How surgical training has changed over time and how this affects the future generation of surgeons entering the workforce.

Aims: The aims of this study were to describe the demographic, socioeconomic, and educational factors associated with core surgical trainees (CSTs) who apply to and receive offers for higher surgical training (ST3) posts in Trauma & Orthopaedics (T&O). Methods: Data collected by the UK Medical Education Database (UKMED) between 1 January 2014 and 31 December 2019 were used in this retrospective longitudinal cohort study comprising 1,960 CSTs eligible for ST3. The primary outcome measures were whether CSTs applied for a T&O ST3 post and if they were subsequently offered a post. A directed acyclic graph was used for detecting confounders and adjusting logistic regression models to calculate odds ratios (ORs), which assessed the association between the primary outcomes and relevant exposures of interest, including: age, sex, ethnicity, parental socioeconomic status (SES), domiciliary status, category of medical school, Situational Judgement Test (SJT) scores at medical school, and success in postgraduate examinations. This study followed STROBE guidelines. Results: Compared to the overall cohort of CSTs, females were significantly less likely to apply to T&O (OR 0.37, 95% CI 0.30 to 0.46; n = 155/720 female vs n = 535/1,240 male; p < 0.001). CSTs who were not UK-domiciled prior to university were nearly twice as likely to apply to T&O (OR 1.99, 95% CI 1.39 to 2.85; n = 50/205 vs not UK-domiciled vs n = 585/1,580 UK-domiciled; p < 0.001). Age, ethnicity, SES, and medical school category were not associated with applying to T&O. Applicants who identified as ‘black and minority ethnic’ (BME) were significantly less likely to be offered a T&O ST3 post (OR 0.70, 95% CI 0.51 to 0.97; n = 165/265 BME vs n = 265/385 white; p = 0.034). Differences in age, sex, SES, medical school category, and SJT scores were not significantly associated with being offered a T&O ST3 post. Conclusion: There is an evident disparity in sex between T&O applicants and an ethnic disparity between those who receive offers on their first attempt. Further high-quality, prospective research in the post-COVID-19 pandemic period is needed to improve equality, diversity, and inclusion in T&O training. Cite this article: Bone Jt Open 2024;5(8):697–707.

Simon Fleming discusses the challenges he faced by standing up to injustices and using his platform to challenge the status quo as a trainee.

The authors highlight parallels between effective online communication and face to face communication in the clinical space, indicating that the rules and what is "effective" and "appropriate" varies between environments.

BACKGROUND:The unequal distribution of academic and professional outcomes between different minority groups is a pervasive issue in many fields, including surgery. The implications of differential attainment remain significant, not only for the individuals affected but also for the wider health care system. An inclusive health care system is crucial in meeting the needs of an increasingly diverse patient population, thereby leading to better outcomes. One barrier to diversifying the workforce is the differential attainment in educational outcomes between Black and Minority Ethnic (BME) and White medical students and doctors in the United Kingdom. BME trainees are known to have lower performance rates in medical examinations, including undergraduate and postgraduate exams, Annual Review of Competence Progression, as well as training and consultant job applications. Studies have shown that BME candidates have a higher likelihood of failing both parts of the Membership of the Royal Colleges of Surgeons exams and are 10% less likely to be considered suitable for core surgical training. Several contributing factors have been identified; however, there has been limited evidence investigating surgical training experiences and their relationship to differential attainment. To understand the nature of differential attainment in surgery and to develop effective strategies to address it, it is essential to examine the underlying causes and contributing factors. The Variation in Experiences and Attainment in Surgery Between Ethnicities of UK Medical Students and Doctors (ATTAIN) study aims to describe and compare the factors and outcomes of attainment between different ethnicities of doctors and medical students.OBJECTIVE:The primary aim will be to compare the effect of experiences and perceptions of surgical education of students and doctors of different ethnicities.METHODS:This protocol describes a nationwide cross-sectional study of medical students and nonconsultant grade doctors in the United Kingdom. Participants will complete a web-based questionnaire collecting data on experiences and perceptions of surgical placements as well as self-reported academic attainment data. A comprehensive data collection strategy will be used to collect a representative sample of the population. A set of surrogate markers relevant to surgical training will be used to establish a primary outcome to determine variations in attainment. Regression analyses will be used to identify potential causes for the variation in attainment.RESULTS:Data collected between February 2022 and September 2022 yielded 1603 respondents. Data analysis is yet to be competed. The protocol was approved by the University College London Research Ethics Committee on September 16, 2021 (ethics approval reference 19071/004). The findings will be disseminated through peer-reviewed publications and conference presentations.CONCLUSIONS:Drawing upon the conclusions of this study, we aim to make recommendations on educational policy reforms. Additionally, the creation of a large, comprehensive data set can be used for further research.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):DERR1-10.2196/40545.

BACKGROUND:There is a lack of information regarding the provision of parental leave for surgical careers. This survey study aims to evaluate the experience of maternity/paternity leave and views on work-life balance globally.METHODS:A 55-item online survey in 24 languages was distributed via social media as per CHERRIES guideline from February to March 2020. It explored parental leave entitlements, attitude towards leave taking, financial impact, time spent with children and compatibility of parenthood with surgical career.RESULTS:Of the 1393 (male : female, 514 : 829) respondents from 65 countries, there were 479 medical students, 349 surgical trainees and 513 consultants. Consultants had less than the recommended duration of maternity leave (43.8 versus 29.1 per cent), no paid maternity (8.3 versus 3.2 per cent) or paternity leave (19.3 versus 11.0 per cent) compared with trainees. Females were less likely to have children than males (36.8 versus 45.6 per cent, P = 0.010) and were more often told surgery is incompatible with parenthood (80.2 versus 59.5 per cent, P < 0.001). Males spent less than 20 per cent of their salary on childcare and fewer than 30 hours/week with their children. More than half (59.2 per cent) of medical students did not believe a surgical career allowed work-life balance.CONCLUSION:Surgeons across the globe had inadequate parental leave. Significant gender disparity was seen in multiple aspects.

Uncomfortable conversations are necessary for a safe work environment.

Introduction The COVID-19 pandemic has impacted students learning, with the time off resulting in students ‘de-skilling’, increasing concerns for upcoming observed structured clinical examinations. Foundation Year 1 (F1) doctors (F1s), despite being expected to teach, rarely receive formal preparation, with COVID-19 exacerbating opportunities to practice. As such, a national orthopaedic teaching programme was designed to provide F1s with opportunities to develop their teaching skills and to synergistically teach medical students how to perform clinical orthopaedic examinations. Methods Six weekly sessions, each delivered by two newly qualified F1 tutors, on each joint examination were delivered online via Zoom Video Communications (USA). Presession and postsession multiple choice questions (MCQs) were provided to students to assess improvement in knowledge. Anonymous feedback forms were provided to both students and tutors. Results Of the 341 students that attended, 87.1% provided feedback. 86.2% felt that they had de-skilled due to time off, with a mean 15 weeks off from placement. Based on a 5-point Likert scale, students displayed a mean improvement in confidence (1.9±1.1, p<0.001) and MCQ scores (1.4±1.3, p<0.001) before and after the sessions. 91.6% and 95.3% agreed that the use of online teaching increased attendance and laid the foundation for practice. Of the six tutors, all reported improvement in confidence to teach and teaching skills. Conclusion We demonstrate that online delivery of clinical orthopaedic examinations is effective, increasing the knowledge and confidence of students, while providing opportunities for F1s to teach. We present our findings to encourage similar teaching programmes to be adopted at other locations and specialties, to synergistically benefit students, doctors and ultimately, patients.

Abstract Introduction A recent publication in the Plastic and Reconstructive Surgery journal (Rohrich et al., 2020) has attracted controversy for its generalised approach to “millennial” plastic surgeons. We suggest that surgeons in training, trainers and colleagues need to adjust their focus from the group to the individual in order to maximise clinical performance, quality of working life and quality of care delivered to patients. Method We outline a simple model, adapted from the Johari window tool, with the aim of delivering a job and training plan with which all parties are content. It considers individual ability to process scenarios and perform tasks (bandwidth), and the resources available to the individual trainee, to assess each aspect of the role. Results No two clinicians have the same strengths and weaknesses, and no two posts are identical. The Johari-like matrix allows trainers and trainees to identify which activities are firmly within the bandwidth and resources of the trainee, those which are clearly not, and those which may cause some concern and require further discussion or modification. Conclusions In this model, we suggest a framework which may help surgeons in training and trainers alike and provide a means of recording this longitudinally as individuals or roles evolve.

The use of social media has continued to grow in medicine and surgery and the scholarly evaluation of its role, as well as potential drawbacks, is prudent. We read with interest a recently published article on social media of vascular surgeons.1 As fellow surgeons, social media users, and researchers, we have some concerns regarding the methodology and conduct of the study, the ethics of the study, and, finally, its conclusions.

Since 2011, aviation has revolutionized their approach to safety. The aviation industry has adopted a multi-faceted approach to improve safety through decreasing duty hour limits and implementing processes to mitigate fatigue-related errors as well as creating cultural shifts in responsibility for safety. These changes have been guided by data generated by quality-improvement methodology. In contrast, duty hour limits in graduate medical education have not yet seen dramatic data-driven reform. Key advancements in aviation fatigue mitigation and implications for residency education are explored in this article. Scientifically based processes to optimize duty hours, quality-improvement strategies to iteratively monitor and reform duty limits, systematic change focusing on a just culture, and financial disincentives and incentives as a catalyst for change are discussed.

Europe represents true diversity, with cultural, linguistic and geopolitical variation spanning a large geographi-cal area. Politics for many of its 750 million inhabitants revolves around the European Union (EU) and its 27 member states. The overarching goal of the EU is to promote peace and the values of the union (inclusion, tolerance, justice, solidarity and non-discrimination).1,2 EFORT was created to connect orthopaedic associations across Europe, fostering relationships between member countries that celebrated diversity and facilitated the exchange of knowledge. Whilst the global landscape changes and politics attempts to interfere in how we live our lives, it is important to remember that a strong organization is a diverse one that evolves over time. Various initiatives exist across the global landscape to support diversity in terms of culture; gender; black, Asian and minority ethnic (BAME) groups; disability groups; lesbian, gay, bisexual, transgender and queer (or questioning) and others (LGBTQ+); and the 'ageing' surgeon. This article explores the creation of some of these initiatives and how they have been supported by different orthopaedic organizations.

Greenberg and colleagues rightly state that the development of psychological injury is “influenced by the way [staff] are supported before, during, and after a challenging incident.”1 But identifying, supporting, and treating people after they have developed moral injuries can be very difficult, so we need a greater focus on preventive measures. Healthcare organisations, with their duty to …

In May, the Australian government began to ease the coronavirus disease 2019 (COVID-19) lockdown restrictions. Residents were allowed to invite two people into their homes. Who would be the first two chosen from one's network of individuals, many of whom would have been in contact virtually during the previous 5 weeks? This question prompted a thought about connectedness – a good topic with which to introduce the journal's new social media editor, Simon Fleming, who co-authors this editorial. Moreover, in this issue a toolbox article on ‘The connected educator’ posits that ‘an educator's impact is amplified through the power of connections’.1 Humans are social creatures: from our first beginnings we have formed groups and then communities. Social and professional connection is important to most of us and certainly to all readers of this journal. The United States Centers for Disease Control and Prevention (CDC) defines connectedness as ‘the degree to which a person or group is socially close, interrelated, or shares resources with other persons or groups’.2 It seems that throughout history the inner and most intimate layer of our network has numbered about five people, our close and useful connections number around 15, the tribe that we identify as belonging to numbers up to 50 and then our wider network reaches a maximum of around 150 individuals.3 Since the earliest 20th century, and as we settle into the 21st century, the human race has had the potential for more connectivity than ever before. Imagine how different lockdown would have been before the internet or even the telephone. Virtual interaction has helped us to stay in touch with our families, friends, colleagues, patients and students globally, but many of us still crave proximity and face to face close interactions, all the more so as time goes on. Of course, not everyone has equal opportunity to be online. For many, reliable internet is a luxury that they cannot afford or that is not readily available in their location, as emphasised in two Insights’ articles focused on COVID-19 in this issue.4, 5 Loneliness and a lack of human connection, even prior to COVID-19, are major determinants of health. Through time we have seen the effects on people that exile from their homelands, shunning through social rejection by their communities and, more generally, the impact of any kind of isolation or othering can have on one's well-being and mental health. In the United Kingdom there is a commonly used phrase of being ‘sent to Coventry’, possibly originating from the civil war in the 17th century, that means a person has been ostracised by his or her peers, who act as if that person no longer exists. This silence has a devastating effect. Many millions of adults worldwide are lonely and socially isolated as a result of the loss of family or family conflict, long-term health conditions, including depression and anxiety, a lack of mobility or being the victims of crime: a situation that has recently been recognised as a major public health problem and a potent killer.6 This has been apparent as a result of the current circumstances – perhaps to varying degrees, depending on location – and yet we are being asked (and in some cases told) to consciously isolate and to actively distance ourselves from others. In fact, the phrase ‘we show compassion by distancing’ has been used more than once. Low social connection will surely lead to poor mental health and to suicide. What is interesting is that the benefits of connectedness do not depend on the number of friends one has but from the subjective sense of feeling connected.7 A synonym of ostracise is excommunicate, however, and perhaps social media (and other tech) have meant that for once, this is not the case. We can be close yet far apart. The COVID-19 pandemic has forced us to re-evaluate not only the quantity of communication episodes that we have with others, but also the quality. For those with easier virtual access and connectivity, there are also challenges – technological advance does have a darker side. There can be pressure to keep up: with information, social media, appearance and productivity. Even the number of one's friends and Twitter followers can now be judged and found wanting. We are connected to a vast quantity of knowledge (and opinion) at the click of a keyboard but it can sometimes feel overwhelming with the amount of ‘stuff’ that finds its way into our inboxes and reminders every day. For clinicians and educators, it may seem that there is always another reference to look up, another journal article to check or another piece of ‘evidence’ to consider. Am I keeping up to date? FOMO (fear of missing out), defined as the fear that something better is happening somewhere without you, and particularly online, leads to the obsessive checking of social media and e-mails.8 One author of this editorial has also been known to experience JOMO (the joy of missing out), the rare feeling of knowing that you can put your feet up and watch from afar, without any of the stress of being somewhere in person – the deluge of podcasts, webinars and the like in recent months has further emphasised that sometimes it's actually better to be there remotely, rather than IRL (in real life). The role of social media and social networking sites in promoting health is interesting. Research suggests that their effects may be positive, if they lead to increased connection and social support, or negative if they fail to address users’ needs, such as acceptance and longing.9 Trolling is certainly not mood enhancing, nor is the provision of pseudoscience, fake news or even harmful ideas as ‘fact’. This is a perfect example of why social media is a powerful mirror of society: the number of followers does not equate to moral, ethical, scientific or behavioural rightness. (As an aside, some of the very closest friends your social media editor now has, both personal and professional, were first met through Twitter: ‘I once described social media to my mum as like having loads of pen pals, only faster and sometimes completely random people read your mail and send you letters, written entirely in capitals, to tell you they disagree …’.) We both agree that if a journal truly wishes knowledge to be as accessible, equitable and interactive as possible, then it must embrace the simple fact that social media are here to stay, whether as a tool for good or evil, to feed fear or to fight it, to challenge rumour with fact, hearsay with science or to bring joy rather than outrage. It's with this ethos that The Clinical Teacher and Medical Education now have a social media editor. The social media editor has the last paragraph: I am also a trainee (resident) with a unique tweet style, a propensity for gif and meme usage, and a desire to use social media not only to make you aware of the latest papers but also to start discourses and to build communities. Connect with us. See you online. @jthistlethwaite @OrthopodReg @ClinicalTeacher @MedEd_Journal

The change precipitated by covid-19 has shown us that just because it’s “always been done this way” doesn’t mean it should be, or has to be

AimsThe increased use of social media creates opportunity for new, effective methods of delivering medical and clinical education. Twitter is a popular social media platform where users can post frequent updates and create threads containing related content using hashtags. This study aims to investigate and analyse the type of content relating to orthopaedic surgery that is being posted on the platform of Twitter.MethodsA retrospective search was performed for tweets containing the words ‘orthopaedic surgery’ or ‘orthopedic surgery’ or the use of the hashtag ‘#OrthoTwitter’ between November 2018 to November 2019. A total of 5243 tweets were included.ResultsTweets containing ‘orthopaedic surgery’ or ‘orthopedic surgery’ most frequently contained promotional or marketing content (30% promotional, 21% marketing), and private organisations were the category of author to which the greatest number of tweets belonged (30%). Tweets containing educational or research content were the least common among all tweets containing ‘orthopaedic surgery’ or ‘orthopedic surgery’ (11%). In contrast, of the tweets containing the hashtag ‘#OrthoTwitter’, 44% contained educational or research content, 15% contained promotional content and no tweets containing marketing content. Furthermore, 87% of all tweets using the hashtag ‘#OrthoTwitter’ were from orthopaedic surgeons, and the least number of tweets were from private organisations (2%).ConclusionTwitter is a widely used social media platform regarding orthopaedic surgery. We propose that the hashtag ‘#OrthoTwitter’ can be used to create an online community of orthopaedic surgeons where members can assist one another through sharing reliable and educational content.