#JHSJC

December #JHSJC Transcript

Thank you to everyone who participated in the final #JHSJC of 2020! We finished the year off strong by discussing two articles from Volume 45, Issue 12 of The Journal of Hand SurgeryEstablishing Validity of a Comprehensive Hand Surgical Training and Educational Platform (STEP) and Clinical, Radiological, and Electrodiagnostic Diagnosis of Pronator Syndrome Concurrent With Carpal Tunnel Syndrome.

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 final #jhsjc session for 2020! Let’s start with the lead article on #surgicalsimulation.
The summary on jhsfocus.org/jhsjc gives some background on this work by an ASSH Taskforce on #surgical simulation. #jhsjc
There were 2 parts to this study: creating the tasks and then scoring them in novice and established surgeons. #jhsjc

Lee M Reichel @LeeMReichel1:
I think that just thinking through the skills and using psycho motor skills has a lot of value and if you can do this repetitively these may be valuable learning tool. Tying everything to measure of competency adds necessary pressure to learning in these simulated techn #jhsjc

Warren @whammert:
the scoring on two groups helps establish the validity and need for assessment #jhsjc

Carl Nunziato @CarlNunziato to @BgTalkinman:
Appreciate the work the ASSH Taskforce, found the modules interesting. #jhsjc

Brent Graham @BgTalkinman:
The scoring of the task performance involved timing and substation of its for errors. Is that the most appropriate approach? #jhsjc

Carl Nunziato @CarlNunziato:
I have less interest in their potential use to evaluate and compare surgical skills similar to the FLS. #jhsjc

Brent Graham @BgTalkinman to @CarlNunziato:
Do you mean that they have more value as a teaching strategy? #jhsjc

Warren @whammert to @BgTalkinman:
You would expect timing to be different. While far from the most important factor, I didn’t have a problem as a metric #jhsjc

Brent Graham @BgTalkinman to @whammert:
What do you think of the approach of timing the tasks and subtracting pots for technical mistakes? Is that a good approach? #jhsjc
That was how it was done in gen surg where time may be important to outcome. Not sure that is true in hand surgery. #jhsjc

Warren @whammert to @BgTalkinman:
I don’t know if the best approach for teaching, but approaches a video game approach which can be fun #jhsjc
while different than Gen Sure, efficiency in any specialty procedure is important. #jhsjc

Brent Graham @BgTalkinman to @whammert:
True! I’m showing my age! #jhsjc

Daniel A. London, MD MS @LondonDA:
Being able to establish discriminatory value between the level of trainees is the next step IMO. Attending to intern is a wide gap! #jhsjc

Brent Graham @BgTalkinman to @LondonDA:
That is true but I think they wanted to take the most basic contrast to prove differences could be shown. #jhsjc

Warren @whammert to @BgTalkinman and @CarlNunziato:
by validity, I meant a skill that can be learned and metric for progress in training #jhsjc

Brent Graham @BgTalkinman to @whammert and @CarlNunziato:
Agreed! #jhsjc

Warren @whammert to @BgTalkinman:
and in US, some surgeons still use more than WALANT and surely center or hospital OR cases:) #jhsjc

Warren @whammert to @BgTalkinman and @LondonDA:
I liked that approach as proof of concept #jhsjc

Daniel A. London, MD MS @LondonDA to @whammert and @BgTalkinman:
Agree 100% There’s was the right contrast to start with. For the between trainee level contrast, time spent may play a more important role. #JHSJC

Brent Graham @BgTalkinman:
Let’s talk about the tasks. The focus was clearly on feasibility and limiting cost but is that really appropriate? #jhsjc
Cost notwithstanding is it worth money to make more sophisticated models involving haptic feedback etc? #jhsjc
It is understood that that makes the #simulation harder and more expensive but these are pretty important physical skills. #jhsjc

Lars Matkin @LarsMatkin:
Agreed that the intern to attending comparison seems rather broad. Would be interesting to see across PGY levels and fellows as some of the skills tested are likely concepts interns have not learned or had any experience with. #JHSJC

Brent Graham @BgTalkinman to @LarsMatkin:
Right! I think that is the logical next step if this can be adopted widely. #jhsjc

Carl Nunziato @CarlNunziato to @BgTalkinman:
We run a summer camp for kids interested in healthcare. these would be great for that venue where cost matters #jhsjc

Brent Graham @BgTalkinman to @CarlNunziato:
Very interesting! These tasks would be great for that. Is it right for people actually training to operate on humans? #jhsjc

Avi Giladi @theaviram to @BgTalkinman and @CarlNunziato:
very cool summer camp idea. just give them the very basic experience. hook them early! #jhsjc

Avi Giladi @theaviram to @BgTalkinman:
depends on whether using the models improves intern skill in the OR. the true value/appropriateness is hard to gauge based on this manuscript. But low cost/easy is certainly a nice place to start #jhsjc

Warren @whammert to @BgTalkinman:
so the goal was to make something that essentially all programs can afford and I think that is the starting point. #jhsjc

Brent Graham @BgTalkinman to @whammert:
Will this…can this be implemented widely? #jhsjc

Warren @whammert to @BgTalkinman:
can it – yes, but will it remains to be seen. My guess is not universally #jhsjc

Warren @whammert to @BgTalkinman:
If there is a great model that is not purchased due to the cost, does it really help? #jhsjc

Brent Graham @BgTalkinman:
If it is implemented in even a few teaching programs, how should it be evaluated? #jhsjc

Daniel A. London, MD MS @LondonDA to @theaviram and @BgTalkinman:
And then the question is how do you assess that skill improvement in the actual OR. This is the $64,000 question for all simulation, whether low fidelity, high fidelity, or VR. #jhsjc

Lars Matkin @LarsMatkin:
I remember doing a very similar series of tasks while interviewing for residency at a certain program. Not sure how effective it was to differentiate candidates at that stage in training but another place that may be applicable. #jhsjc

Brent Graham @BgTalkinman to @LarsMatkin:
Do you mean they tested your technical skills as an interviewing element? #jhsjc

Brent Graham @BgTalkinman to @whammert:
I agree but maybe this is what teaching is in 2020, especially if learning in the OR will not be practical. #jhsjc

Warren @whammert to @BgTalkinman:
repeat each year – there should be progress between years – competency based progression #jhsjc

Brent Graham @BgTalkinman to @whammert:
Competency-based training — another important discussion! #jhsjc

Avi Giladi @theaviram to @whammert:
can also link to case volume for the specific procedure (some PGY3 will have done more fixation vs. more scope etc) #jhsjc

Nina Suh @NinaSuh9:
I would agree competency based progression would be most reasonable #jhsjc

Warren @whammert to @BgTalkinman:
this is not unique to hand – sports has arthroscopy simulators- a good way to prepare so OR time for advanced #jhsjc

Daniel A. London, MD MS @LondonDA to @whammert:
With a likely need for comparison to one’s previous attempts, one’s peers, and the historical norms for that training program for the trainee’s level. @BgTalkinman #jhsjc

Warren @whammert to @BgTalkinman:
Canada well ahead of US in this respect and not sure we will ever have true competency based progression #jhsjc

Brent Graham @BgTalkinman to @whammert:
my impression is that it hasn’t been as successful as hoped here in Canada. #jhsjc

Lars Matkin @LarsMatkin to @BgTalkinman:
Yes, There was an arthroscopy section, plunge test, interfrag screw and knot tying if I remember correctly. #jhsjc

Brent Graham @BgTalkinman to @theaviram and @whammert:
we have had a few papers on trainee exposure to various procedures- very institution-specific #jhsjc

RyanC @RPCalfeeSTL:
competency based progression would be great but challenging with current trainee expectations #jhsjc

Daniel A. London, MD MS @LondonDA to @BgTalkinman and @whammert:
What have the challenges/disappointments been? #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL:
On of the problems here has been that surgeons don’t want to be saddled with trainees slow to achieve the competencies #jhsjc

Brent Graham @BgTalkinman to @LondonDA and @whammert:
If someone can’t progress its hard to know what to do with them. Remediation? #jhsjc

Warren @whammert to @RPCalfeeSTL:
not to mention fed gov’t funding in US #jhsjc

RyanC @RPCalfeeSTL:
hard to hold back people but I would also think hard logistically to advance quicker in current environment #jhsjc

Daniel A. London, MD MS @LondonDA to @RPCalfeeSTL:
Thinking through the current structure with PGY determined rotations that are not always repeated every year this could be a logistical nightmare. Plus there’s the fellowship application process, too. #jhsjc

Brent Graham @BgTalkinman to @whammert and @RPCalfeeSTL:
There have even been threats to institutions that don’t move trainees forward. It’s a quagmire. #jhsjc

Warren @whammert to @BgTalkinman and @RPCalfeeSTL:
well that undermines the concept. #jhsjc

Brent Graham @BgTalkinman to @whammert and @RPCalfeeSTL:
Exactly! #jhsjc

Brent Graham @BgTalkinman:
Let’s move on to the paper #pronatorsyndrome. #jhsjc
This was a paper from Turkey #jhsjc
There were methodologic challenges with this study but it’s good as could be expected for a condition some people even doubt exists #jhsjc

Warren @whammert to @BgTalkinman:
Interesting diagnosis – I thought US would have been more accurate #jhsjc

Lars Matkin @LarsMatkin:
did the rate of pronator syndrome seem rather high by exam? #jhsjc

Brent Graham @BgTalkinman to @LarsMatkin:
My take on that is that this is high prevalence sample — all had median nv problems attributed in part to #CTS. #jhsjc

Brent Graham @BgTalkinman:
Personally I believe that the condition is real but I’ve always relied on a clinical eval only. I think that is what the study shows #jhsjc

Carl Nunziato @CarlNunziato to @BgTalkingman:
Seems like the conclusion should have been “clinical diagnosis doesn’t correlate with advanced studies” #jhsjc
rather than “advance studies have low sensitivity”. Outcome data following treatment based on EDX/US/MRI etc would have been nice #jhsjc

Brent Graham @BgTalkinman to @CarlNunziato:
How about “advanced studies don’t improve on clinical evaluation”? #jhsjc
This gets down to the old conundrum of what should be the reference standard. Lots of discussion on that in #CTS #jhsjc

RyanC @RPCalfeeSTL:
pronation syndrome may have seen me but I have only seen it a couple times in the last decade #jhsjc

Brent Graham @BgTalkinman to @RPCalfeeSTL:
That would be true for me too. #jhsjc

Warren @whammert to @BgTalkinman:
since David is not here, how do you know tx is better than placebo with no objective confirmatory test #jhsjc

Brent Graham @BgTalkinman to @whammert:
It’s a question for sure – but not necessarily so different than for #CTS. #jhsjc

Carl Nunziato @CarlNunziato to @BgTalkinman:
but what if they do improve on clinical evaluation? they assume 100% specificity for their clinical exam #jhsjc

Brent Graham @BgTalkinman:
Was the constellation of clinical findings, hx/px, a reasonable reference standard? #jhsjc

Charles Carroll IV, MD, FAAOS @CCarrollmd:
i would agree #jhsjc

Brent Graham @BgTalkinman to @CCarrollmd:
Charles!! Wonderful to see you here! #jhsjc

Brent Graham @BgTalkinman:
That is the key consideration here. If it is, then the findings of poor performance of the various tests has practical importance. #jhsjc
For this of you who see #pronatorsyndrome as a clinical condition, how is it diagnosed? #jhsjc
Is it justified to put patients through the discomfort, time spent and cost of EDX if they are positive in less than ¼ of cases? #jhsjc

David Ring @DrDavidRing:
Doctor: I know what’s wrong, let’s do surgery. Patient: How can you be so sure when all the tests are normal? #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Right – like in #CTS. What is your response to that person? #jhsjc
In my world all of these diagnoses are probabilistic propositions. #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
For #CTS when all the tests are normal-at worst-very mild disease. So surgery is out of the question. #jhsjc

Dr. ORTHOCARE @superguy60:
I have seen 4 cases . 3 out the 4 had weakness of the FPL and FDP index which helped me confirm the diagnosis #JHSJC

Brent Graham @BgTalkinman to @superguy60:
That would be the main clinical setting in which I would make that dx; not sure any tests would help more. #jhsjc

Warren @whammert to @BgTalkinman and @superguy60:
For me, changes in nerve diameter n ultrasound would make me feel better than just weakness #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Isn’t it possible that mild disease is troubling for some patients – enough to merit intervention? #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Medicine is mostly probabilistic. And comfort with uncertainty is a key to good health. Also good care. #jhsjc
When mild disease is troubling, be careful not to miss the mental and social health opportunities. #jhsjc
gph.is/1VtFUZX #jhsjc

David Ring @DrDavidRing to @BgTalkinman:
Patient: You’re my only hope. I know you can fix it. Surgeon: Um, well, yes. Of course I can fix it. #jhsjc

Brent Graham @BgTalkinman to @DrDavidRing:
Shouldn’t we try and help then? #jhsjc

Brent Graham @BgTalkinman to @whammert and @superguy60:
They report the sensitivity of US is only 57% suggesting that many with the condition might not be diagnosed #jhsjc

Charles Carroll IV, MD, FAAOS @CCarrollmd:
The question is the severity if the symptoms and the relation to autonomy and benificence? #jhsjc

Brent Graham @BgTalkinman to @CCarrollmd:
Maybe Im naive but I guess if I think I can help and the risk of me making the situation worse is small I feel justified. #jhsjc

Dr. ORTHOCARE @superguy60:
Of Course I can fix it. Now trying to convince WC it needs to be fixed is another story. It took me 6 months to convince them because all studies were negative on my patient #JHSJC

Charles Carroll IV, MD, FAAOS @CCarrollmd:
I agree with DR o mental and social issues as well #jhsjc
BG, I understand your thoughts though #jhsjc

Brent Graham @BgTalkinman to @CCarrollmd:
Definitely, but there are people with physical problems that are well addressed by surgical treatment. Let’s be holistic! #jhsjc

Carl Nunziato @CarlNunziato to @BgTalkinman and @DrDavidRing:
As a resident reading these: https://twitter.com/i/status/1336505707689103367 #jhsjc

Charles Carroll IV, MD, FAAOS @CCarrollmd:
No issue from here on that comment #jhsjc

Brent Graham @BgTalkinman to @CarlNunziato:
🙂 #jhsjc

Nina Suh @NinaSuh9 to @CarlNunziato:
Very true! Haha #jhsjc

Brent Graham @BgTalkinman:
As usual, thought-provoking, mode-ranging discussion! Thanks to all!! #jhsjc

Nina Suh @NinaSuh9:
I still have to develop comfort with uncertainty so I appreciate this thread! #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @BgTalkinman:
Sorry late to the game! I think it’s all clinical diagnosis. #jhsjc

Brent Graham @BgTalkinman to @ChrisDyMD:
That would be my point of view and I think that isnt what the study showed. Not sure what then group thought. #jhsjc

David Ring @DrDavidRing to @ChrisDyMD and @BgTalkinman:
When I see “clinical diagnosis” it feels to me like: “i’m the surgeon, I can do whatever I want” #jhsjc
Science be damned. #jhsjc

Charles Carroll IV, MD, FAAOS @CCarrollmd:
Not so…Hx, PE, Studies and judgement with autonomy and benificence. #jhsjc

Christopher J. Dy MD MPH FACS @ChrisDyMD to @BgTalkinman:
The clinical exam is more nuanced than what is typically used … but easy to fall into overdiagnosis and potential over-treatment surgically. Have tried to find the right balance. Agree w article that edx and US not reliable for this entity. #JHSJC

Teemu Karjalainen @TeemuVKarjalain to @BgTalkinman:
The #jhsjc idea is absolutely fantastic. However, timing seems to an issue for Europeans. Optimally the discussion should go on for a few days. But Twitter doesn’t link the comments under the same thread so impossible to follow with smart phone.

Brent Graham @BgTalkinman to @TeemuVKarjalain:
Does Twitter not link the discussion via the jhsjc hashtag #JHSJC?

Brent Graham @BgTalkinman to @CCarrollmd:
Thank you for participating Charles! #jhsjc

Charles Carroll IV, MD, FAAOS @CCarrollmd:
BG…any time. Lets work to expand…c #jhsjc
Happy Holidays etc. to all #jhsjc

Brent Graham @BgTalkinman:
I wish all of you a happy and safe holiday and hope for a better 2021. We will back here Jan 12. #jhsjc

Charles Carroll IV, MD, FAAOS @CCarrollmd:
All lets work in 2021 to improve this platform and discussion. Pronator syndrome and CTS are tough topics. On to 2021. #jhsjc

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