Unique Orthopedic Residency Ensuring Doctors Can Communicate
Joseph Zuckerman, M.D. knows how to communicate. Dr. Zuckerman, chair of the Department of Orthopaedic Surgery at NYU Langone Medical Center and a former president of the American Academy of Orthopaedic Surgeons (AAOS), wants to ensure that his residents do too. He tells OTW, “I am proud to say that we are at the forefront of orthopedic resident education, largely because of our Direct Observation and Feedback (DO&F). With the DO&F residents are observed from the beginning to the end of an encounter. Faculty members are trained to observe resident-patient interactions; this incorporates basic communications skills, professionalism, and physical examination. While the DO&F has often been used in medical school, we are the only orthopedic training program using it thus far.”
“We are primarily looking at skills that are related to communication. Our guidelines are the four Es (engagement, empathy, education, patient enlistment) that emanated from the AAOS communications skills workshop developed in 2001. Faculty members provide feedback immediately after a patient encounter, emphasizing what went well and what challenges they faced. The resident is asked to self-assess while the faculty member facilitates the conversation.”
Donna Phillips, M.D. is director of Resident Assessment for the Department of Orthopaedic Surgery at NYU Langone Medical Center. She tells OTW, “The residents have all been taught communications skills in medical school, and they participate in the AAOS communications skills workshop. The DO&F is an educational tool meant to assess what the residents have learned and what skills they can incorporate into patient encounters.”
“We have a checklist for all of the core competencies, focusing on the non-technical competencies. We look for issues of fatigue and professionalism, and overall communications skills. In addition, we assess cost containment, clinical reasoning, and cultural competency. Is the resident dismissive of a patient? Does she treat some patients differently? Is the resident neatly groomed? The trainees self-assess and learning goals are determined. We typically assess each resident four times per year. Thus far we have trained 63 faculty members on how to perform these assessments; as of May 1, 2015 we have performed 245 assessments.”
“Residents usually have the weakest scores on making empathetic statements, responding to patient emotions, assessing understanding, and engaging in shared decision making. We have learned over time that residents think that patients don’t understand what they are saying. We attribute this in part to the clinician feeling rushed at the end of the encounter.”
“If we find a resident who has major deficiencies we meet with that person individually and work with them one on one. If we find a deficiency across the residency program then we add that to our curriculum. This is an exciting program that is being received with enthusiasm. We believe that these efforts will ultimately have an impact on patient safety, quality, outcomes, patient experience and the risk of malpractice.”
Dr. Zuckerman notes, “As part of this program Dr. Phillips is evaluating the impact of the program to document the changes that may result. If successful in improving resident performance in these important areas, their goal is to present their data to other orthopaedic programs so the program can be reproduced. Of course, the ultimate benefit would be for the patients.”
Can Stem Cells Treat Knee Arthritis?
When you get down to bone-on-bone, is there anywhere to go but a total knee? Andreas Gomoll, M.D. thinks so. Dr. Gomoll, an orthopedic surgeon with Brigham and Women’s Hospital in Boston, is working with Jack Farr, M.D. of OrthoIndy to evaluate a new treatment for knee osteoarthritis. Dr. Gomoll tells OTW, “In the past, the only things we could offer patients with knee arthritis were corticosteroids and viscosupplementation. But cortisone injections don’t work for very long, and there are many questions about the effectiveness of viscosupplementation.”
“This new treatment involves only one injection of frozen amniotic membrane and amniotic fluid stem cells, both of which have been shown to promote healing with a reduced amount of scar tissue and anti-inflammatory properties.”
“During the delivery of a healthy baby the physician aspirates the amniotic fluid; those get concentrated so there is no manipulation involved. After delivery, the amniotic membrane is cryomilled, so it is made into a powder. When it’s time for use on a knee, the surgeon has two vials, one with stem cell concentrate and one with amniotic membrane.”
“For the pilot study we had six patients with end stage arthritis. They were structurally very bad…bone-on-bone, and were candidates for total knee replacement. The upside was that if something went wrong you could save the situation by doing a total knee replacement.”
“For those six patients we looked at safety and wanted to ensure that nothing unexpected happened (the study was not powered for efficacy). In fact there were no negative reactions or incidents; there was a trend toward improvement in pain level.”
“We are now setting up a multicenter randomized trial to compare stem cells injected with a placebo injection (saline) versus a viscosupplementation injection. Stem cells are being used in breathtaking numbers despite the fact that there is only very limited real data to support their use. People are charging a lot of money for these treatments and we don’t even know if they work. That’s why we felt we should do the right thing and look at this carefully in a controlled trial before making it available for everyone.”
Note: Dr. Gomoll indicates that he and Dr. Farr have a research and royalty agreement with the company manufacturing this product.
Robert L. Mauck, Ph.D. Wins Kappa Delta Young Investigator Award
Robert L. Mauck, Ph.D. is having a good year. An associate professor of orthopaedic surgery at the Perelman School of Medicine at the University of Pennsylvania, Dr. Mauck and his colleagues have just been honored with the 2015 Kappa Delta Young Investigator Award. Dr. Mauck, a researcher at the McKay Orthopaedic Research Laboratory, was one of four scientists given awards by the Kappa Delta Sorority and the Orthopaedic Research and Education Foundation.
Dr. Mauck and his colleagues have received this award because of their research on developing and optimizing nanofibrous scaffolds. He tells OTW, “This review paper catalogued our progress in fiber tissue engineering over the last 10 years. Our work is founded on an appreciation of the organization, structure, and architecture of native tissues such as menisci, tendons, and ligaments…with an emphasis on how important organization is for their proper functioning. Along with Dawn Elliott and Jason Burdick, we developed technologies for the fabrication of polymeric scaffolds that have a particular organization engineered into them so that we could replicate the mechanical features of native tissue.”
“These dense connective tissues are load bearing, and so the design criteria we use to engineer scaffolds are founded on the dynamic load transfer that occurs daily. We know a lot about native tissues and how they age; as they get older they are less cellular so their inherent healing capacity is diminished. The tissue gets denser, stiffer, and less cellular. Many scaffolds are designed to provide structure and function, but these have the capacity to release agents; you can engineer them with degradable components that allow for drug delivery. This means that you can entice cells to migrate to the wound site, and then direct what they do once they are there. It is a great example of how you can start with the fundamental principles of tissue mechanics and use engineering design to recapitulate the basic features and manipulate wound repair.”
“These scaffolds are intended for dense connective tissue repair. As the technology matures we are advancing towards evaluation in pre-clinical models. First, we made a base template; then we figured out how to make it dynamic and tunable—and capable of delivering drugs. The next phase will be testing in an in vivo environment and looking for efficacy and long term improvements in repair.”
“It is particularly exciting that this award captures a lot of contributions from a large, collaborative group. It is an amazing interaction between scientists, engineers, and surgeons that has the potential to change the way we approach dense connective tissue repair.”
The amniotic products do NOT contain stem cells of any significance and therefore your title is incorrect and misleading. The investigators of the study should make to clarify this myth !