Team Physicians in Men's and Women's Professional Sports Leagues: Gender Representation and Career Path Analysis.

Background: The most common orthopaedic fellowship is for sports medicine, but few fellowship-trained orthopaedic surgeons fill roles as team physicians. Gender disparities within the field of orthopaedics, coupled with male-dominated professional sports leagues in the United States, may lead to lower representation of women as professional team physicians. Purpose: To (1) determine the career path trajectories of current head team physicians in professional sports, (2) quantify gender disparities across team physician representation, and (3) further characterize professional profiles of team physicians appointed to women's and men's professional sports leagues in the United States. Study Design: Cross-sectional study. Methods: This is a cross-sectional study of professional sports head team physicians in 8 major American sports leagues: American football (National Football League), baseball (Major League Baseball), basketball (National Basketball Association and Women's National Basketball Association), hockey (National Hockey League and National Women's Hockey League), and soccer (Major League Soccer and National Women's Soccer League). Online searches were used to compile information on gender, specialty, medical school, residency, fellowship, years in practice, clinical practice type, practice setting, and research productivity. Differences according to league type (men's vs women's leagues) were analyzed with the chi-square test for categorical variables, t test for continuous variables, and Mann-Whitney U test for nonparametric means. Bonferroni correction was applied for multiple comparisons. Results: Within the 172 professional sports teams, 183 head team physicians were identified, including 170 men (92.9%) and 13 women (7.1%). Team physicians in both men's and women's sports leagues were predominantly men. Overall, 96.7% of team physicians in men's leagues were men, and 73.3% of team physicians in women's leagues were men (P < .001). The most common physician specialties were orthopaedic surgery (70.0%) and family medicine (19.1%). Compared with team physicians in women's leagues, those in men's leagues were more likely to be orthopaedic surgeons (40.0% vs 71.9%, respectively; P = .001) and to have more experience (15.9 vs 22.4 years, respectively; P < .001). Conclusion: Study findings indicated disparities in gender, practice experience, and physician specialty representation among team physicians in men's versus women's professional sports leagues.

The Socioeconomic consequences of femoral shaft fracture for patients in Malawi.

Background: Femoral shaft fractures are common in Malawi, with an annual incidence of 44 per 100,000 people. Inadequate treatment and delayed presentation often result in functional, biopsychosocial, and financial challenges for patients. The purpose of this study was to examine the socioeconomic consequences of femoral shaft fractures for patients in Malawi. Methods: This study of 42 patients was part of a larger study that prospectively examined quality of life. Questionnaires were distributed to patients at 1-year follow-up following femoral shaft fracture treatment. Patients reported pre- and post-injury standard of living and financial well-being. Results: Patients reported relatively high transportation costs to and from the hospital. One year after injury, 17 patients (40%) had not returned to work. Of the 25 (60%) who had returned, 5 (20%) changed jobs due to their injury, all reported decreased productivity. Household income decreased for 29% of patients. 20 (49%) of 41 patients reported food insecurity in the week prior to questionnaire completion. Many patients reported changing their residence, borrowing money, selling personal property, and unenrolling children from school due to financial hardship caused by their injury. Conclusion: While the Malawian public healthcare system is free at the point of care, it lacks the financial risk protection that is essential to universal health coverage (UHC). In this study, we found that the indirect costs of care due to femoral shaft fractures had substantial socioeconomic consequences on the majority of patients and their families. Increased investment of financial and human capital should be made into capacity building and preventative measures to decrease the burden of injury, increase access to care, improve care delivery, and provide financial risk protection for patients with traumatic injuries in Malawi.

Putting the Pieces Together: Student Thinking about Transformations of Energy and Matter.

Research on student thinking facilitates the design of instructional materials that build on student ideas. The pieces framework views student knowledge as consisting of independent pieces that students assemble in fluctuating ways based on the context at hand. This perspective affords important insights about the reasons students think the way they do. We used the pieces framework to investigate student thinking about the concept transformations of energy and matter with a specific focus on metabolism. We conducted think-aloud interviews with undergraduate introductory biology and biochemistry students as they solved a metabolism problem set. Through knowledge analysis, we identified two categories of knowledge elements cued during metabolism problem solving: 1) those about the visual representation of negative feedback inhibition; and 2) those pertaining to student focus on different metabolic compounds in a pathway. Through resource graph analysis, we found that participants tend to use knowledge elements independently and in a fluctuating way. Participants generally showed low representational competence. We recommend further research using the pieces perspective, including research on improving representational competence. We suggest that metabolism instructors teach metabolism as a concept, not a collection of example pathways, and explicitly instruct students about the meaning of visual representations associated with metabolism.

Return to Play and Performance After Anterior Cruciate Ligament Reconstruction in National Football League Players.

Background: Considerable variability exists in return-to-play rates after anterior cruciate ligament (ACL) injury and reconstruction (ACLR) among National Football League (NFL) players of different positions. Purpose/Hypothesis: The purpose of this study was to compare return-to-play and performance levels by position in NFL players after ACLR. It was hypothesized that (1) ACL injuries have significant effects on the careers of NFL players, including return to play and performance, and (2) players of certain positions that involve relatively less pivoting and cutting perform better after ACLR. Study Design: Descriptive epidemiology study. Methods: All NFL players who underwent ACLR between 2013 and 2018 were identified using the FantasyData injury database. Player characteristics, snap count, games played, games started, and performance metrics were collected for 3 years before and after injury using the Pro Football Reference database. Performance was measured using an approximate value (AV) algorithm to compare performance across positions and over time. Nonparametric tests were used to compare the pre- and postinjury data and the percentage change in performance between different positions. Results: Overall, 312 NFL players were included in this study, and 174 (55.8%) returned to play. Of the eligible players, only 28.5% (n = 59/207) remained in the league 3 years postinjury. Within the first 3 years postinjury, players played in fewer games (8.7 vs 13.7; P < .0001), started in fewer games (3.0 vs 8.3; P < .0001), had lower AVs (1.5 vs 4.3; P < .0001), and had decreased snap counts (259.0 vs 619.0; P < .0001) compared with preinjury. Quarterbacks were most likely to return to play (92.9% vs 53.7%; P = .0040) and to return to performance (2% vs 50% decrease in AV; P = .0165) compared with the other positions. Running backs had the largest decrease in AV (90.5%), followed by defensive linemen (76.2%) and linebackers (62.5%). Conclusion: The study findings indicated that NFL players are severely affected by ACL injury, with only 28.5% still active in the league 3 years after the injury. Running backs, defensive linemen, and linebackers performed the worst after injury. Quarterbacks were most likely to return to play and had superior postinjury performance compared with the other positions.

Medical Student Mentorship in Orthopaedic Surgery.

Mentorship is a key aspect of medical education, but the availability and quality of mentorship varies considerably between institutions. The lack of standardization results in information asymmetry and creates notable inequities. This disparity is particularly important for students interested in pursuing competitive specialties, such as orthopaedic surgery. The purpose of this study was to (1) demonstrate the importance of mentorship in orthopaedics, (2) provide a framework for orthopaedic surgeon mentors, and (3) guide medical students interested in activating and expanding their networks.

The Health & Economic Disparities of Congenital Musculoskeletal Disease Worldwide: An Analysis of 25 Years (1992-2017).

Background: Large disparities exist in congenital musculoskeletal disease burden worldwide. The purpose of this study is to examine and quantify the health and economic disparities of congenital musculoskeletal disease by country income level from 1992 to 2017. Methods: The Global Burden of Disease database was queried for information on disease burden attributed to "congenital musculoskeletal and limb anomalies" from 1992 to 2017. Gross national income per capita was extracted from the World Bank website. Nonparametric Kruskal-Wallis tests were used to compare morbidity and mortality across years and income levels. The number of avertable DALYs was converted to an economic disparity using the human-capital and value of a statistical life approach. Results: From 1992 to 2017, a significant decrease in deaths/100 000 was observed only in upper-middle and high income countries. Northern Africa, the Middle East, and Eastern Europe were disproportionately affected. If the burden of disease in low- and middle- income countries (LMICs) was equivalent to that in high income countries (HICs), 10% of all DALYs and 70% of all deaths attributable to congenital musculoskeletal disease in LMICs could be averted. This equates to an economic disparity of about $2 billion to $3 billion (in 2020 $USD). Conclusion: Considerable inequity exists in the burden of congenital musculoskeletal disease worldwide and there has been no change over the last 25 years in total disease burden and geographical distribution. By reducing the disease burden in LMICs to rates found in HICs, a large proportion of the health and economic consequences could be averted.

Effect of Gender Differences on Patient-Reported Outcomes and Complications in Total Ankle Replacement.

BACKGROUND: The purpose of this study was to evaluate gender differences in patient outcomes and complications following total ankle replacement (TAR). METHODS: Consecutive patients who underwent primary TAR from July 2007 through May 2016 were prospectively followed and retrospectively reviewed. Demographic, operative, patient-reported outcomes (PROs), and complication data were collected and analyzed. PROs included the visual analog scale (VAS), 36-Item Short-Form Health Survey (SF-36), American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale, and Short Musculoskeletal Function Assessment (SMFA). A total of 475 patients were evaluated, including 248 males (52.2%) and 227 females (47.8%) with an average of 56.8 months follow-up. RESULTS: Women were more likely to have inflammatory arthritis (13.7% vs 2.8%; P < .01) and significantly worse preoperative SF-36 total, SF-36 mental health component, AOFAS total, AOFAS pain, SMFA function, and SMFA bother scores (all P < .05). Both genders demonstrated significant improvement in PROs at 1, 2, and 5 years. The magnitude of improvement was similar between genders for all PROs (all P < .05) with the exception of SF-36 physical function, which was greater in men. Females underwent more nonrevision reoperations (32.2% vs 22.6%; P = .0191), but there was no significant difference in failure rates (male 7.3% vs female 3.5%; P = .07). The reoperation and failure rates at 2 years postoperation were 10.1% and 1.6% for men and 18.5% and 0.9% for women, respectively. CONCLUSION: Women undergoing TAR were more likely to have worse preoperative PROs and higher rates of nonrevision reoperations, which remains true when controlling for their increased incidence of inflammatory arthritis. However, women reported similar improvements in PROs and had similar prosthetic survival rates as men. Increased understanding of these disparities, combined with gender-based interventions, may further advance patient outcomes. LEVEL OF EVIDENCE: Level III, therapeutic, retrospective comparative series.

Symptoms upon postural change and orthostatic hypotension in adolescents with concussion.

Objective: Concussion is associated with dysautonomia, altered blood pressure (BP) control, and may cause Orthostatic Hypotension (OH). We measured prevalence of OH using the 1-minute supine-to-standing OH Test in adolescents with concussion and controls.Participants: Adolescents within 10 days of injury (Concussion Group, n = 297, 15.0 ± 1.7 years, 59% male) were compared with controls (Control Group, n = 214, 15.0 ± 1.5 years, 58% male).Methods: BP, heart rate (HR), and complaints of lightheadedness/dizziness were measured after 2-minute supine and 1-minute standing. Control Group was assessed once. Concussion Group was assessed twice; (1) initial visit (mean 6.0 ± 3 days-since-injury) and (2) after clinical recovery (mean 46.3 ± 42 days-since-injury).Results: Initial visit; Concussion Group reported feeling lightheaded/dizzy on postural change more often than the Control Group (37% vs 4%, p < .001) but did not differ in meeting standard OH criteria (3% vs 5%, p = .32). Experiencing symptoms did not correlate with meeting OH criteria, but correlated with abnormal vestibulo-ocular reflex. After clinical recovery; Concussion Group did not differ in experiencing lightheaded/dizziness on postural change than controls (4%, p = .65).Conclusion: Adolescents commonly experience orthostatic intolerance after concussion without meeting the standard criteria for OH.

Radiation safety education as a component of orthopedic training.

Fluoroscopy poses an occupational hazard to orthopedic surgeons. The purpose of this study was to examine resident and faculty understanding of radiation safety and to determine whether or not a radiation safety intervention would improve radiation safety knowledge. An anonymous survey was developed to assess attitudes and knowledge regarding radiation safety and exposure. It was distributed to faculty and residents at an academic orthopedic program before and after a radiation safety lecture. Pre- and post-lecture survey results were compared. 19 residents and 22 faculty members completed the pre-lecture survey while 11 residents and 17 faculty members completed the post-lecture survey. Pre-lecture survey scores were 48.3% for residents and 49.5% for faculty; post-lecture survey scores were 52.7% and 46.1% respectively. Differences between pre and post-survey scores were not significant. This study revealed low baseline radiation safety knowledge scores for both orthopedic residents and faculty. As evidence by our results, a single radiation safety information lecture did not significantly impact radiation knowledge. Radiation safety training should have a formal role in orthopedic surgery academic curricula.

Applications of Machine Learning Using Electronic Medical Records in Spine Surgery.

Developments in machine learning in recent years have precipitated a surge in research on the applications of artificial intelligence within medicine. Machine learning algorithms are beginning to impact medicine broadly, and the field of spine surgery is no exception. Electronic medical records are a key source of medical data that can be leveraged for the creation of clinically valuable machine learning algorithms. This review examines the current state of machine learning using electronic medical records as it applies to spine surgery. Studies across the electronic medical record data domains of imaging, text, and structured data are reviewed. Discussed applications include clinical prognostication, preoperative planning, diagnostics, and dynamic clinical assistance, among others. The limitations and future challenges for machine learning research using electronic medical records are also discussed.

Orthopedic Master's in Business Administration: A career path analysis.

In recent years, it has become increasingly important for physicians to understand the healthcare system holistically. Thus, some physicians have sought formal education in business through a Master's in Business Administration (MBA). In this study, we looked specifically at orthopedic MD-MBAs and their career trajectories. We conducted a cross-sectional study of 127 orthopedic surgeons who have both MD and MBA degrees. Through online searches and phone calls, we compiled information regarding years in practice, fellowship training, practice type, non-clinical roles, and business school education. Almost all (96.85%) orthopedic MD-MBAs identified are still practicing clinically. The most common nonclinical roles are administration (38.58%), industry consulting (20.47%), and entrepreneurship (11.02%). Most (65.35%) pursued MBAs after medical school, but dual-degree programs are increasing in popularity. Almost all (88.57%) graduates of such programs have been practicing for less than 15 years. Orthopedic surgeons participate in a variety of nonclinical roles including administration, consulting, and entrepreneurship. For those currently in training, it is important to recognize the many opportunities that exist and the potential paths to pursuing them.

Student difficulties during structure-function problem solving.

Protein structure-function is a key concept in biochemistry. We used the perspective of domain-specific problem-solving to investigate students' solutions to a well-defined protein structure-function problem. We conducted think-aloud interviews with 13 undergraduate students and performed qualitative content analysis to examine the differences in the domain-general and domain-specific knowledge among correct and incorrect solutions. Our work revealed that students used domain-general and domain-specific knowledge in their problem solving. We also identified difficulties for students with the amino acid backbone, amino acid categorization, and causal mechanisms of noncovalent interactions. Using the identified difficulties, we make recommendations for the design of instructional materials targeted to improve protein structure-function problem solving in the biochemistry classroom. © 2018 International Union of Biochemistry and Molecular Biology, 46(5):453-463, 2018.

Office Pediatric Orthopaedics for the General Orthopaedic Surgeon: Staying Current and Avoiding Mistakes.

Pediatric and adolescent patients frequently are seen in the outpatient practices of general orthopaedic surgeons. Orthopaedic conditions may be a challenge to diagnose and manage in pediatric and adolescent patients. To avoid complications, general orthopaedic surgeons should understand current diagnostic techniques, evaluation methods, and treatment options for orthopaedic spine, hip, and lower extremity conditions that are common in pediatric and adolescent patients. General orthopaedic surgeons should understand the indications for surgical treatment in this patient population. In addition, general orthopaedic surgeons must understand methods to accurately, efficiently, and safely evaluate and manage orthopaedic conditions in pediatric and adolescent patients.

An analysis of technology usage for streaming digital video in support of a preclinical curriculum.

Usage of streaming digital video of lectures in preclinical courses was measured by analysis of the data in the log file maintained on the web server. We observed that students use the video when it is available. They do not use it to replace classroom attendance but rather for review before examinations or when a class has been missed. Usage of video has not increased significantly for any course within the 18 month duration of this project.

Assessment of laryngeal view: percentage of glottic opening score vs Cormack and Lehane grading.

PURPOSE: To examine the intra- and inter-rater reliability of two methods that categorize laryngeal view during direct laryngoscopy, the Cormack-Lehane grading system and a new scale, the percentage of glottic opening (POGO) scale. METHODS: Seven anesthesiologists from the University of Pennsylvania Health System viewed 25 identical pairs of slides of laryngeal views during direct laryngoscopy. Each anesthesiologist rated the 50 slides for both Cormack-Lehane grades and POGO scores. The latter CL replaces grades 1 and 2 C-L grades with a percentage of glottic opening: the POGO score. Inter and intra-physician reliability for the Cormack-Lehane grades were determined using the kappa statistic analysis, comparison of POGO scores was performed using the intraclass correlation coefficients (rI). RESULTS: The POGO score had a better inter and intra-physician reliability than the Cormack-Lehane grading system. The intra-physician reliability for the POGO score was very good with an average interclass rI value of 0.88. The inter-physician score was good with a rI of 0.73. The Cormack-Lehane grading system had excellent intra-physician concordance (average kappa = 0.83.) but the inter-physician reliability was poor (kappa = 0.16.) CONCLUSION: The Cormack-Lehane grading system has very poor inter-physician reliability. The lack of inter-physician reliability with Cormack-Lehane grading calls into question the results of previous studies in which different laryngoscopists used this method to assess laryngeal view. The POGO score appears to have good intra and inter-rater reliability. It has several theoretical advantages and may prove to be more useful for research studies in direct laryngoscopy.

Devices for difficult airway management in academic emergency departments: results of a national survey.

STUDY OBJECTIVE: We conducted a national survey of emergency medicine residency program directors to determine which alternative devices were available in their emergency departments for difficult airway management. We also assessed the residency directors' experience in use of these devices. METHODS: After approval was received from the institutional review board at our institution, residency directors were contacted by mail, fax, or phone in October 1997. Alternative intubation devices were defined as devices that do not involve use of a laryngoscope and direct visualization for tracheal tube placement. Alternative ventilation devices were defined as those that do not use a face mask for ventilation. We asked whether the following alternative intubation devices were stocked in their department: a flexible fiberoptic bronchoscope, a rigid fiberoptic device (ie, Bullard, Wu-Scope), a lighted stylet, or a retrograde intubation kit. We also asked about the following alternative ventilation devices: a transtracheal jet ventilation system with a 50-psi oxygen source and control valve, the esophageal tracheal twin-lumen airway device (Combitube), or the laryngeal mask airway. Residency directors were also questioned about their duration of practice, intubation experience, and use of these devices. RESULTS: We obtained information from 95 of 118 (81%) programs. Of 95 programs, 61 (64%) had a fiberoptic bronchoscope, 43 (45%) a retrograde intubation kit, 33 (35%) a lighted stylet, and 6 (.06%) a rigid fiberoptic device. Forty-seven (49%) of the programs reported 2 or more devices, and 20 (21%) reported having no alternative intubation devices. Of 95 programs, 64 (67%) had a transtracheal jet ventilation system, 25 (26%) had the Combitube, and 25 (26%) had the laryngeal mask airway. Thirty-one (33%) programs had at least 2 alternative ventilation devices, and 20 (21%) had none. Ten (11%) programs had no alternative intubating or ventilation devices. Additional information on duration of practice, intubation experience, and actual use of alternative devices was obtained from 83 of the 95 (87%) emergency medicine residency directors contacted. Forty-one (49%) reported never having used an alternative device for intubation. The most commonly used alternative intubation device was the flexible fiberoptic bronchoscope (37%), and the mean number of times any alternative device was used was 7. CONCLUSION: The availability of devices for difficult airway management varies tremendously across emergency medicine residency programs. Only half of residency program directors had any experience with these devices, and among those that reported any experience, they are used rarely.

Assessment of airway visualization: validation of the percentage of glottic opening (POGO) scale.

OBJECTIVE: Research defining optimal methods of intubation has been limited by the lack of a validated outcome measure to assess airway visualization. The objective of this study was to develop a reliable scale for the assessment of airway visualization during endotracheal intubation. METHODS: This prospective study was performed to assess the intra- and interphysician reliabilities of emergency physicians (EPs) for estimating the percentage of glottic opening (POGO) that is visualized during direct laryngoscopy. Using video images of laryngeal views obtained from a commercially available videotape, still slide images were prepared representing glottic openings ranging from 0% to 100%. Five EPs, blinded to study objective, reviewed 25 pairs of airway slides (50 slides total). For each slide, the physicians recorded the POGO and their scores using a modified Cormack-Lehane (MCL) scale, where grade I is a view of the full glottic opening, MCL grade II is a partial view of the glottic opening, and MCL grade III is a view of the epiglottis only. Inter- and intraphysician reliabilities were assessed using the kappa statistic (K) for MCL grade and intraclass correlation coefficient for the POGO scores. RESULTS: For the POGO score, the degree of intrarater reliability was very good, with an intraphysician correlation of 0.85 and an interphysician correlation of 0.74. For the MCL score, the intraphysician concordance had a K of 0.71, and interphysician concordance was also good, with a kappa of 0.59. CONCLUSION: Both the modified version of the Cormack-Lehane grading classification and the POGO score have good interphysician and intraphysician reliabilities. Because the POGO score can distinguish patients with large and small degrees of partial glottic visibility, it might provide a better outcome for assessing the difference between various intubation techniques.