What makes a “great resident”: the resident perspective

Orthopedic surgery residency training is a difficult endeavor, and the selection of residents that will perform well in a rigorous training program is challenging for residency program directors. Even defining a “great” resident is a difficult endeavor. However, there are certain qualities that anecdotally are associated with high-performing residents, which include being trustworthy, hard-working and efficient, self-directed learners, detail-oriented, and personable. These qualities are difficult to teach and are likely learned by an individual during their early years of education and groomed during college and medical school. Individuals possessing these characteristics are more likely to bring a high-level of professionalism to their work as residents and to perform well on objective measures of success in residency such as high OITE scores, good faculty evaluations, and peer-reviewed publications. We discuss the available, but limited, literature on what makes a “great” resident and share the resident perspective on this topic.     

What makes a great resident? The programme director perspective

A career in orthopedic surgery in the United Kingdom is highly competitive. Great residents are trainees who understand that ultimately, they are responsible for their own training. They need to work with their Training Program Director to plan their career, to develop as surgeons, to reflect on their performance and any feedback they receive, be flexible, and plan ahead. There is competition but it is fair for everyone and the great resident will excel within this environment and will be successful in the long term.     

Prostacyclin mediates neuropathic pain through interleukin 1β-expressing resident macrophages

Prostacyclin is an important mediator of peripheral pain sensation. Here, we investigated its potential participation in mediating neuropathic pain and found that prostacyclin receptor (IP) knockout mice exhibited markedly decreased pain behavior. Application of an IP antagonist to the injury site or selective IP deficiency in myeloid cells mimicked the antinociceptive effect observed in IP knockout mice. At the site of nerve injury, IP was expressed in interleukin (IL) 1β-containing resident macrophages, which were less common in IP knockout mice. Local administration of the IP agonist cicaprost inhibited macrophage migration in vitro and promoted accumulation of IP- and IL1β-expressing cells as well as an increase of IL1β concentrations at the application site in vivo. Fittingly, the IL1-receptor antagonist anakinra (IL-1ra) decreased neuropathic pain behavior in wild-type mice but not in IP knockout mice. Finally, continuous, but not single administration, of the cyclooxygenase inhibitor meloxicam early after nerve injury decreased pain behavior and the number of resident macrophages. Thus, early synthesis of prostacyclin at the site of injury causes accumulation of IL1β-expressing macrophages as a key step in neuropathic pain after traumatic injury.     

Fragile TIM-4–expressing tissue resident macrophages are migratory and immunoregulatory

Macrophages characterized as M2 and M2-like regulate immune responses associated with immune suppression and healing; however, the relationship of this macrophage subset to CD169⁺ tissue-resident macrophages and their contribution to shaping alloimmune responses is unknown. Here we identified a population of M2-like tissue-resident macrophages that express high levels of the phosphatidylserine receptor TIM-4 and CD169 (TIM-4^hiCD169⁺). Labeling and tracking of TIM-4^hiCD169⁺ macrophages in mice revealed that this population is a major subset of tissue-resident macrophages, homes to draining LNs following oxidative stress, exhibits an immunoregulatory and hypostimulatory phenotype that is maintained after migration to secondary lymphoid organs, favors preferential induction of antigen-stimulated Tregs, and is highly susceptible to apoptosis. Moreover, CD169⁺ tissue-resident macrophages were resistant to oxidative stress–induced apoptosis in mice lacking TIM-4. Compared with heart allografts from WT mice, Tim4^–/– heart allografts survived much longer and were more easily tolerized by non-immunosuppressed recipients. Furthermore, Tim4^–/– allograft survival was associated with the infiltration of Tregs into the graft. Together, our data provide evidence that M2-like TIM-4^hiCD169⁺ tissue-resident macrophages are immunoregulatory and promote engraftment of cardiac allografts, but their influence is diminished by TIM-4–dependent programmed cell death.     

A role for human skin–resident T cells in wound healing

Epidermal T cells have been shown to play unique roles in tissue homeostasis and repair in mice through local secretion of distinct growth factors in the skin. Human epidermis contains both αβ⁺ and γδ⁺ T cells whose functional capabilities are not understood. We demonstrate that human epidermal T cells are able to produce insulin-like growth factor 1 (IGF-1) upon activation and promote wound healing in a skin organ culture model. Moreover, an analysis of the functional capabilities of T cells isolated from acute versus chronic wounds revealed a striking difference. Both αβ⁺ and Vδ1⁺ T cells isolated from acute wounds actively produced IGF-1, demonstrating that they are activated during tissue damage to participate in wound repair. In contrast, IGF-1 production could not be detected in T cells isolated from chronic wounds. In fact, skin T cells isolated from chronic wounds were refractory to further stimulation, suggesting an unresponsive state. Collectively, these results define a novel role for human epidermis–resident T cells in wound healing and provide new insight into our understanding of chronic wound persistence.The epidermis is a barrier tissue that is exposed to the environment and susceptible to injury. Cooperation between epithelial cells, growth factors, chemokines, and inflammatory cells leads to rapid repair of most injuries. However, increasing numbers of patients suffer from chronic, nonhealing wounds (1). Although much is known about processes leading to effective tissue repair, the role of human epithelial–resident T cells in wound healing has not been examined. γδ⁺ T cells are found in both the epidermis and dermis of human skin (2–4). In contrast to rodents, there is also a major resident population of epidermal αβ⁺ T cells (5). Other than analysis of their presence, little is known about these human skin–resident T cell populations. The T cell compartment in mouse epidermis is exclusively composed of γδ⁺ T cells, with invariant TCRs designated as dendritic epidermal T cells (DETCs) (6). These cells are critical for tumor immunosurveillance (7), skin homeostasis (8), and wound repair (9). Identification of a human skin T cell equivalent with specialized wound healing properties would provide crucial insight into the mechanism of effective repair of acute wounds and elucidate new targets for therapeutic intervention in the treatment of chronic wounds. In this report, we show that human epidermal αβ⁺ and γδ⁺ T cells contribute to the effective healing of acute wounds and are functionally defective in patients with chronic wounds, demonstrating a previously unrecognized component of human epidermal wound healing.     

Can administrative data identify active diagnoses for long-term care resident assessment?

Many veterans receive rehabilitation services in Department of Veterans Affairs (VA) nursing homes. Efficient methods for the identification of active diagnoses could facilitate care planning and outcomes assessment. We set out to determine whether diagnostic data from VA databases can be used to identify active diagnoses for Minimum Data Set (MDS) assessments. We evaluated diagnoses being considered for inclusion in MDS version 3.0 and present in at least 15% of a sample of VA nursing home residents. A research nurse following a standardized protocol identified active diagnoses from the medical records of 120 residents. A clinical nurse also identified active diagnoses in 58 of these patients. Inpatient and outpatient diagnoses from the VA National Patient Care Database were identified for the past year. We calculated kappa, sensitivity, and specificity values, considering the nurses' assessments the gold standard. We found that kappa values comparing research nurses and databases were generally poor, with only 8 of the 19 diagnoses having a value >0.60. Levels of agreement between the clinical nurse and administrative data were generally similar. We conclude that VA administrative data cannot be used to accurately identify active diagnoses for nursing home residents. How best to efficiently collect these important data remains uncertain.     

What skills should simulation training in arthroscopy teach residents? A focus on resident input

Purpose

   Our purpose was to identify what surgical skills trainees consider important to possess before performing in the operating room and the components of an optimal simulator.

Methods

   An online survey composed of 35 questions was completed by 67 orthopedic residents from across Canada. The questions examined the opinions of residents for their perspective on what constitutes an optimal design of an arthroscopic simulator.

Results

   The average year of residency of the respondents was 3.2, and the average number of arthroscopies assisted on was 66.1 with a range of 0–300. Identification of structures and navigation of the arthroscope were ranked highly in terms of importance for trainee surgeons to possess before performing in the operating room. Higher fidelity simulation models such as cadaveric specimens or the use of synthetic knees were preferred over lower fidelity simulation models such as virtual reality simulators or bench top models.

Conclusion

   The information from trainees can be used in the development of a simulator for medical education as well as program and curriculum design. The report also highlights the importance of the pre-RCT phases leading to the development of the most effective simulation programs.     

Central nervous system (CNS)–resident natural killer cells suppress Th17 responses and CNS autoimmune pathology

Natural killer (NK) cells of the innate immune system can profoundly impact the development of adaptive immune responses. Inflammatory and autoimmune responses in anatomical locations such as the central nervous system (CNS) differ substantially from those found in peripheral organs. We show in a mouse model of multiple sclerosis that NK cell enrichment results in disease amelioration, whereas selective blockade of NK cell homing to the CNS results in disease exacerbation. Importantly, the effects of NK cells on CNS pathology were dependent on the activity of CNS-resident, but not peripheral, NK cells. This activity of CNS-resident NK cells involved interactions with microglia and suppression of myelin-reactive Th17 cells. Our studies suggest an organ-specific activity of NK cells on the magnitude of CNS inflammation, providing potential new targets for therapeutic intervention.Inflammatory and immune responses within the central nervous system (CNS) significantly affect the clinical presentation and outcome of brain disorders, including stroke, trauma, Alzheimer’s disease, Parkinson’s disease, epilepsy, encephalomyelitis, and multiple sclerosis (MS; Weiner and Selkoe, 2002). In the case of MS and its animal model experimental autoimmune encephalomyelitis (EAE), a classical inflammatory disease characterized by cellular influx, demyelination, and axonal damage of the CNS, initiation of disease is controlled by an interplay between cells of the innate and adaptive immune systems (Steinman, 1996; Wekerle, 1998). NK cells are an important cell subset of the innate immune system represented by large granular lymphocytes that respond rapidly to a variety of insults with cytolytic activity and cytokine secretion (Kärre et al., 1986; Biron et al., 1999; Yokoyama and Plougastel, 2003; Raulet, 2004; Lanier, 2008). Recently, there has been a growing understanding of NK cells, particularly with regard to their roles in autoimmunity in the joints, pancreas, and CNS (French and Yokoyama, 2004; Shi and Van Kaer, 2006; Wu et al., 2007; Feuerer et al., 2009). Mechanisms by which NK cells could have an impact on autoimmune responses include a rapid cytokine release by NK cells before autoreactive helper T cell differentiation and modulation of interactions between autoreactive T cells, B cells, and APCs (Chambers et al., 1996; Shi et al., 2000; Martín-Fontecha et al., 2004; Laouar et al., 2005). However, much of this evidence is derived from studying peripheral lymphoid organs. Whether NK cells can act in target organs of autoimmunity such as the CNS has not yet been investigated.The manifestations of CNS disease, such as MS and EAE, require the homing of myelin-reactive T cells to the CNS, where T cells undergo reactivation, further differentiation, and expansion. The spectrum of APCs, antigens, and neuroimmune interactions within the CNS are unique (Shi and Ransohoff, 2010), and the outcome of an immune response cannot be predicted solely by the events that occurred in the periphery. NK cells readily home to the CNS under an array of pathological circumstances (Shi and Ransohoff, 2010). It is not known whether these NK cells are simply passive migrants or actively participate in the CNS pathogenesis.In this paper, we investigated the role of NK cells in the CNS in shaping autoimmunity and pathology. Our findings have revealed a critical role of CNS-resident NK cells in controlling the magnitude of CNS inflammation. This observation could be exploited for therapeutic intervention in CNS disease.     

Nurse and resident satisfaction in magnet long‐term care organizations: do high involvement approaches matter?

AIM: This study examines the association of high involvement nursing work practices with employer-of-choice (magnet) status in a sample of Canadian nursing homes. BACKGROUND: In response to a severe shortage of registered nursing personnel, it is imperative for health care organizations to more effectively recruit and retain nursing personnel. Some long-term care organizations are developing employee-centred cultures that allow them to effectively enhance nurse and resident satisfaction. At the same time, many nursing homes have adopted progressive nursing workplace practices (high involvement work practices) that emphasize greater employee empowerment, participation and commitment. METHOD: A mail survey was sent to the director of nursing in 300 nursing homes in western Canada. In total, 125 useable questionnaires were returned and constituted the data set for this study. Separate ordinary least squares regressions are performed with magnet strength, nurse satisfaction and resident satisfaction used as dependent variables. RESULTS: Nursing homes that demonstrate strong magnet (employer-of-choice) characteristics are more likely to have higher levels of nurse and patient satisfaction, even after controlling for a number of significant factors at the establishment level. Magnet nursing homes are more likely to have progressive participatory decision-making cultures and much more likely to spend considerable resources on job-related training for their nursing staff. The presence of high involvement work practices is not found to be a significant predictor in magnet strength, nurse or resident satisfaction. CONCLUSION: Merely adopting more high involvement nursing work practices may be insufficient for nursing homes, which desire to become 'employers-of-choice' in their marketplaces, especially if these practices are adopted without a concomitant investment in nurse training or an enhanced commitment to establishing a more democratic and participatory decision-making style involving all nursing staff.     

Does the use of standardized history and physical forms improve billable income and resident physician awareness of billing codes?

OBJECTIVES: Resident physician knowledge of financial reimbursement guidelines for patient encounters is limited. We determined whether the use of standardized history and physical examination forms by residents for hospital admissions plus a brief lecture would increase the level of billing codes, increase billable income, and increase resident awareness of billing guidelines. METHODS: Residents used history and physical examination forms after a brief documentation lecture. Pretrial and posttrial surveys measured awareness of billing guidelines. The admission billing codes for a 6-month period were obtained, and the percentages were compared with a control 6-month period. RESULTS: There was an absolute increase of 14.5% in the highest code between the two study periods (P < 0.0001). Billable income increased by $10,385. Resident documentation awareness also increased (P < 0.001). CONCLUSIONS: The use of history and physical examination forms, combined with a brief lecture, significantly increased the percentage of highest billing codes, which increased billable income. Resident awareness of documentation requirements significantly improved.     

Recognition and management of BPPV for an elderly female patient referred for low back pain: a resident’s case study

Abstract

Benign paroxysmal positional vertigo (BPPV) is common among older adults and frequently misdiagnosed or unidentified. Undiagnosed BPPV has been associated with depression, falls and ADL limitations. This case study describes the diagnostic process and management of BPPV for a 65-year-old patient with a primary complaint of chronic low back pain (LBP) in an outpatient orthopedic physical therapy setting. Following routine screening performed on initial evaluation, the patient was educated about examination findings that indicated the potential for BPPV and given the option to proceed with further assessment or defer until LBP was under control. The patient attended 16 visits over the course of care and the complaint of vertigo, described as a true spinning sensation, was assessed further on the visit 5. Continued assessment confirmed BPPV and the canalith repositioning procedure was administered. Following positive response to this intervention, the maneuver was re-administered on visit 6. Complete resolution of symptoms was reported on visit 7 and for the remainder of physical therapy services over the following month. Physical therapists may play a vital role in reducing healthcare expenses associated with cost to arrive at the diagnosis of BPPV, as well as improving the quality of life and safety of the older adult population affected by BPPV.