Aims. We aim to objectively assess the impact of COVID-19 on mean total operative cases for all indicative procedures (as outlined by the Joint Committee on Surgical Training (JCST)) experienced by orthopaedic trainees in the deanery of the Republic of Ireland. Subjective experiences were reported for each trainee using questionnaires. Methods. During the first four weeks of the nationwide lockdown due to COVID-19, the objective impact of the pandemic on each trainee’s surgical caseload exposure was assessed using data from individual trainee logbook profiles in the deanery of the Republic of Ireland. Independent predictor variables included the trainee grade (ST 3 to 8), the individual trainee, the unit that the logbook was reported from, and the year in which the logbook was recorded. We used the analysis of variance (ANOVA) test to assess for any statistically significant predictor variables. The subjective experience of each trainee was captured using an electronic questionnaire. Results. The mean number of total procedures per trainee over four weeks was 36.8 (7 to 99; standard deviation (SD) 19.67) in 2018, 40.6 (6 to 81; SD 17.90) in 2019, and 18.3 (3 to 65; SD 11.70) during the pandemic of 2020 (p = 0.043). Significant reductions were noted for all elective indicative procedures, including arthroplasty (p = 0.019), osteotomy (p = 0.045), nerve decompression (p = 0.024) and arthroscopy (p = 0.024). In contrast, none of the nine indicative procedures for trauma were reduced. There was a significant inter-unit difference in the mean number of total cases (p = 0.029) and indicative cases (p = 0.0005) per trainee. We noted that 7.69% (n = 3) of trainees contracted COVID-19. Conclusion. During the COVID-19 pandemic, the mean number of operative cases per trainee has been significantly reduced for four of the 13 indicative procedures, as outlined by the JCST. Reassignment of trainees to high-volume institutions in the future may be a plausible approach to mitigate significant training deficits in those trainees worst impacted by the reduction in operative exposure

Aims. The COVID-19 pandemic has had a significant impact on the provision of orthopaedic care across the UK. During the pandemic orthopaedic specialist registrars were redeployed to “frontline” specialties occupying non-surgical roles. The impact of the COVID-19 pandemic on orthopaedic training in the UK is unknown. This paper sought to examine the role of orthopaedic trainees during the COVID-19 and the impact of COVID-19 pandemic on postgraduate orthopaedic education. Methods. A 42-point questionnaire was designed, validated, and disseminated via e-mail and an instant-messaging platform. Results. A total of 101 orthopaedic trainees, representing the four nations (Wales, England, Scotland, and Northern Ireland), completed the questionnaire. Overall, 23.1% (23/101) of trainees were redeployed to non-surgical roles. Of these, 73% (17/23) were redeployed to intensive treatment units (ITUs), 13% (3/23) to A/E, and 13%(3/23%) to general medicine. Of the trainees redeployed to ITU 100%, (17/17) received formal induction. Non-deployed or returning trainees had a significant reduction in sessions. In total, 42.9% (42/101) % of trainees were not timetabled into fracture clinic, 53% (53/101) of trainees had one allocated theatre list per week, and 63.8%(64/101) of trainees did not feel they obtained enough experience in the attached subspecialty and preferred repeating this. Overall, 93% (93/101) of respondents attended at least one weekly online webinar, with 79% (79/101) of trainees rating these as useful or very useful, while 95% (95/101) trainees attended online deanery teaching which was rated as more useful than online webinars (p = 0.005). Conclusion. Orthopaedic specialist trainees occupied an important role during the COVID-19 pandemic. COVID-19 has had a significant impact on orthopaedic training. It is imperative this is properly understood to ensure orthopaedic specialist trainees achieve competencies set out in the training curriculum. Cite this article: Bone Joint Open 2020;1-11:676–682

Introduction. Procedure Based Assessments (PBAs) were recently introduced for orthopaedic trainees and play an increasing role in assessment. The study aims to describe the attitudes of trainees to the educational benefit of PBAs and the factors which underlie these attitudes. Methodology. A link to an online questionnaire was sent via the eLogbook email system to all orthopaedic trainees in the UK with a National Training Number (NTN). The questions were attitude statements with Likert-type scaled responses, free text responses and closed questions. Results. Of 668 responses, 616 trainees with NTNs were included, with a good spread of seniority and geographical location. Trainees found PBAs useful for delivery of feedback (53%). The role of PBAs as evidence of competence in the annual review of progression was more controversial, with 31.8% agreeing. 61% of respondents found there were barriers to the successful use of PBAs. Trainee and trainer behaviours have been identified that significantly increase the chance of trainees improving their practice, such as completing the PBA at the time of the procedure (p< 0.001) and the trainer delivering quality feedback when using PBAs (p< 0.001), but completing higher numbers of PBAs does not have this effect (p=0.26). Training Programme Directors (TPDs) were perceived to be supportive of the use of PBAs (67.3%), and trainees with strongly supportive TPDs were more likely to improve their practice using PBAs (p=0.014). There were wide variations between Training Programmes in use of and satisfaction with PBAs. Conclusion. This is the first nationwide study in the UK investigating the attitudes of trainees to PBAs. Trainees found PBAs can be educationally beneficial, but that this benefit is contingent on a variety of factors highlighted in this study. These findings may inform the debate as to how to improve the effective use of PBAs in orthopaedic training

Aims. Global literature suggests that female surgical trainees have lower rates of independent operating (operative autonomy) than their male counterparts. The objective of this study was to identify any association between gender and lead/independent operating in speciality orthopaedic trainees within the UK national training programme. Methods. This was a retrospective case-control study using electronic surgical logbook data from 2009 to 2021 for 274 UK orthopaedic trainees. Total operative numbers and level of supervision were compared between male and female trainees, with correction for less than full-time training (LTFT), prior experience, and time out during training (OOP). The primary outcome was the percentage of cases undertaken as lead surgeon (supervised and unsupervised) by UK orthopaedic trainees by gender. Results. All participants gave permission for their data to be used. In total, 274 UK orthopaedic trainees submitted data (65% men (n = 177) and 33% women (n = 91)), with a total of 285,915 surgical procedures logged over 1,364 trainee-years. Males were lead surgeon (under supervision) on 3% more cases than females (61% (115,948/189,378) to 58% (50,285/86,375), respectively; p < 0.001), and independent operator (unsupervised) on 1% more cases. A similar trend of higher operative numbers in male trainees was seen for senior (ST6 to 8) trainees (+5% and +1%; p < 0.001), those with no time OOP (+6% and +8%; p < 0.001), and those with orthopaedic experience prior to orthopaedic specialty training (+7% and +3% for lead surgeon and independent operator, respectively; p < 0.001). The gender difference was less marked for those on LTFT training, those who took time OOP, and those with no prior orthopaedic experience. Conclusion. This study showed that males perform 3% more cases as the lead surgeon than females during UK orthopaedic training (p < 0.001). This may be due to differences in how cases are recorded, but must engender further research to ensure that all surgeons are treated equitably during their training. Cite this article: Bone Joint J 2023;105-B(7):821–832

The process of obtaining informed consent is an important and complex pursuit, especially within a paediatric setting. Medical governing bodies have stated that the role of the trainee surgeon must be explained to patients and their families during the consent process. Despite this, attitudes and practices of surgeons and their trainees regarding disclosure of the trainee's participation during the consent process has not been reported in the paediatric setting. Nineteen face-to-face interviews were conducted with surgical trainees and staff surgeons at a tertiary level paediatric hospital in Toronto, Canada. These were transcribed and subsequently thematically coded by three reviewers. Five main themes were identified from the interviews. 1) Surgeons do not consistently disclose the role of surgical trainees to parents. 2) Surgical trainees are purposefully vague in disclosing their role during the consent discussion without being misleading. 3) Surgeons and surgical trainees believe parents do not fully understand the specific role of surgical trainees. 4) Graduated responsibility is an important aspect of training surgeons. 5) Surgeons feel a responsibility towards both their patients and their trainees. Surgeons don't explicitly inform patients about the involvement of trainees, believing there is a lack of understanding of the training process. Trainee perspectives reflect this, with the view that families are aware of their participation but likely underestimate their role, and suggest that information is kept purposely vague to reduce anxiety. The majority of surgeons and surgical trainees do not voluntarily disclose the degree of trainee participation in surgery during the informed consent discussion with parents. An open and honest discussion should occur, allowing for parents to make an informed decision regarding their child's care. Further patient education regarding trainees' roles would help develop a more thorough and patient centred informed consent process

Aims. This study was conducted to investigate the influence of surgical experience on the outcomes and component positioning of total knee arthroplasty (TKA). We compared the outcomes and component positioning of simultaneous bilateral TKAs performed by supervisors and trainee surgeons. Patients and Methods. A total of 20 patients (40 knees) who underwent simultaneous bilateral primary TKA using the same cruciate-retaining TKA system between 2011 and 2015 were included. The mean patient age was 76 years (range: 64 to 86 years). There were 2 males and 18 females. The first phase of the operation was performed on the knee that was more severely degenerated by one supervisor who had performed over 1000 TKAs. The other knee was operated on next by trainee surgeons who had performed less than 20 TKAs. The knees were categorized into two groups: those operated on by supervisors (group S) and those operated on by trainee surgeons (group T). Outcome measures included range of motion (ROM), Knee Score (KS), and Function Score (FS). We also evaluated operative time, alignment of the leg, and the orientation of components, which was determined on post-operative long-leg coronal films. Results. The mean pre-operative maximal flexion was 119.8° in group T and 114.8° in group S (p=0.548). The mean pre-operative KS was 47.5 in group T and 35.6 in group S (p<0.01). The mean operative time was 124.5 min in group T and 91.8 min in group S (p<0.01). The mean post-operative maximal flexion was 114.0° in group T and 113.0° in group S (p=0.967). The mean post-operative KS was 93.9 in group T and 92.9 in group S (p=0.978). There were no significant differences in the ROM and KS when comparing supervisor and trainee surgeons. The overall mean FS increased to 70 from 42. The varus angle of the mean coronal tibial component was −1.12° in group T and 1.12° in group S (p<0.01). The varus angle of the mean coronal femoral component was 0.24° in group T and 1.82° in group S (p=0.0447). The mean FTA was 172.7° in group T and 176.4° in group S (p<0.01). The mean HKA was 179.2° in group T and 182.9° in group S (p<0.01). Conclusions. Operative time was significantly longer for TKAs performed by trainee surgeons compared to those performed by supervisors. However, alignment for knees in the supervisor group were significantly more likely to be varus compared with those in the trainee group. This study showed no significant difference in ROM and KS between supervisors and trainee surgeons

Introduction. Entry into orthopaedic higher surgical training remains extremely competitive, however little evidence exists regarding the validity of short-listing and interviewing for selection. This paper assesses the relative correlations of short-listing and interview scores in predicting subsequent performance as an orthopaedic trainee. Methods. We compared data from the selection process (short-listing and interview scores) to subsequent performance during training (academic output and an annual assessment score by Programme Director). Data was prospectively collected from 115 trainees on the South West Thames region of the U.K. during 2000–2010. Results. We found that trainees achieving an interview score within the top third subsequently produced a higher academic output and had a higher annual assessment score than their peers (MANOVA, p>0.05) see Figure 1. [Academic output vs interview score rank (thirds)]. The short-listing scores did not correlate with subsequent academic output or annual assessment score see Figure 2. [Academic output vs shortlist score rank (thirds)]. We found no statistical correlation between the short-listing and interview scores (r. 2. < 0.1). Discussion. This study provides an evidence base to support the value of interviews by senior surgeons in the selection of trainees. We support the following selection process for orthopaedic trainees: long listing followed by a competitive interview(s) of all remaining candidates

The Accreditation Council of Graduate Medical Education (ACGME) has formalized a limit of 16 consecutive duty hours for first year and 20 hours for intermediate level trainees, while maintaining a maximum of 80 duty hours per week despite social pressure to further reduce this limit. Deterioration in cognitive and technical performance secondary to fatigue is the basis for the 16 hour rule, along with the notion that “strategic napping” be strongly encouraged for trainees that must remain for longer shifts. For more senior trainees, graduated independence and responsibility are recognized as important to prepare for the independent practice of medicine. Yet, a reduction of nearly 7000 hours, or the equivalent of 2 years of surgical education and experience, results from the 80-hour duty limitation compared to surgical training of two decades ago. The contention is that duty hours must be constrained to optimize patient safety and the learning environment, but it is unclear whether mastery of the necessary cognitive and technical competencies can be achieved in such a constricted time period. Another worrisome by-product of legislated duty hour limitations is the unintended encouragement of a “shift worker” mentality and erosion of the ethos of professionalism among trainees. Effective mentoring takes on critical importance in this challenging environment, yet productive mentoring may be counter to learned adaptive behaviours and instinctive personality traits of some accomplished surgeon educators. Fostering effective mentors in academic surgery requires us to develop behaviors that are conducive to the mentoring process. As our trainees struggle to achieve mastery of a surgical discipline within a prescribed and constricted time period, we must consider a competency-based system of surgical education rather than one that is time-defined. Likewise, the personal and professional growth of our trainees in this system, as well as the succession planning for our specialty, are dependent upon the creation of an environment conducive to effective mentoring in academic orthopaedics

Background. The aim of our study was to assess the ability of orthopaedic surgical trainees to adequately assess ankle radiographs following operative fixation of unstable ankle fracture. Methods and results. We identified 26 Supination-External rotation (SER) stage IV fractures, and 4 Pronation-External rotation (PER) stage III fractures treated surgically in our institution. Radiographs were evaluated for shortening of the fibula, widening of the joint space, malrotation of the fibula and widening of the medial clear space. Trainees were shown these radiographs and asked to comment on the adequacy of reduction. They were then given a simple tutorial on assessing adequacy of reduction and asked to reassess these radiographs. The parameters discussed included assessment of medial clear space, drawing of the tibiofibular line, use of the “circle sign” and measurement of the talocrural angle. There was a statistically significant improvement from 64% to 71.4% (P< 0.05) in the radiographs correctly assessed by orthopaedic trainees following a short tutorial on radiographical assessment. Conclusions. Despite the frequency with which junior surgical trainees deal with ankle fractures, there is a lack of awareness on the objective means of adequately assessing ankle fracture fixation. We highlight this deficiency and demonstrate that a short tutorial on radiographic parameters results in improved assessment and better critical analysis of adequacy of reduction following ankle fracture fixation. As with fractures about the wrist, careful assessment of radiographic parameters should be considered standard practice in assessment of adequacy of reduction in fractures about the ankle

Introduction. Motion analysis is a validated method of assessing technical dexterity within surgical skills centers. A more accessible and cost-effective method of skills assessment is to use a global rating scale (GRS). We aimed to perform a validation experiment to compare an arthroscopic GRS against motion analysis for monitoring orthopaedic trainees learning simulated arthroscopic meniscal repairs. Methods. An arthroscopic meniscal repair task on a knee simulator was set up in a bioskills laboratory. Nineteen orthopaedic trainees with no experience of meniscal repair were recruited and their performance assessed whilst undertaking a standardized meniscal repair on 12 occasions. An arthroscopic GRS, assessing parameters such as “depth perception,” “bimanual dexterity,” “instrument handling,” and “final product analysis” was used to evaluate technical skill. Performance was assessed blindly by watching video recordings of the arthroscopic tasks. Dexterity analysis was performed using a motion analysis tracking system which measured “time taken,” “total path length of the subject's hands,” and “number of hand movements”. Results. Motion analysis objectively defined the learning curves and demonstrated significant improvement in performance over the 12 tasks (p< 0.0001). The GRS demonstrated the same learning curve with a significant improvement in performance (p< 0.0001). Importantly, for each individual subject, there was significant improvement in performance as assessed by GRS over the 12 tasks (p< 0.0001). There was a moderate correlation (p< 0.0001) between GRS and all the motion analysis parameters (r values: time=−0.58, path length=−0.58, hand movements=−0.51). Conclusion. Established arthroscopic GRSs have not previously been used to monitor learning curves during complex arthroscopic tasks. The results demonstrate that both the GRS and motion analysis are able to detect performance improvement during such tasks. This further validates the arthroscopic GRS for use in monitoring individual trainees and has the advantage over motion analysis of being directly transferrable to the operating room

Time at the surgical ‘coal-face’ has been reduced by introduction of the European Working Time Directive (EWTD) significantly impacting training opportunity. Our null hypothesis was that duration of surgery is significantly longer if a trainee were performing the operation despite supervision or level of trainee experience. Cemented hip hemiarthroplasty was chosen as our index procedure as complexity is largely comparable between cases. 461 patients were identified on the hospital trauma database. Data were augmented by information regarding level of surgeon, assistant and time of surgery from the hospital theatre database. There was no significant difference in registrar and consultant operative times, mean time 69 and 72 minutes respectively. SHOs were significantly slower (mean 80 minutes, p=0.0006). Junior (ST5 or less) registrars were significantly slower (mean 81minutes, p=0.0002) whereas senior registrars were not. Supervision level had no effect on duration of senior registrar operations but when junior registrars were consultant supervised they were not significantly slower (mean 75 minutes, p=0.09). Supervised operating therefore reduces time variability and should be promoted within a climate of training. Increase in mean operative time in registrars and SHOs is insignificant within a day's operating and is unlikely to lead to cancellations of cases

Orthopaedic surgery residents typically learn total knee arthroplasty (TKA) through an apprenticeship-type model, which is a necessarily slow process. If residents could learn the required technical and cognitive skills more quickly, they could make better use of reduced hours in the operating room, surgeons could teach at a higher level, patients could have shorter operating times with better outcomes, and the healthcare system would have reduced costs and better-trained surgeons. Surgical skills courses, using artificial bones, have been shown to improve technical and cognitive skills significantly within a couple of days. Computer-assisted surgery (CAS) provides real-time feedback and component position planning, leading to improved alignment and a shorter learning curve. Combining these two approaches challenges the participants to consider the same task in different contexts, promoting cognitive flexibility. We designed a hands-on educational intervention for junior residents incorporating a conventional tibiofemoral TKA station, two different tibiofemoral CAS stations and a conventional and CAS patellar resection station. The same implant system was used in all cases. Both qualitative and quantitative analyses were performed. Qualitatively, structured interviews before and after the course were analysed for recurring themes. Quantitatively, subjects were evaluated on their technical skills in a timed conventional TKA test before and after the course, and on their knowledge and error-detection skills after the course. Their performance was compared to senior residents who performed only the testing. Four themes emerged: increased confidence, improved awareness, deepening knowledge and changed perspectives. The residents' attitudes to CAS changed from negative before the course to neutral or positive after the course. They expected it to be difficult to use and found that it was easy. They originally distrusted the system, but came to think they would use it for their most difficult cases. The junior resident group improved their task completion rate from 23% to 75% of tasks (p<0.01), compared to 45% of tasks completed by the senior resident group. As a result of the course, the residents will be more aware what to focus on in the operating room. High impact educational interventions, promoting cognitive flexibility and including real-time feedback from computer-assisted surgery simulations, would benefit trainees, surgeons, the healthcare system and patients

Aims. Physician burnout and its consequences have been recognized as increasingly prevalent and important issues for both organizations and individuals involved in healthcare delivery. The purpose of this study was to describe and compare the patterns of self-reported wellness in orthopaedic surgeons and trainees from multiple nations with varying health systems. Methods. A cross-sectional survey of 774 orthopaedic surgeons and trainees in five countries (Australia, Canada, New Zealand, UK, and USA) was conducted in 2019. Respondents were asked to complete the Mayo Clinic Well-Being Index and the Stanford Professional Fulfillment Index in addition to 31 personal/demographic questions and 27 employment-related questions via an anonymous online survey. Results. A total of 684 participants from five countries (Australia (n = 74), Canada (n = 90), New Zealand (n = 69), UK (n = 105), and USA (n = 346)) completed both of the risk assessment questionnaires (Mayo and Stanford). Of these, 42.8% (n = 293) were trainees and 57.2% (n = 391) were attending surgeons. On the Mayo Clinic Well-Being Index, 58.6% of the overall sample reported feeling burned out (n = 401). Significant differences were found between nations with regards to the proportion categorized as being at risk for poor outcomes (27.5% for New Zealand (19/69) vs 54.4% for Canada (49/90) ; p = 0.001). On the Stanford Professional Fulfillment Index, 38.9% of the respondents were classified as being burned out (266/684). Prevalence of burnout ranged from 27% for Australia (20/74 up to 47.8% for Canadian respondents (43/90; p = 0.010). Younger age groups (20 to 29: RR 2.52 (95% confidence interval (CI) 1.39 to 4.58; p = 0.002); 30 to 39: RR 2.40 (95% CI 1.36 to 4.24; p = 0.003); 40 to 49: RR 2.30 (95% CI 1.35 to 3.9; p = 0.002)) and trainee status (RR 1.53 (95% CI 1.15 to 2.03 p = 0.004)) were independently associated with increased relative risk of having a ‘at-risk’ or ‘burnout’ score. Conclusions. The rate of self-reported burnout and risk for poor outcomes among orthopaedic surgeons and trainees varies between countries but remains unacceptably high throughout. Both individual and health system characteristics contribute to physician wellness and should be considered in the development of strategies to improve surgeon wellbeing. Level of Evidence: III. Cite this article: Bone Jt Open 2021;2(11):932–939

Physician health is a global concern, with increasing research efforts directed towards the challenge. Australia has limited published specialty-specific well-being data for trainees and consultants in medicine and surgery. We measured distress in Australian Orthopaedic trainees using the Physician Well-Being Index (PWBI, MedEd Web Solutions) using an online anonymous survey sent by the Australian Orthopaedic Association. The survey response rate was 38% (88/230). Forty-four percent of survey respondents met criteria for distress. Self-reported burnout in the 30 days prior was reported by 63% of respondents. Fifty-eight percent of females and 41% of males met criteria for distress. Of the 19% or respondents identifying as an ethnic minority, 53% were distressed compared to 42% of those identifying as non-ethnic minority. Trainees without a mentor had a 50% distress rate compared to those with a mentor (37% distress rate). Twenty-five percent of all trainees wished they had picked a career outside of medicine and 16% wished they had pursued a medical career other than Orthopaedic Surgery. Of those trainees who had already passed the fellowship exam, 17% wished they had pursued a career outside of medicine and 21% wished they had pursued a medical career in an area other than Orthopaedic Surgery. These findings suggest concerning rates of career regret and gender-related trends in distress in Australian Orthopaedic trainees. Females may be over-represented in our results as 17% of the source population was female compared to 22% of respondents. Further research is required across all Australian specialties to gain further understanding of factors contributing to distress and to assist in the development of strategy to protect against physician burnout

Augmented reality simulators offer opportunities for practice of orthopaedic procedures outside of theatre environments. We developed an augmented reality simulator that allows trainees to practice pinning of paediatric supracondylar humeral fractures (SCHF) in a radiation-free environment at no extra risk to patients. The simulator is composed of a tangible child's elbow model, and simulated fluoroscopy on a tablet device. The treatment of these fractures is likely one of the first procedures involving X-ray guided wire insertion that trainee orthopaedic surgeons will encounter. This study aims to examine the extent of improvement simulator training provides to real-world operating theatre performance. This multi-centre study will involve four cohorts of New Zealand orthopaedic trainees in their SET1 year. Trainees with no simulator exposure in 2019 - 2021 will form the comparator cohort. Trainees in 2022 will receive additional, regular simulator training as the intervention cohort. The comparator cohort's performance in paediatric SCHF surgery will be retrospectively audited using routinely collected operative outcomes and parameters over a six-month period. The performance of the intervention cohorts will be collected in the same way over a comparable period. The data collected for both groups will be used to examine whether additional training with an augmented reality simulator shows improved real-world surgical outcomes compared to traditional surgical training. This protocol has been approved by the University of Otago Health Ethics committee, and the study is due for completion in 2024. This study is the first nation-wide transfer validity study of a surgical simulator in New Zealand. As of September 2022, all trainees in the intervention cohort have been recruited along with eight retrospective trainees via email. We present this protocol to maintain transparency of the prespecified research plans and ensure robust scientific methods. This protocol may also assist other researchers conducting similar studies within small populations

This qualitative study aims to explore and highlight the experiences of trainees in the Orthopaedic Surgical Education Training (SET) program in New Zealand, with a focus on identifying gender-specific biases which may impact professional development. Orthopaedic SET trainees in New Zealand were invited to complete a qualitative, semi-structured questionnaire exploring their experiences in the Orthopaedic SET program. A broad range of topics were covered, addressing culture, belonging, learning styles and role modelling. Recurrent themes were identified using inductive methods. Analysis of questionnaire responses identified several key themes for women in the Orthopaedic SET program, compared to their male counterparts, including (1) role incredulity, (2) confidence vs. competence, (3) adaptation, (4) interdisciplinary relationships and (5) role modelling. Female participants described experiencing gender bias or discrimination by both patients and interdisciplinary colleagues at a higher rate than their male counterparts. The majority of female participants described feeling as competent as their male counterparts at the same SET level, however, identified that they do not typically exhibit the same confidence in their surgical abilities. Whilst similar numbers of female and male participants described experiencing barriers to career progression, female participants described having to adapt both physically and socially to overcome additional gender-specific barriers. Positive influences on training experience included role modelling and supportive relationships amongst trainee groups. This study highlighted gender-specific biases experienced by trainees in the Orthopaedic SET program in New Zealand. Further investigation is warranted to determine how these experiences affect professional development, and how they may be addressed to foster increased gender equity in the surgical profession. This will likely require system-level interventions to create meaningful and sustainable culture change

The COVID-19 pandemic has disrupted all segments of daily life, with the healthcare sector being at the forefront of this upheaval. Unprecedented efforts have been taken worldwide to curb this ongoing global catastrophe that has already resulted in many fatalities. One of the areas that has received little attention amid this turmoil is the disruption to trainee education, particularly in specialties that involve acquisition of procedural skills. Hand surgery in Singapore is a standalone combined programme that relies heavily on dedicated cross-hospital rotations, an extensive didactic curriculum and supervised hands-on training of increasing complexity. All aspects of this training programme have been affected because of the cancellation of elective surgical procedures, suspension of cross-hospital rotations, redeployment of residents, and an unsustainable duty roster. There is a real concern that trainees will not be able to meet their training requirements and suffer serious issues like burnout and depression. The long-term impact of suspending training indefinitely is a severe disruption of essential medical services. This article examines the impact of a global pandemic on trainee education in a demanding surgical speciality. We have outlined strategies to maintain trainee competencies based on the following considerations: 1) the safety and wellbeing of trainees is paramount; 2) resource utilization must be thoroughly rationalized; 3) technology and innovative learning methods must supplant traditional teaching methods; and 4) the changes implemented must be sustainable. We hope that these lessons will be valuable to other training programs struggling to deliver quality education to their trainees, even as we work together to battle this global catastrophe

Orthopaedics has been left behind in the worldwide drive towards diversity and inclusion. In the UK, only 7% of orthopaedic consultants are female. There is growing evidence that diversity increases innovation as well as patient outcomes. This paper has reviewed the literature to identify some of the common issues affecting female surgeons in orthopaedics, and ways in which we can address them: there is a wealth of evidence documenting the differences in the journey of men and women towards a consultant role. We also look at lessons learned from research in the business sector and the military. The ‘Hidden Curriculum’ is out of date and needs to enter the 21st century: microaggressions in the workplace must be challenged; we need to consider more flexible training options and support trainees who wish to become pregnant; mentors, both male and female, are imperative to provide support for trainees. The world has changed, and we need to consider how we can improve diversity to stay relevant and effective. Cite this article: Bone Jt Open 2021;2-10:893–899

Aims. The ongoing COVID-19 pandemic has disrupted and delayed medical and surgical examinations where attendance is required in person. Our article aims to outline the validity of online assessment, the range of benefits to both candidate and assessor, and the challenges to its implementation. In addition, we propose pragmatic suggestions for its introduction into medical assessment. Methods. We reviewed the literature concerning the present status of online medical and surgical assessment to establish the perceived benefits, limitations, and potential problems with this method of assessment. Results. Global experience with online, remote virtual examination has been largely successful with many benefits conferred to the trainee, and both an economic and logistical advantage conferred to the assessor or organization. Advances in online examination software and remote proctoring are overcoming practical caveats including candidate authentication, cheating prevention, cybersecurity, and IT failure. Conclusion. Virtual assessment provides benefits to both trainee and assessor in medical and surgical examinations and may also result in cost savings. Virtual assessment is likely to be increasingly used in the post-COVID world and we present recommendations for the continued adoption of virtual examination. It is, however, currently unable to completely replace clinical assessment of trainees. Cite this article: Bone Jt Open 2021;2(2):111–118

Aims. The number of females within the speciality of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify: 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy; 2) any barriers faced towards pregnancy with a career in T&O surgery; and 3) areas for improvement. Methods. This is a cross-sectional study using an anonymous 13-section web-based survey distributed to female-identifying T&O trainees, speciality and associate specialist surgeons (SASs) and locally employed doctors (LEDs), fellows, and consultants in the UK. Demographic data was collected as well as closed and open questions with adaptive answering relating to attitudes towards childbearing and experiences of fertility and complications associated with pregnancy. A descriptive data analysis was carried out. Results. A total of 226 UK female T&O surgeons completed the survey. All regions of the UK were represented. Overall, 99/226 (44%) of respondents had at least one child, while 21/226 (9.3%) did not want children. Median age at first child was 33 years (interquartile range 32 to 36). Two-thirds (149/226; 66%) of respondents delayed childbearing due to a career in T&O and 140/226 (69%) of respondents had experienced bias from colleagues directed at female T&O surgeons having children during training. Nearly 24/121 (20%) of respondents required fertility assistance, 35/121 (28.9%) had experienced a miscarriage, and 53/121 (43.8%) had experienced obstetric complications. Conclusion. A large proportion of female T&O surgeons have and want children. T&O surgeons in the UK delay childbearing, have experienced bias and have high rates of infertility and obstetric complications. The information from this study will support female T&O surgeons with decision making and assist employers with workforce planning. Further steps are necessary in order to support female T&O surgeons having families. Cite this article: Bone Jt Open 2023;4(12):970–979