Ten Years at JBJS: Lessons Learned

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Grand Rounds by Dr James Heckman at the Massachusetts General Hospital.
April 15, 2010

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Ten Years at JBJS: Lessons Learned

  1. 1. Ten Years At JBJS: Lessons Learned James Heckman, MD Grand Rounds presented on April 15 th , 2010 Massachusetts General Hospital, Boston, MA
  2. 2. I. TheOrthopaedic Information Base Is Weak
  3. 3. Orthopaedic Information <ul><li>Predominantly Level 4 and 5 evidence drives clinical decision making </li></ul>
  4. 6. Pelvic Inlet and Outlet Radiographs <ul><li>Classically obtained as orthogonal views 45 degrees cephalad and caudad from AP, or some other random angle </li></ul><ul><li>Basis: A movie made by Pennal in 1981 </li></ul><ul><li>JBJS Ms. 09-01580:Ricci et al: </li></ul><ul><li>Used pelvic CT scan reconstructions to show: </li></ul>
  5. 7. Pelvic Inlet and Outlet Radiographs <ul><li>To most accurately profile the clinically relevant posterior bony pelvic anatomy, screening inlet and screening outlet radiographs taken at 25 degrees and 60 degrees, respectively, are recommended. </li></ul>
  6. 8. REASONS <ul><li>Limited number of high level studies </li></ul><ul><li>Level 1 studies may not be able to address all important questions ( example: fatal pulmonary embolism) </li></ul><ul><li>We have been slow to adopt the concept of registries </li></ul><ul><li>Academic programs have emphasized clinical productivity over research </li></ul>
  7. 9. REASONS <ul><li>We have very few clinician-scientists </li></ul><ul><li>The Department of Justice rulings have restricted clinical research </li></ul><ul><li>Conflict of interest concerns </li></ul>
  8. 10. SOLUTIONS <ul><li>Orthopaedic leadership needs to promote research </li></ul><ul><li>We need to develop more clinician- scientists </li></ul><ul><li>The important questions need to be defined to focus research in productive areas </li></ul>
  9. 11. “ Prioritizing Perioperative Quality Improvement in Orthopaedic Surgery” by Schilling et al University of Michigan JBJS, August 2010
  10. 12. Schilling et al JBJS August 2010 <ul><li>ACS database on hospital adverse events </li></ul><ul><li>10 procedures accounted for 70% of adverse events and 65% of excess hospital days. </li></ul>
  11. 13. Top 10 <ul><li>Hip Fracture Repair </li></ul><ul><li>TKA </li></ul><ul><li>THA </li></ul><ul><li>Revision THA </li></ul><ul><li>Knee arthroscopy </li></ul><ul><li>Laminectomy </li></ul><ul><li>Spine fusion </li></ul><ul><li>Femur fracture </li></ul><ul><li>Revision TKA </li></ul><ul><li>Ankle Fracture </li></ul>
  12. 14. Schilling et al JBJS August 2010 <ul><li>ACS database on hospital adverse events </li></ul><ul><li>10 procedures accounted for 70% of adverse events and 65% of excess hospital days </li></ul><ul><li>No other procedure accounted for more than 2% of all adverse events </li></ul><ul><li>Clinical research should focus on these areas </li></ul>
  13. 15. SOLUTIONS <ul><li>Orthopaedic leadership needs to promote research </li></ul><ul><li>We need to develop more clinician- scientists </li></ul><ul><li>Define the important questions to focus research in productive areas </li></ul><ul><li>Support OREF </li></ul><ul><li>Do good research!!! </li></ul>
  14. 16. II. Everyone Can Do First Class Research <ul><li>You do not need to be at the great university </li></ul>
  15. 19. II. Everyone Can Do First Class Research <ul><li>You do not need to be at the great university </li></ul><ul><li>You just need a plan ! </li></ul>
  16. 20. CRITICAL STEPS <ul><li>Pick a good topic with adequate numbers </li></ul><ul><li>Collect data prospectively </li></ul><ul><li>Have a consistent treatment approach: don’t change with the wind or because the sales rep says you must </li></ul><ul><li>Write as you go along </li></ul><ul><li>Stick to your plan; orthopaedic practice really changes very slowly </li></ul>
  17. 21. POTENTIAL RESULTS <ul><li>650 new orthopaedic surgeons annually </li></ul><ul><li>If 10% follow this suggestion, in 10 years we will begin to generate 65 new studies annually </li></ul>
  18. 22. III. Peer review is flawed, subjective, biased, and not always fair or accurate,but…..
  19. 23. … ..but, just like democracy, it beats the heck out of any other system we have explored.
  20. 25. For peer review to work effectively <ul><li>Reviewers must be educated about the process </li></ul><ul><li>There must be an appeal process in place </li></ul><ul><li>Conflict of interest must be managed </li></ul><ul><li>There must be a reasonable alternative for rejected manuscripts </li></ul>
  21. 26. IV. If you want to keep a secret from an orthopaedic surgeon, put it in writing!
  22. 28. Friday July 22, 2005 Cape Cod
  23. 29. STOP THE PRESSES !!!
  24. 31. Recent Cases <ul><li>Research Misconduct </li></ul><ul><li>Fraud </li></ul>
  25. 38. “ Tattered Threads” by S. Shafer MD <ul><li>“ ..many threads of evidence give beauty, elegance, and intellectual strength to the interwoven tapestry of human understanding.” </li></ul><ul><li>“ A thread has been ripped out of that tapestry” </li></ul><ul><li>“ The fabric of our understanding of perioperative analgesia has been badly damaged.” </li></ul>
  26. 41. Plagiarism <ul><li>Reporting the work (published and unpublished) of others as your own </li></ul>
  27. 42. Recap • CrossCheck is not just a plagiarism detection tool, but rather a multi-pronged initiative to make plagiarism screening feasible and effective for the broader academic publishing community
  28. 43. TEXT
  29. 44. ILLUSTRATIONS
  30. 46. RECENT SUBMISSION <ul><li>Review article “Total Elbow Arthroplasty” submitted for consideration as a Current Concepts Review </li></ul><ul><li>94% exact match with “Total Elbow Arthroplasty: Current Concepts” by Stephen D Trigg MD The Northeast Florida Medical Journal 57(3): 3-40, 2006 </li></ul>
  31. 48. Corrective Action <ul><li>“ Stop the presses” </li></ul><ul><li>Letter to the Editor from the author </li></ul>
  32. 49. Corrective Action <ul><li>“ Stop the presses” </li></ul><ul><li>Letter to the Editor from the author </li></ul><ul><li>Retraction of a published article </li></ul>
  33. 50. Corrective Action <ul><li>“ Stop the presses” </li></ul><ul><li>Letter to the Editor from the author </li></ul><ul><li>Retraction of a published article </li></ul><ul><li>Institutional action as it sees fit </li></ul>
  34. 52. PREVENTION <ul><li>Spread the word </li></ul><ul><li>Advise/educate authors better </li></ul>
  35. 54. PREVENTION <ul><li>Spread the word </li></ul><ul><li>Advise/educate authors better </li></ul><ul><li>Mentoring </li></ul><ul><li>Those journals (“official journals”) requiring </li></ul><ul><li>submission should exercise greater caution </li></ul><ul><li>Punish the offenders: 1)Journal sanctions </li></ul><ul><li>2)AAOS Standards of Professionalism(SOPs) </li></ul>
  36. 55. AAOS SOPs: Research and Academic Responsibilities, Mandatory Standards <ul><li>“ An orthopaedic surgeon shall report those who engage in fraudulent or deceptive research to the appropriate authorities” </li></ul><ul><li>“ An orthopaedic surgeon shall disclose the existence of duplicate articles, manuscripts or other materials that report his or her scientific or clinical research” </li></ul>
  37. 56. AAOS Professional Compliance Program <ul><li>“ ..set minimal levels of acceptable conduct for all fellows and members…” </li></ul><ul><li>“ Alleged violations of the SOPs may serve as the basis for a formal grievance to AAOS.” </li></ul><ul><li>“ If a grievance is upheld, the AAOS Board of Directors may censure, suspend or expell a member…” </li></ul><ul><li>AAOS Bulletin Feb,2006 </li></ul>
  38. 58. VI Orthopaedic Manufacturers Are NOT Evil <ul><li>Recent events such as the DoJ investigations have spotlighted a problem </li></ul><ul><li>There were some individuals who took advantage of the situation to their financial benefit </li></ul><ul><li>Conflict of interest concerns have been appropriately highlighted </li></ul>
  39. 59. Orthopaedic Industry <ul><li>We (our patients) need them and they need us </li></ul><ul><li>Incredible advances have occurred over the past 4 decades as a result of collaborations between industry and surgeons </li></ul><ul><li>The surgeon/inventor is a unique animal which must be protected, nourished and encouraged </li></ul>
  40. 60. Orthopaedic Industry <ul><li>Conflicts of Interest must be clearly defined and managed in a completely transparent manner. </li></ul>
  41. 61. VII. There remain many orthopaedic Luddites <ul><li>Recent AAOS survey: 37% of active AAOS Fellows never access JBJS online despite the fact that it costs nothing to do so </li></ul><ul><li>Conclusion: The print version will be around at least a while longer </li></ul>
  42. 62. VIII. 10 Years is Enough <ul><li>If you can’t succeed in 10 years at something, you probably cannot succeed. </li></ul><ul><li>After 10 years, one becomes tired, cynical, and comfortable with “the way we do it”. (Example:Bowden;Exception: Paterno) </li></ul><ul><li>All activities are revitalized by new people with new ideas. </li></ul>
  43. 64. “ Its Good to be the King.” <ul><li>Mel Brooks </li></ul>
  44. 66. Change is Good for the Soul <ul><li>Reinvigorating </li></ul><ul><li>Use transportable skills </li></ul><ul><li>Go out on top </li></ul>
  45. 67. Thanks to MGH <ul><li>Clinical experience has kept me in touch </li></ul><ul><li>Journal Club has kept me on my toes </li></ul><ul><li>The relationship with the Brigham has kept me confused </li></ul><ul><li>The residents have encouraged me about the bright future of orthopaedics </li></ul><ul><li>The many friendships have made it all worthwhile </li></ul>

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