent a formal above-knee amputation 2 days later. Cultures obtained during the second case were positive for Group A Streptococcus. CONCLUSION: This case highlights the variable presentation of NSTIs as well as has having a high index of suspicion to ensure this highly morbid and fatal disease process is diagnosed expeditiously. This case is also unique in that it developed without any obvious wounds and that monomicrobial Group A Streptococcus was the culprit, while most NSTIs are polymicrobial.

The BARC biosensor applied to the detection of biological warfare agents.

The Bead ARray Counter (BARC) is a multi-analyte biosensor that uses DNA hybridization, magnetic microbeads, and giant magnetoresistive (GMR) sensors to detect and identify biological warfare agents. The current prototype is a table-top instrument consisting of a microfabricated chip (solid substrate) with an array of GMR sensors, a chip carrier board with electronics for lock-in detection, a fluidics cell and cartridge, and an electromagnet. DNA probes are patterned onto the solid substrate chip directly above the GMR sensors, and sample analyte containing complementary DNA hybridizes with the probes on the surface. Labeled, micron-sized magnetic beads are then injected that specifically bind to the sample DNA. A magnetic field is applied, removing any beads that are not specifically bound to the surface. The beads remaining on the surface are detected by the GMR sensors, and the intensity and location of the signal indicate the concentration and identity of pathogens present in the sample. The current BARC chip contains a 64-element sensor array, however, with recent advances in magnetoresistive technology, chips with millions of these GMR sensors will soon be commercially available, allowing simultaneous detection of thousands of analytes. Because each GMR sensor is capable of detecting a single magnetic bead, in theory, the BARC biosensor should be able to detect the presence of a single analyte molecule.

A biosensor based on magnetoresistance technology.

We are developing a biosensor that will measure, at the level of single molecules, the forces that bind DNA-DNA, antibody-antigen, or ligand-receptor pairs together. The Bead Array Counter (BARC) will use these interaction forces to hold magnetic microbeads to a solid substrate. Microfabricated magnetoresistive transducers on the substrate will indicate whether or not the beads are removed when pulled by magnetic forces. By adapting magnetoresistive computer memory technology, it may be possible to fabricate millions of transducers on a chip and detect or screen thousands of analytes. The multi-analyte capability of this portable sensor would be ideal for on-site testing, while the potential to directly gauge intermolecular interaction strengths suggests drug discovery applications.

Scanning probe microscopy.

During the past year, scanning probe microscopy, especially atomic force microscopy (AFM), has taken root in the biological sciences community, as is evident from the large number of publications and from the variety of specialized journals in which these papers appear. Furthermore, there is a strong indication that the technique is evolving from a qualitative imaging tool to a probe of the critical dimensions and properties of biomolecules and living cells. The next stage of the evolution involves the development of microinstruments for process control and sensing applications. Recent advances have been reported in AFM instrumentation and method. For example, the tapping mode of operation is becoming the method of choice to image biological molecules; work to extend tapping-mode operation in liquids has been reported. Biological molecules can also be imaged at low temperature in a cryo-AFM with improved resolution. The measurement of recognition forces between individual molecules continues to attract much attention and has spawned new concepts for ultra-sensitive biosensors. The AFM is being used increasingly for property measurements such as determining the viscoelastic properties of biological molecules. Finally, structural studies using the AFM abound. Some specific highlights include the mapping of DNA using restriction enzymes, imaging during DNA transcription and determining the mode of drug binding to DNA.

Direct measurement of the forces between complementary strands of DNA.

Interaction forces between single strands of DNA were measured with the atomic force microscope by a procedure in which DNA oligonucleotides were covalently attached to a spherical probe and surface. Adhesive forces measured between complementary 20-base strands fell into three distinct distributions centered at 1.52, 1.11, and 0.83 nano-newtons, which are associated with the rupture of the interchain interaction between a single pair of molecules involving 20, 16, and 12 base pairs, respectively. When a third long DNA molecule was coupled between complementary surfaces, both intra- and interchain forces were observed. The intrachain interaction resulting from the molecule's elasticity manifested itself as a long-range cohesive force.

Self-arrangement of molybdenum particles into cubes.

An unusual distribution of particle sizes has been observed following the formation of molybdenum particles by argon ion sputtering. Many of the molybdenum particles produced by sputtering at the threshold pressure for particle formation in the vapor appear to be single crystalline cubes. There are two prominent peaks in the edge length distribution of the cubes, one centered at 4.8 nanometers with a halfwidth of approximately 1.3 nanometers and the other at 17.5 nanometers. The peak for the larger cubes is approximately square and has a total width of 7.0 nanometers. Evidence is presented that the larger cubes are formed by a 3 by 3 by 3 self-arrangement of the smaller cubes, which contain approximately 7000 atoms. Self-arrangement in inorganic structures is normally only observed when the building blocks are atoms, molecules, or clusters of less than 100 atoms.

Atomistic mechanisms and dynamics of adhesion, nanoindentation, and fracture.

Molecular dynamics simulations and atomic force microscopy are used to investigate the atomistic mechanisms of adhesion, contact formation, nanoindentation, separation, and fracture that occur when a nickel tip interacts with a gold surface. The theoretically predicted and experimentally measured hysteresis in the force versus tip-to-sample distance relationship, found upon approach and subsequent separation of the tip from the sample, is related to inelastic deformation of the sample surface characterized by adhesion of gold atoms to the nickel tip and formation of a connective neck of atoms. At small tipsample distances, mechanical instability causes the tip and surface to jump-to-contact, which in turn leads to adhesion-induced wetting of the nickel tip by gold atoms. Subsequent indentation of the substrate results in the onset of plastic deformation of the gold surface. The atomic-scale mechanisms underlying the formation and elongation of a connective neck, which forms upon separation, consist of structural transformations involving elastic and yielding stages.

Enhanced detection of drugs in complex mixtures by derivatization/secondary ion mass spectrometry.

Derivatization/secondary ion (SI) mass spectrometry is a sensitive surface analysis technique. It can detect ppm levels of selected compounds in complex mixtures, as can tandem mass spectrometry. However, unlike tandem mass spectrometry it uses simpler instrumentation, since chemistry is used to select the compound of interest instead of a mass spectrometer. The application of derivatization/SI mass spectrometry is discussed regarding the analysis of drugs in aqueous media, tablets or human urine.