We took a short break for the summer but #JHSJC is back! Thank you to everyone who participated in the September #JHSJC. We looked at two excellent articles from Volume 45, Issue 9 of The Journal of Hand Surgery: Telemedicine After Upper Extremity Surgery: A Prospective Study of Program Implementation and Canadian Plastic Surgery Resident Operative Experience in Hand Surgery.
Feel free to continue the conversation below in the comments! And please check out previous #JHSJC transcripts (please scroll to the bottom of the page).
Brent Graham @BgTalkinman:
Welcome to the resumption of monthly #jhsjc! Let’s start with the article on #telemedicine https://www.jhandsurg.org/article/S0363-5023(20)30315-4/fulltext #jhsjc
Brent Graham @BgTalkinman:
This study was planned and implemented well before the #pandemic. It’s a clinic in a #ruralmedicine setting. #jhsjc
Q1 Are the experiences reported in the paper consistent with what most clinicians have experienced during the #pandemic? #jhsjc
Warren @whammert to @BgTalkinman:
this is similar to our findings when forced to move to some telehealth during pandemic #jhsjc
If you choose the right patients, it can be effective. And that is what they did as well. Trying to do this for all didn’t work #jhsjc
Brent Graham @BgTalkinman to @whammert:
Did you have any patients that experienced. both types of visits and could compare? #jhsjc
Warren @whammert to @BgTalkinman:
we started being able to select who could have telehealth visit and I choose as they did – post op, MRI f/u… #jhsjc
Brent Graham @BgTalkinman to @whammert:
What were some of the obstacles you encountered? #jhsjc
Warren @whammert:
When they opened it to anyone who wanted an appt, it was a challenge – we did both phone and video. Video was better #jhsjc
Dr. Ray Raven @RayRavenMD to @JHandSurg:
A1: I have been using #telemedicine for postops since 2016. If there are no sutures to be removed and X-rays are not needed, telemedicine is the most cost-effective and convenient way to track patients after surgery. #JHSJC
Brent Graham @BgTalkinman to @whammert:
so there were no criteria for using this? The #pandemic made this necessary and not necessarily amenable to planning. #jhsjc
Warren @whammert
Post op and straight forward F/U, really no obstacles with patients once we were on – a few missed the link or just there. #jhsjc
Chris Grandizio @ChrisGrandizio to @whammert and @BgTalkinman:
Opening up video visits to new patients has been more challenging than expected even after having done postops #jhsjc
Brent Graham @BgTalkinman to @ChrisGrandizio:
The author has joined us! Feel free to direct questions to him! #jhsjc
Brent Graham @BgTalkinman to @whammert:
Were there many pts who did not have access to technology? #jhsjc
Warren @whammert to @BgTalkinman:
Initially our choice, then became choice of non providers and that was the issue – second opinion WC,… #jhsjc
I was a bit surprised – some I thought would struggle did well and some I thought would do fine did not. #jhsjc
If no access to video, they got telephone appts and that was also a challenge – dorsal volar, middle ring… #jhsjc
Brent Graham @BgTalkinman to @whammert:
@ChrisGrandizio and I discuss the help some pts received from family members in our #podcast https://www.jhandsurg.org/pb-assets/Health%20Advance/journals/yjhsu/September_2020-1598965138603.mp3 #jhsjc
Brent Graham @BgTalkinman:
Q2 What is the potential scope of this strategy especially if the #pandemic continues? #jhsjc
Brent Graham @BgTalkinman:
Q2 The physical exam is a major consideration. Is there a way to experience elements of that via video? #jhsjc
Warren @whammert to @BgTalkinman:
Has potential advantages, especially in more rural areas, but also can be used for global visits if times flexible #jhsjc
Brent Graham @BgTalkinman to @whammert:
Q2 Other than post-op visits what other clinical activities might be possible right now? #jhsjc
Chris Grandizio @ChrisGrandizio to @whammert and @BgTalkinman:
yearly f/u after shoulder/elbow arthroplasty, etc. still have to coordinate the xrays. #JHSJC
Brent Graham @BgTalkinman to @ChrisGrandizio and @whammert:
Radiographs seem very feasible to review. How about ROM, basic sensation? #jhsjc
Brent Graham @BgTalkinman:
Q3 If advanced care nurses can demonstrate a physical exam could this take hold more widely to help underserviced areas? #jhsjc
Warren @whammert to @BgTalkinman and @ChrisGrandizio:
key will be to identify the patient at visit and note if a candidate can understand sensation #jhsjc
Chris Grandizio @ChrisGrandizio to @BgTalkinman and @whammert:
Some good opportunities to study video sensory exams. ROM is reproducible on video. #JHSJC
Dr. Ray Raven @RayRavenMD to @BgTalkinman and @whammert:
Initial eval for many conditions such as trigger finger, CTS, tennis elbow, etc can be effectively screened and started on a treatment regimen #JHSJC
Brent Graham @BgTalkinman to @ChrisGrandizio and @whammert:
I see this as a definite field for growth in the future. #jhsjc
Dr. Ray Raven @RayRavenMD to @BgTalkinman:
Absolutely. And it will save a lot of costs to the system and increase access for patients. #JHSJC
Brent Graham @BgTalkinman:
I will be interested to see what research is done in the post-#pandemic period. #jhsjc
Dr. Ray Raven @RayRavenMD to @BgTalkinman:
I have a feeling a lot of studies will be revealed. #JHSJC
Brent Graham @BgTalkinman:
Let’s move on to the other article on #plasticsurgery #resident education in #hand surgery. #jhsjc
Article #2: Canadian Plastic Surgery Resident Operative Experience in Hand Surgery
https://www.jhandsurg.org/article/S0363-5023(20)30272-0/fulltext
J Hand Surg Am- ASSH @JHandSurg
Let’s move on to the next article: https://www.jhandsurg.org/article/S0363-5023(20)30272-0/fulltext
Brent Graham @BgTalkinman:
Let’s think about Q2 first. Are these findings generalizable? #jhsjc
Warren @whammert to @BgTalkinman:
I think we need to understand differences in each country -US, many plastic programs do not have dedicated hand surgeons #jhsjc
where almost all ortho programs do, but this may be much different in CA #jhsjc
Brent Graham @BgTalkinman to @whammert:
It’s actually the opposite. In Canada most hand surgery is done by #plasticsurgery. #jhsjc
Brent Graham @BgTalkinman to @whammert:
I wonder if that means that US #plasticsurgery #residents are possibly even less prepared? #jhsjc
Warren @whammert to @BgTalkinman:
probably varies – some places well prepared and others not- that is what prompted ASSH PS visiting professor #jhsjc
definition of hand surgery varies as well. #jhsjc
Brent Graham @BgTalkinman to @whammert:
Obviously a positive initiative but very limited in what it can achieve. #jhsjc
Warren @whammert to @BgTalkinman:
yes – hard to implement change based on this, but should increase awareness #jhsjc
Brent Graham @BgTalkinman:
Q3 A previous paper showed that many post-fellowship #SCOSH candidates are not on track to meet the requirements. #jhsjc
Q3 Does this mean that the problems start well before fellowship? #jhsjc
Warren @whammert to @BgTalkinman:
That is different though – based on what happens in practice rather than competency in training #jhsjc
Brent Graham @BgTalkinman to @whammert:
To me this is actually the main problem. Is the bar too high – defining a hand surgeon or a core competency? #jhsjc
Chris Grandizio @ChrisGrandizio to @whammert and @BgTalkinman:
Can be hard to balance in board collection if your practice has a large S&E component #JHSJC
Warren @whammert to @BgTalkinman:
I don’t think so – for CTR – 12 was the avg number I believe -some will need less and some more. #jhsjc
Brent Graham @BgTalkinman:
The study defined 42 core competency procedures in #handsurgery. That seems a much wider scope than my practice ever has been. #jhsjc
Warren @whammert:
Hand surgery is broad – unlike adult reconstruction, so there will be procedure not done, but good technique should get you close #jhsjc
Brent Graham @BgTalkinman to @whammert:
A large prortion did 10 or fewer (some 0) experience with 60% of the top ten most freq #jhsjc
Warren @whammert:
I think defining hand procedure for gen PS or Ortho surg is different than fellowship trained hand surgeon #jhsjc
Brent Graham @BgTalkinman:
A large proportion reported < 10 experiences (some 0) for as many as 6 of the 10 most commonly done procedures. #jhsjc
Joe Rosenbaum, MD @JRHandSurg to @BgTalkinman and @whammert:
As a current second-year hand surgeon looking ahead to #SCOSH case list submission soon, I think 4 of 9 is eminently doable, and 5 of 9 a bit more of a challenge but still realistic, esp if you define a cutaneous abscess as “skin problem”, which isn’t much of a stretch #jhsjc
Brent Graham @BgTalkinman to @whammert:
Agreed. Maybe they don’t even consider #handsurgery if they go through residency with limited experience. #jhsjc
Warren @whammert to @BgTalkinman:
these are general plastic surgeons and not fellowship trained hand surgeons #jhsjc
Brent Graham @BgTalkinman:
If core competency in hand surgery at residency level was CTR, trigg fing, fingertip repair, metacarpal fracture would that be wrong? #jhsjc
Warren @whammert to @BgTalkinman:
I think those are appropriate for ortho and plastic – deQuervains and maybe thumb arthritis #jhsjc
Brent Graham @BgTalkinman:
My point is that defining core competency in had surgery for residents seems unattainable in 2020 training setting #jhsjc
Brent Graham @BgTalkinman to @whammert:
Yes! That is 6 procedures, not 42! #jhsjc
Christopher J. Dy MD MPH FACS @ChrisDyMD to @BgTalkinman:
Sorry to be late to #JHSJC… but what about cubital tunnel surgeries?
Warren @whammert to @ChrisDyMD and @BgTalkinman:
probably 10 or so procedures is realistic and max – need 8 of 10 or something similar #jhsjc
Joe Rosenbaum, MD @JRHandSurg to @BgTalkinman:
Replying I don’t think so. Those interested will seek out more advanced experiences. Those who aren’t, while they might benefit from lessons learned in, say, micro cases or flaps, or tendon transfers, won’t use it in practice. #jhsjc
But yes also CuTR as @ChrisDyMD mentioned #nerve
Brent Graham @BgTalkinman to @ChrisDyMD:
Ok! 7 core competencies then. #jhsjc
Brent Graham @BgTalkinman:
Do most full time hand surgeons do a wider scope than that? CTR, 1st CMC, DRF malunion, deQ would likely be 50% of my cases. #jhsjc
Brent Graham @BgTalkinman to @whammert and @ChrisDyMD:
Agreed CuTS/CTR about the same. There are probably some other highly transferable operative competencies. #jhsjc
Brent Graham @BgTalkinman:
I think this requires some very serious thought by educators to ensure that expectations are realistic for residents in #handsurgery #jhsjc
John Froelich, MD @JOHN_FROELICH to @BgTalkinman:
Where would scaphoid and or distal radius fractures fall under?
Brent Graham @BgTalkinman to @JOHN_FROELICH:
If you are a hand surgeon, they are important; if you are a resident trying to demonstrate basic competency in hand surgery, they aren’t critical skills, IMHO #JHSJC
Hipnknee @Hipnknee2 to @BgTalkinman and @JOHN_FROELICH:
Understand scaphoid fracture surgery being hand surgeon… but surely the majority of distal radius fractures are classed as a core skill???
Brent Graham @BgTalkinman to @Hipnknee2 and @JOHN_FROELICH:
I’m really not sure. Managing a DRF should usually be about non-operative treatment; from that standpoint I would agree. However, operative management is another story. I would not necessarily expect a resident to be able to operate successfully on an intra-articular fracture.
Hipnknee @Hipnknee2 to @BgTalkinman and @JOHN_FROELICH:
We would expect trainees to be able to manage these operatively (with appropriate level of support depending on their competency)
John Froelich, MD @JOHN_FROELICH to @Hipnknee2 and @BgTalkinman:
Agree! Complex hand off, every graduating resident should be familiar with the approach and basic principles of fixation for a distal radius fracture.
Hipnknee @Hipnknee2 to @BgTalkinman and @JOHN_FROELICH:
Absolutely agree regarding the complex/intraarticular ones; these get passed to our hand colleagues. Remainder that require Kwires or plate we all do ourselves as part of general on call
Very General Orthopedist @generalorthomd to @BgTalkinman
and @David_Bui_:
As a rural general ortho (trained in last 10 yrs), I perform CTR, cubital tunnel, trigger, DR, MC, finger fxs, acute extensor tendons, perform and care for amps, maybe some others. I refer thumb UCL, operative scaphoid, thumb CMC arthritis, etc. I think this is a reasonable goal
Brent Graham @BgTalkinman to @generalorthomd and @David_Bui_:
Agreed! And you aren’t expected to do flaps, repair nerves, or do tendon grafts and yet these are considered “core competencies” by a consensus of US and Canadian plastic surgeons.
Chris English @CE_HandSurg to @BgTalkinman:
Malunion 1 per year, deq 1 every 3 month, cmc 1 per month.
Lots of drfx, tendon lacs, peds fx.
Brent Graham @BgTalkinman to @CE_HandSurg:
This shows how practices vary and why a short, basic list of critical skills is important; my profile would be DRF malunion, 20/year, deQ 1/month, CMC 5/month, DRF fx 2/year (gen ortho at my hospital look after that), tendon lac, 1/month, 0 ped
Brent Graham @BgTalkinman:
Thanks to all for your interest! We are back October 13. #jhsjc
J Hand Surg Am- ASSH @JHandSurg:
We appreciate your participation in #JHSJC! Thank you for the great discussions! #OrthoTwitter #MedTwitter #HandSurgery
See you next time!
