243 C OPYRIGHT Ó 2016

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T HE J OURNAL

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AND J OINT

S URGERY, I NCORPORATED

the

Orthopaedic forum

What to Read and How to Read It A Guide for Orthopaedic Surgeons Chad A. Krueger, MD, Joseph R. Hsu, MD, and Philip J. Belmont Jr, MD Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

With the increasing amount of information available to orthopaedic surgeons, the choice of what to read can seem difficult bordering on overwhelming. As orthopaedic surgery continues to evolve toward a more evidence-based education system, deciding what information resources to use is ever more important. Many orthopaedic surgeons have had little formal instruction on what educational resources to read or how to best understand the information and assimilate it into their practice. This lack of knowledge may contribute to difficulties when trying to learn a topic, develop a plan of care, build a knowledge base for patient care, or develop a method for maintenance reading. This article reviews the rationale for using evidence-based medicine, explores the different types of educational resources available to orthopaedic surgeons, and delivers insight into the science of reading. This information should aid orthopaedic surgeons in using peer-reviewed publications to aid in their decision-making processes. An Overwhelming Amount of Information Although the exponential rise in publications has added immense knowledge to the field of orthopaedic surgery, the influx of data

has made staying current with the literature very difficult. A few recent articles have attempted to address this issue1-3. There are more than 100 orthopaedic journals indexed on MEDLINE4, and more than 12,000 articles were published in orthopaedic or sports medicine journals in 20135. In addition, more than 600 of the orthopaedic surgery books available on Amazon.com were published in 2014 alone6. For an orthopaedic surgeon, reading only the articles in The Journal of Bone & Joint Surgery (American Volume) (JBJS) and Clinical Orthopaedics and Related Research would equate to reading approximately 120 articles per month. For a specialist primarily focused on reading The American Journal of Sports Medicine and Arthroscopy, there are nearly sixty articles to read per month. If this is what is considered “staying current,” the time requirement to read even most of these articles is substantial and likely exceeds the amount of time that most responsible surgeons budget toward maintenance reading. Furthermore, this reading does not account for the time an orthopaedic surgeon spends finding, downloading, and interpreting information concerning patient or procedure-specific questions or reading other resources such as textbooks. This volume of information necessitates that an orthopaedic surgeon understand

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article. Disclaimer: The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Army, Department of Defense, or the US government.

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TABLE I List of Recommend Articles and Web Sites That Can Help Educate Readers on the Best Ways to Read Articles and Incorporate Information Using an Evidence-Based Approach Source

Article or Web Site

Publications Journal of Bone & Joint Surgery (American Volume)

User’s Guide to the Orthopaedic Literature: How to Use an Article 1 About a Surgical Therapy User’s Guide to the Orthopaedic Literature: How to Use a Systematic 2 Literature Review How to Read the Literature to Change Your Practice: An Evidence-Based 3 Medicine Approach 35

Clinical Epidemiology and Biostatistics: A Primer for Orthopaedic Surgeons 36

Lessons Learned from Benchmark Orthopaedic Trials

Hierarchy of Evidence: Where Observational Studies Fit in and Why We 37 Need Them 38

Journal of Bone & Joint Surgery (British Volume) Journal of the American Academy of Orthopaedic Surgeons

Statistics in Orthopaedic Papers Reading and Reviewing the Orthopaedic Literature: A Systematic, Evidence-Based 39 Medicine Approach

Injury

Evidence-Based Medicine: What It Is and What It Is Not

40

Online resources OrthoEvidence

http://myorthoevidence.com/

Cochrane Database of Systematic Reviews

http://community.cochrane.org/editorial-and-publishing-policy-resource/ cochrane-database-systematic-reviews-cdsr

AAOS evidence-based medicine information

http://www.aaos.org/research/evidence/ebmmain.asp

JAMAevidence

http://jamaevidence.mhmedical.com

what resources to use in what circumstance and how each resource can most efficiently be utilized. We are unaware of any widespread, formal instruction on how to identify the resources that will most effectively provide residents and practicing orthopaedists with the information they seek. The difficulties in identifying high-yield materials combined with varying levels of comfort in properly interpreting the methods and results of many primary sources7,8 leaves surgeons frustrated with the perceived overload of educational material available. For many of these reasons, surgeons and trainees alike tend not to read full scientific articles, preferring the more manageable abstracts instead9,10. Take-Home Point There is too much information produced in orthopaedics for one person to read and assimilate without a self-directed educational plan. Evidence-Based Medicine The evidence-based medicine (EBM) paradigm was developed to provide scientific information to physicians so they can improve the quality of their patient care11. In EBM, physicians are taught to use information grounded in the scientific process to best evaluate and treat patients. The fact that the EBM model is still relatively young and many practicing orthopaedic surgeons were trained prior to or during the early stages of its implementation may help explain why some orthopaedic surgeons do not regularly use EBM principles to guide their reading. Additionally, the strength of

EBM is dependent on the quality of the supporting evidence. In the setting of clinical practice guideline development, there is often a shortage of Level-I studies to support “strong” EBM recommendations, so EBM recommendations are often classified as “weak.” Schemitsch et al.12 surveyed members of the AOA (American Orthopaedic Association) and found that over 40% of those surveyed “rarely or never” incorporate EBM when making decisions on how to treat patients, and close to 50% of those surveyed primarily use personal experience or Level-Vevidence when making clinical decisions. Similarly, surveys of surgery residents in multiple subspecialties found that, although most of the residents thought that incorporating EBM into their practice was important, only 28% felt they had received the proper training to do so13. This perceived lack of training in EBM deserves attention, since improved care with EBM has been demonstrated in various medical specialties14,15. The numerous resources available to physicians on critical reading and EBM decision-making can help readers decide which evidence warrants a change in practice (Table I). We encourage readers to utilize these resources to better understand how to apply EBM principles to their practice. The AAOS (American Academy of Orthopaedic Surgeons) has many EBM resources available to its members16. The clinical practice guidelines and appropriate use criteria have been developed through work groups as tools to educate surgeons on the best evidence available for common orthopaedic conditions and on how to use that evidence to improve orthopaedic care. Although the clinical practice guidelines are sometimes unable to provide the definitive answers surgeons

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TABLE II General Reading Categories* Type of Reading

Reading Goal

Suggested Source

Knowledge

Learning a subject

Textbook

Application to practice

Specific question, generally about a patient, seeking a detailed answer for comprehension

Scientific articles

Immediate knowledge

Specific question, generally about a patient, seeking a quick answer

JAAOS articles, textbook chapters, instructional course lectures, journal review articles

Surgical case preparation

Knowledge of surgical indications, surgical approach, procedure technique, complications, and postoperative care

Anatomy and surgical atlases, surgical textbooks, surgical device technique manuals, Orthopaedic Knowledge Online videos

Exam. preparation

Review of the most commonly tested concepts

Review texts and online sources

*The columns summarize why an orthopaedic surgeon would be reading (left column), what the surgeon would hope to gain from such reading (middle column), and the source that is most likely to help the surgeon accomplish the goal (right column).

desire, because of a lack of available evidence17, they provide a foundation of knowledge on which surgeons are able to base their clinical decisions. Take-Home Points The majority of orthopaedic surgeons do not currently use EBM in their clinical decision-making. Orthopaedic surgeons should familiarize themselves with the EBM publications and online resources to best incorporate EBM in their clinical practices. Identifying Reading Goals and Determining the Appropriate Reading Source Multiple questions need to be answered in order to find the most appropriate reading source. The depth of knowledge a surgeon needs to answer an examination question concerning an orthopaedic injury is likely to be different from that needed to perform a basic orthopaedic surgical procedure. For example, in an examination question concerning surgical treatment, the surgeon may be provided pertinent information in the question stem, an imaging study needed to make the diagnosis, and a list of possible answers. In contrast, a surgeon assessing a potential surgical candidate needs to ask all of the appropriate questions to obtain the patient’s history, determine the correct imaging study to order, and finally decide on the appropriate surgical treatment without a “right” answer directly visible. Guiding questions that one should ask while determining what to read are: What is my level of training or specialization? Am I reading for general knowledge, to answer a specific question, or for a quick review? What educational materials do I have access to? Research has indicated that a surgeon is unlikely to pay for an article, instead opting for free educational resources whose quality may not be as high9. Once the goals of the reading have been determined (Table II), an orthopaedic surgeon can start to look for the reading material that will satisfy the need. Residents and attending physicians do not employ the same strategies of teaching or learning within the operating room18,19, and it is safe to assume that these differences exist

when trying to read or learn about a topic as well. Previous studies have indicated that residents appear to be more concerned with technical aspects of the disease treatment process, whereas attending physicians feel it is more important to learn about the natural history of the disease20. Additionally, residents are often unaware of what they do not know 20, making a focus on more general diagnostic and treatment information important. This type of general topical information can be found in many Journal of the American Academy of Orthopaedic Surgeons (JAAOS) articles, JBJS Reviews, instructional course lectures, clinical practice guidelines, or textbook chapters. Such sources are typically easy to read and comprehensive, allowing them to be understood by surgeons who have less familiarity with the content discussed21. The downside to these comprehensive resources is that the material may be so basic that it serves merely as a review rather than a resource to efficiently inform someone with substantial background knowledge on the topic21. Scientific articles, in contrast, may necessitate a more robust knowledge base and be better suited for experienced surgeons. Primary articles may also require substantial effort to interpret findings, allowing readers to make stronger inferences and deeper connections with the presented information in determining how it shall apply to clinical practice19,21. In short, differences in the structure of texts substantially impact what a reader is likely to learn from them22. Table III provides a description of common orthopaedic surgery reading sources along with their strengths and weaknesses. Although each surgeon will undoubtedly develop an affinity for certain resources on the basis of their content and design, many surgeons are unaware of the learning style they commonly employ 22,23. This learning is directly affected by the format of the article itself 19. Although residents are more likely than attending physicians to use web-based searches for information20, previous surveys have shown that residents are sometimes less satisfied with online-based information sources13. Multiple studies in the field of psychology show that readers often skim in a predictable fashion when

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TABLE III The Strengths and Weakness of Commonly Used Information Sources in Orthopaedic Surgery Reading Type

Strengths

Weaknesses

JAAOS or review articles

Emphasis on current literature, comprehensive analysis

“Filter effect”: information filtered by multiple peer reviewers toward the journal’s goal

Orthopaedic Knowledge Update

Based on reductionist theory, annotated bibliography, vetted by AAOS

Publication lag on the current literature presented

Textbooks

General foundation of knowledge, good for concepts

Publication lag, biased by author, less peer-reviewed than review articles

Scientific articles

Real-time knowledge, minimal filtering

Information not useful by itself and lacks context, not always applicable

Review texts

Focused on testable information

Publication lag, may lack clinical applicability

Review web sites

Real-time review information

Information not always vetted or peer-reviewed

completing web-based readings and that readers exhibit decreased recall accuracy and less focus with web-based formats24. These findings, however, do not seem to have decreased either resident or attending physician enthusiasm for using electronic devices for patient and clinical data25. Once it has been determined that an article is of interest, the next step is to examine the authors and their institutions. Studies have shown that research projects by surgeons who have self-reported conflicts of interest are significantly more likely to report positive findings than those completed by surgeons without those conflicts and that financial disclosures are not always as forthright as one would hope26,27. Surgeons may also have nonfinancial conflicts of interest that can affect an article’s tone or conclusions. These “intellectual conflicts” can lead to bias on the part of surgeons during both the data collection and data reporting processes, thereby influencing an article’s conclusions28,29. Such conflicts, which are often not obvious when reading, include situations in which an author strongly believes in a specific treatment or diagnostic test and constructs studies or writes texts in a manner supporting his or her own beliefs while discounting conflicting evidence or opinion. Also, the author may practice at a facility that has treatment and rehabilitative options that are not generalizable to the reader’s practice (poor external validity), making the results of the study interesting but less applicable. The author’s practice or hospital affiliation can often inform readers about the practice setting in which the research was performed and how similar or dissimilar it is to the reader’s own practice setting. All of these conflicts should be considered both before and after reading a text, as the source’s credibility will impact the learning experience of the reader and affect the article’s external validity30. The reader can also find out if the author has written about a certain technique or test in the past and use those manuscripts to better understand any potential intellectual conflicts that may influence the author. Take-Home Points It is important for orthopaedic surgeons to establish their learning objectives prior to reading a text or online resource and make sure that those objectives align with the material. Understanding

the authors’ financial or intellectual conflicts of interest is relevant when interpreting whether the results should apply to the reader’s practice. Practical Approach to Reading Most readers tend to remember information that aligns with the intended purpose of their reading31, so it is important to consider that purpose before studying an article or a textbook. Reading a journal article or book chapter and learning material from it are different processes21 that are affected by factors such as a text’s content and structure as well as by the reader’s attention, desire to learn, mood, and background knowledge19,31,32. The basic process, however, requires the readers to see information, to determine if it is worth remembering or relating to their previous knowledge, and to form new inferences that can be used in clinical situations19. Although there are a few articles showing a correlation between specific reading programs and improved in-training examination scores33, very little data actually exist regarding how a surgeon should read to improve general or specific knowledge34. Surgeons must also be aware of potential misconceptions they may have regarding a topic prior to reading. These fallacies make it more difficult to understand and recall material than if the reader had no prior knowledge of the subject at all19,32. Such misunderstandings are most effectively altered by using sources designed in such a way as to refute previously established beliefs (e.g., “myth buster” articles) by presenting the previously misconceived data next to the correct information19,32. If an orthopaedic surgeon is reading to answer a specific question, it may be efficient to peruse an article until that information is found. If reading for general knowledge, reading the article from start to finish may work best24. Most people will slow down their reading, paraphrase, and try to make connections between the reading material and their background knowledge when reading to gain information31. When the surgeon is familiar with the topic, a text can be quite complex and he or she will still be able to follow, and learn from, the discussion21. The same cannot be said when the topic being discussed is unfamiliar. In those situations, finding articles that are easier to read will benefit

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Fig. 1

Recommendations on how to most efficiently skim texts.

the surgeon by requiring less technical effort and allowing more focus to be placed on the material itself 21. Research has also shown that readers are likely to have an easier time integrating information from the text into their working knowledge when they perceive that the text is from a highly credible source30. Book chapters provide more a more comprehensive review of topic information but can be quite time-consuming to read. If readers desire to gain a general understanding of a text without reading it completely, skimming the text may actually provide them with a better general understanding of the material than choosing to linearly read only parts of the chapter24. Skimmers appear to spend more time at the beginning of both paragraphs and pages—reading the first couple of sentences or paragraphs and then moving forward in the text in search of new information. Although skimming may be advantageous in certain aspects, it does not allow for a complete grasp of topic knowledge or for a reader to become aware of previous misconceptions as well as slow, purposeful reading would24,32. On occasions when time constraints prohibit conventional reading of textbook chapters and review articles, recommendations for skimming can be found in Figure 1. Many surgeons may attempt to apply these skimming tactics to scientific articles in an effort to maximize the information learned while minimizing the time spent reading. Such a strategy can be challenging since the idea of skipping to “important parts” of a text would seem to require the surgeon to know a priori what information is important and what information can be skipped. Skimming a scientific article may therefore lead a surgeon to miss key differences involving the applicability of the methodology or details of the results that would change how the surgeon interprets the study. Instead of skimming a scientific article, a method of article triaging can help optimize efficiency. The external validity

of a scientific article will determine its relevance to the practice of the reader. External validity is questioned when there are differences in the practice patterns or patient populations between those in the article being evaluated and those that the orthopaedic surgeon encounters and treats in his or her practice35. The internal validity of the article determines whether the results are meaningful1. Those studies with the best internal validity are typically those that are randomized and controlled in an effort to minimize bias and possible confounding variables35. By first assessing the external and internal validity of the article, relevant and valid articles can be quickly identified for complete reading while irrelevant or flawed papers can be eliminated without additional time investment. This is most easily accomplished by reading the methods section of an article first. If the methods are not sound, then the internal validity is low and the results may be invalid. If the methods are sound but the patient population or practice setting is different from the reader’s, then the external validity is low and the results may not be applicable to the reader’s practice. Recommendations on how to best triage scientific articles for reading can be found in Figure 2. Take-Home Points (1) If a surgeon has a firm understanding of a topic, reading a more controversial article or book chapter is likely to result in maximum recall from the reading. (2) If a surgeon has a more rudimentary understanding of a topic, choosing a more straightforward source will be most beneficial. (3) Skimming a textbook is unlikely to result in a gross misunderstanding of the book’s contents. However, skimming a scientific article may cause a reader to overlook key points of information that could dramatically alter their interpretation of the article’s findings. (4) When reading scientific articles, a surgeon should first determine the internal and external validity of the article.

Fig. 2

Recommendations on how to best triage scientific articles to determine if the information they contain should be read and incorporated into the surgeon’s knowledge.

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Take-Home Points Junior residents should focus on reading more general texts that provide them with broad understandings of general topics. As residents ascend through their orthopaedic surgery residency training, they should utilize more primary articles to fine-tune their understanding of decision-making in a topic and become increasingly familiar with EBM recommendations. Practicing surgeons should focus their reading on high-level evidence and EBM articles, while critically evaluating the relevance of the articles and effect on their practice.

Fig. 3

Diagram showing the different levels of information gathering and knowledge acquisition for orthopaedic residents and attending physicians at different career stages.

Reading Based on Level of Training What an orthopaedic surgeon reads will largely depend on their career stage (Fig. 3). Interns and junior residents are in the data-gathering phase of their education, and they should focus their readings on textbooks and other generalized resources that allow them to learn the terminology and basic concepts of orthopaedic surgery. Senior residents, however, are starting to compare data and concepts in order to develop a more meaningful understanding of certain topics or controversies, and they should incorporate more primary articles into their readings. Younger surgeons are developing their clinical practice, preferred treatment algorithms, and longitudinal patient care. Incorporation of studies with Level-I evidence and best available evidence into their practice in an effort to further improve their patient outcomes is recommended. This necessitates reading high-quality articles and EBM guidelines that are specific to their scope of practice. Mid-career and senior surgeons should also incorporate data from Level-I studies and EBM into their work and have the opportunity to evaluate how previous adaptions have affected their patient outcomes.

Summary There is an overwhelming amount of information available to orthopaedic surgeons. A surgeon needs to know the strengths and weaknesses of each source and understand how each text may be most useful. By developing specific goals and understanding how they are most likely to learn the information presented in the text, surgeons are able to develop an efficient reading plan for gaining general knowledge and for answering patient-specific questions. This basic understanding will serve orthopaedic surgeons well throughout their career and enable them to maximize the value of the wealth of orthopaedic knowledge that is currently available. n

Chad A. Krueger, MD Orthopaedic Surgery, San Antonio Military Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234. E-mail address: [email protected] Joseph R. Hsu, MD Department of Orthopaedic Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC 28204 Philip J. Belmont Jr, MD Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79920

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What to Read and How to Read It: A Guide for Orthopaedic Surgeons.

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