For this month’s Twitter-based debate, we looked at “Perception of the Virtual Interview Format in Hand Surgery Fellowship Applicants” (https://www.jhandsurg.org/article/S0363-5023(22)00306-9/fulltext) and “The Impact of Smoking on Delayed Osseous Union After Arthrodesis Procedures in the Hand and Wrist” (https://www.jhandsurg.org/article/S0363-5023(22)00305-7/fulltext). It was an exciting discussion and we thank all of our participants! We hope you’ll plan on joining us next month. To do so, you can find the instructions for using the TwChat platform here.
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).
J Hand Surg Am- ASSH @JHandSurg:
February’s #JHSJC is happening now! Let’s get the discussion going. #HandSurgery #education #fellowships #arthrodesis #smoking #hand #wrist #outcomes
Brent Graham @BgTalkinman:
Welcome to the Feb edition of our journal club! Let’s start with article #1: perceptions of the #virtualinterview format https://www.jhandsurg.org/article/S0363-5023(22)00306-9/fulltext #jhsjc
Warren @whammert:
I think applicants might tell you what they think you want to hear #jhsjc
Brent Graham @BgTalkinman to @whammert:
That may be true. How does that relate to the findings of this study? #jhsjc
Brent Graham @BgTalkinman:
Here is the interview I did with the lead author Dr. Melanie Major: https://t.co/tByCcuJuGg #jhsjc
RyanC @RPCalfeeSTL:
I suspect some very different opinions depending on applicant and also mixed opinions on interview format based on what fellowship is asked #jhsjc
Brent Graham @BgTalkinman:
During the pandemic many fellowship programs relied on a virtual interview format to select their fellows in the 2020-2021 academic year. The authors used a survey to explore the insights and perceptions of applicants to their program on the virtual interview. #jhsjc
Although over 94% of the respondents preferred the in-person interview before having a virtual interview, 80% recommended the virtual interview after engaging in one. #jhsjc
Warren @whammert:
I am not sure virtual interviews are the answer – and less then 50% recommended, yet that was the conclusion #jhsjc
Brent Graham @BgTalkinman to @whammert:
I think it was 80% who recommended the virtual interview format. #jhsjc
Warren @whammert to @BgTalkinman:
Conclusion was 47% preferred virtual interviews after the cycle #jhsjc
RyanC @RPCalfeeSTL to @whammert and @BigTalkinman:
I do think some positives with virtual format seemed to be lack of travel expense and less time away from rotations #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
The average number of programs applied to was over 40 suggesting that travel expenses might be otherwise an impediment to widely applying. #jhsjc
Brent Graham @BgTalkinman to @whammert:
The conclusion in the abstract states: “Nearly 80% of survey respondents recommended virtual interviews in the future.” #jhsjc
Warren @whammert to @BgTalkinman:
yes, but while 94% preferred in person before, 47% preferred virtual after. So preferred may be different than recommended #jhsjc
Brent Graham @BgTalkinman:
Is the avg number of applications, 40, a result of the conditions of the pandemic time limiting travel and encouraging virtual interviews? Is the large number of applications good for applicants and for programs? Is that likely to affect some programs more than others? #jhsjc
Warren @whammert to @RPCalfeeSTL:
I agree there are advantages- less cost, time away, more opportunities to interview, but this may also allow the top applicants to take interviews at programs they are not really interested in as there is not much they have to commit #jhsjc
Brent Graham @BgTalkinman to @whammert:
OK -let me ask this then: One possibility for the future seems likely to be a hybrid approach in which some applicants are interviewed in-person and others in a virtual interview. What are the risks with respect to bias in terms of who is selected? #jhsjc
Chris Grandizio @ChrisGrandizio:
I am not sure the application numbers would change, but I’d be curious to see what impact signaling (currently for residency match) would have on this if it were adopted for hand fellowship applications. #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
The hybrid setup seems like the worst option. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
I agree, but doesn’t that seem like a possibility? #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
anything is possible, but hybrid seems likely to favor in person for countless reasons, essentially disadvantaging the already disadvantaged (financially, travel ability, etc etc) #jhsjc
Brent Graham @BgTalkinman to @theaviram:
Of course! I understand – that’s why I ask. If there us a preference on the part of applicants for the virtual interview how should programs approach that – to avoid bias? #jhsjc
Warren @whammert to @BgTalkinman:
I think the hybrid approach would have to be each institution can decide, but each institution should be all virtual or all in person – to hard to remove the bias for in person if a program offers both #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
I worry about bias in hybrid approach largely in favor of in person applicants. I like thought by @ChrisGrandizio about signaling as that is limited and helpful for residency applicants #jhsjc
Avi Giladi @theaviram to @RPCalfeeSTL:
benefit of signaling seems to be related to how many “signals” you can have. It’s a nice concept but I am not sure it actually makes the process any better #jhsjc
RyanC @RPCalfeeSTL to @theaviram:
with limited number of “signals” then at least you know top places of interest. Agree if not limited then doesn’t help #jhsjc
Avi Giladi @theaviram to @RPCalfeeSTL:
yeah i get the concept, but the value will be dictated by how many signals each applicant is allowed to have #jhsjc
Brent Graham @BgTalkinman to @ChrisGrandizio:
What do you mean specifically by “signalling” – is that signalling interest? #jhsjc
Chris Grandizio @ChrisGrandizio to @BgTalkinmam:
Yes- similar to what was done this year for residency match. Applicants can “signal” interest to a pre-specified number of programs. Agree this would depend on number of signals. #jhsjc
Brent Graham @BgTalkinman:
If high prestige programs for example go in-person only, doesn’t that introduce bias against the less advantaged applicant? #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
I think all should be in person or virtual. program splitting is problematic. although ultimately if someone cant interview without a virtual option I guess that’s exclusionary too. no good solution for everyone #jhsjc
Warren @whammert to @BgTalkinman:
We are basing the preference on a small sample size of residents that applied to one program – is this generalizable to all residents applying? #jhsjc
Brent Graham @BgTalkinman to @whammert:
I don’t know – nobody does – but it certainly raises questions about how programs should use this information. #jhsjc
Avi Giladi @theaviram to @whammert:
and only the 30% of them that chose to reply… #jhsjc
Warren @whammert to @theaviram:
Yes- and while that may be acceptable for a survey, it is still a small size and not convinced this preference is generalizable to all applicants. #jhsjc
Brent Graham @BgTalkinman to @whammert and @theaviram:
These are the same response rates for every survey – which is why we don’t publish many – however, I am inclined that they are more likely than not representative and I think it raises questions about what programs should do. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
This is exactly the conundrum I see this data presenting. What is the policy for your program – in the same city as the one in which the investigation was carried out? #jhsjc
Brent Graham @BgTalkinman:
What is the policy for your program? #jhsjc
Warren @whammert to @BgTalkinman:
There has obviously been a lot of discussion at multiple places. Fortunately most applicants will get a position #jhsjc
Brent Graham @BgTalkinman to @whammert:
I know that – there are more spots than ever before – but they are not all considered equal. #jhsjc
Warren @whammert to @BgTalkinman:
Hard to define equal – each program has its own personality, but ACGME has standards and all are accredited. So should provide adequate training #jhsjc
Chris Grandizio @ChrisGrandizio:
Outside the scope of this study…but I do wonder if future changes will be driven by applicant responses or program faculty preferences / responses to a similar survey. #jhsjc
Warren @whammert @BgTalkinman:
We are doing in person this year and each applicant indicated they were appreciative to be able to see the program in person and happy to have in person interviews this year. But I think they will tell you what they think you want to hear #jhsjc
Brent Graham @BgTalkinman to @whammert:
That’s consistent with what the study identified as the downsides with the virtual interview but I wonder how that weighs against the downsides of cost and being away. I will guess that applicants won’t apply to an avg of 40 programs. #jhsjc
Warren @whammert to @BgTalkinman:
I think they can still apply, but can not take as many interviews, so have to choose the places they really want to go – essentially the in person equivalent of the “signal” #jhsjc
Avi Giladi @theaviram to @whammert:
completely agree! #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
We decided to only do in person this year. faculty had a long discussion about it, we all agreed hybrid was the worst option, and many preferred in person so that’s what won out. #jhsjc
Brent Graham @BgTalkinman:
Let’s move on to the other study on the association between smoking and union of upper extremity arthrodeses. It looks like senior author @ChrisGrandizio is here. https://jhandsurg.org/article/S0363-5023(22)00305-7/fulltext #jhsjc
The authors conducted a retrospective study of all cases of arthrodesis involving joints of the hand at their institution between the years 2006 and 2020 seeking to evaluate the influence of smoking on rates of delayed union and non-union. #jhsjc
The study included 309 patients of whom 24% were active smokers. The probability of delayed union in smokers was approximately twice as high as that in smokers (27% vs 14%). The rate on non-union in smokers was more than double that of non-smokers (15% vs 6%). #jhsjc
The authors conclude that smoking is an important variable and that patients should be advised to stop smoking in the peri-operative period. #jhsjc
Warren @whammert to @BgTalkinman:
Results were as expected- higher incidence of delayed union and nonunion #jhsjc
A limitation is the inability to quantify amount of smoking based in limitations of records #jhsjc
RyanC @RPCalfeeSTL to @whammert:
agree. Often studies limited by that lack of specific data on amount of smoking #jhsjc
Brent Graham @BgTalkinman:
This study used the presence of crossing trabeculae on at least 2 views of plain radiographs as a definition for union and assumed that there was delayed union if that had not been observed within 90 days of the intervention. Is that an appropriate definition? #jhsjc
The sample included all types of arthrodeses from the DIP joint to the radiocarpal joint and a wide range of implants. How likely is it that the rate of complications are specific to a given joint and the effect of smoking varies depending on the site of the arthrodesis? #jhsjc
Are the effects of smoking likely to be a modifiable variable? How long would it be expected that a person would have to stop smoking to lower the risk to that of a non-smoker? This is a key consideration if a surgeon is contemplating delaying surgery because of smoking. #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
I don’t know for sure about varied risk of nonunion by site but would think that the effect of smoking could certainly vary #jhsjc
Chris Grandizio @ChrisGrandizio:
I would agree the effect is likely similar but this probably would matter less for the DIP where radiographic delayed or nonunion can be asymptomatic. #jhsjc
Brent Graham @BgTalkinman to @ChrisGrandizio:
That’s what I’m getting at because some joints are harder to achieve fusion in than are others. I wonder if the effect of smoking is greater, the same or less for those. #jhsjc
Chris Grandizio @ChrisGrandizio to @BgTalkinman:
That is a great question. It seems like smoking decrease rates of Union for a variety of bones but the timing of cessation has not been well studied for decreasing risk #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
it’s likely modifiable, also likely not just the smoking that’s the problem. Smoking is bad, no doubt, but we have a very poor handle on how much/how often is truly bad, how to fix it, and what else it impacts. #jhsjc
Brent Graham @BgTalkinman to @theaviram:
I agree with you – it may also be a surrogate for other negative factors, things like alcohol use etc. #jhsjc
Brent Graham @BgTalkinman:
If we accept that it is modifiable, do any of you require proof that a person has quit smoking before doing this kind of surgery? If so, how long? I will start – I have never considered it other than to tell patients it could cause problems. #jhsjc
Jane McEachan jmceachan to @BgTalkinman:
I’m with you! Warn of the risks – I do however, give a strong recommendation to stop in scaphoid nonunion surgery. Or indeed any nonunion surgery. Not sure any Fifer has ever stopped on my recommendation, but second golden rule is never punish the patient.
RyanC RPCalfeeSTL to @BgTalkinman:
I have only required proof for revision surgeries for nonunions and some large fusions if I’m very worried about overall healing potential #jhsjc
Chris Grandizio @ChrisGrandizio:
I discuss the risk of smoking with them and discuss why they should quit. It is pretty rare that I will test them to confirm that they have quit. Some of my spine colleagues routinely obtain cotinine screens in these cases #jhsjc
Brent Graham to @BgTalkinman:
I just think the value of this kind if data isn’t necessarily in dictating whether surgery should be done but in stratifying risk as part of a shared decision-making process. #jhsjc
Avi Giladi @theaviram to @BgTalkinman:
No. i dont think the reported impact (accurate or not) is enough to justify withholding care. I discuss risk, as you mentioned. If pt needs major revision/risky surgery and refuses to quit I might balk but fortunately havent had that issue #jhsjc
Brent Graham @BgTalkinman to @theaviram:
I certainly get the “primum non nocere” part I can’t see myself refusing to do something based on greater risk alone – but I agree that carefully explaining findings like these is very important. #jhsjc
Brent Graham @BgTalkinman:
We are at the end of our hour together! Thanks for all of your insights and comments. They are extremely important and really add value to these provocative papers. We are back March 14. #jhsjc
