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What Gives? Orthopedic Residency Education
More to learn, less time to learn it, and a field that is not always exactly in agreement about what should be learned…these are some of the issues facing hospital administrators, educators and others standing on the shifting sands of U.S. residency education. Now, thanks to a few visionaries in New York, they have found firmer footing.
Laura Robbins, DSW, a researcher at Hospital for Special Surgery (HSS), is lead author on an article recently published in the Journal of Bone and Joint Surgery that outlines the results of an orthopedic residency directors peer forum. She says, “In 2006-2007 we at HSS began to seriously look at the issue of how to maintain our world class orthopedic residency training program and still meet the stringent external requirements such as the work hour restriction mandated by the Accreditation Council for Graduate Medical Education (ACGME). The issue arose in a number of meetings and we all came away feeling like we were the only program experiencing these difficulties. A ‘eureka’ moment struck, and we decided to convene a meeting of program directors from several other top level training programs in order to determine what issues our colleagues were facing. I think everyone was a bit relieved to learn that we are all dealing with the same challenges.”
When the 12 program directors came together for two days in May 2008, they had already done some pre-meeting homework. Dr. Robbins:
Prior to the event the program directors were asked to evaluate whether the traditional residency model is appropriate for the training of future surgeons, and to note approaches that have been successfully implemented in residency programs.
"Our hope was that by outlining areas of need, those who provide oversight regarding residency requirements will move forward with us to find solutions.”
As the two-day meeting progressed, certain themes took shape. “Nearly everyone has felt the crunch of the 80-hour work hour restrictions mandated in 2002,” says Dr. Robbins. “You will find much in the literature about how learning basic orthopedic surgery skills may be compromised because of things such as less time in the OR, reduced continuity of care, and less experience with disease process evolution. In our discussions we reviewed the possibility that these issues may also be affected by other ACGME restrictions, such as the eight-hour break between shifts and mandated ‘one day off in seven’ days. To meet these challenges, most if not all programs have made changes to their call systems, hired more Physician Assistants and Nurse Practitioners, and restructured the scheduling of night floats.”
As for HSS, they are glad to see their 70 physician assistants walk in the door each morning. “Most programs have hired physician assistants and nurse practitioners to handle some of the pre and post surgical care. The major issue everyone in a hospital faces is the challenge of delivering appropriate continuity of care to each patient. To do that, program administrators must clearly delineate roles, understand each person’s responsibilities and ensure effective team communication so that nothing gets ‘dropped.’ Some programs have had success with electronic communication, but I think for everyone to be on the same page, face-to-face communication between team members, for instance with team rounding, is essential to good patient care.”
Is it possible that orthopedists might need to know less about lupus and more about reading an MRI?
“The group examined each training year and developed four recommendations regarding the first year of residency. We thought it best to assess the impact of the work hour restriction as early as possible in training. The group’s first proposal was that training programs should reclaim three months of general surgery, meaning that PGY1 would expand to include six months of orthopedics. The second proposal was that programs should determine whether residents are spending time in rotations that maximize their knowledge acquisition. This may mean, for example, less rheumatology and more imaging. Third, the group advised that night rotations should only be utilized when there is a clear educational value and that there is good communication and handoff of the patient at the start of the morning shift.”
Then the group turned its attention to an area prone to turf battles…what exactly is the most important knowledge that orthopedic residents need to learn? Dr. Robbins says, “Program administrators must look at what it means for residents to be competent in the exam room and in the OR. While this is a broad topic, the group did identify the first step, which is to define what core orthopedic knowledge should be imparted to residents during their training. To do that, the group suggested that administrators examine such issues as how many cases of any given type a trainee should perform, how much exposure to X,Y and Z a resident should have outside of the OR, etc. The ACGME does not prescribe how much residents need to know for any given surgery, and while required to ensure preop or postop time engaged in these activities, it is left to the individual program to figure out the right formula for effective resident learning.”
New forms, new labs, new focus…these are some of the core knowledge recommendations flowing from the HSS meeting.
The group developed 10 recommendations, some of which include: have a reading list that captures core knowledge, define and require a minimum of cases by anatomic area and difficulty, and require a number of cases where the resident has a specific operative role.
"With the growing knowledge in the field of orthopedics coupled with specialized operative techniques, program directors are beginning to identify those procedures and skills which are essential to educate a competent orthopedic resident. ACGME also requires that residents engage in research, so the group recommended that each resident be required to have institutional review board training and certification in order to ensure that they are prepared for research training. By making this a requirement, the group hoped to foster a cadre of researchers who would be able to add to new orthopedic knowledge and surgical advances. Also, the program directors suggested that educators develop a standard comprehensive preoperative planning form.”
U.S. Navy photo by Photographer’s Mate 2nd Class Johansen Laurel/Wikimedia Commons
One of the core knowledge recommendations dovetails nicely with the fact that orthopedists love nothing more than being in the OR. And with the decreased time on the job due to work hour restrictions, they need as much hands on experience as possible. Dr. Robbins explains, “Because cadaver labs have been found to be effective in developing and refining coordination and psychomotor skills, the group felt that a psychomotor lab skills course should be required in the second year of training. The thinking was that due to the expense of such an effort, a consortium of programs could join forces to create one or more national laboratories that would be open to all.”
The third theme emerging from the meeting of orthopedic minds captured a trend in the field…measuring. “Outcomes research is the current trend, and for good reason. The group recommended that program directors and administrative oversight groups should define and require standard formats for measuring residents’ performance (such as resident portfolios). Tools such as the portfolio would allow useful performance outcomes such as resident self learning case vignettes that can then be used with more objective performance data such as OITE [Orthopaedics In-Training Examination] scores by teaching faculty and program directors to improve the overall resident curriculum. Among the other proposals was that there should be a standard format for the biannual evaluation process. The program directors selected the Duke University School of Medicine’s format as a model. That format employs a resident-completed pre-evaluation form and an evaluation that includes input from mentor physicians, attending physicians, nurses, patients, other residents, and medical students. Lastly, it involves a face-to-face debriefing session between the resident and the faculty mentor to provide useful feedback and areas of mutual agreement for further training and development.”
Also included in the benchmarking proposals was a recommendation that residents be provided with more meaningful feedback about their performance.
Dr. Robbins notes, “Letters of commendation could be shared with faculty and other residents; also, administrators should explore ways of codifying the behaviors that led to the commendation. Another suggestion was that programs debrief residents who scored in the top 10% of the Orthopaedics In-Training Examination, with an eye toward understanding their study strategies, documenting them, and then disseminating them to other residents.”
The final theme addressed by the group members brought into focus a very real shift in wider society that has, quite naturally, made its way into residency training…how people of varying ages acquire information. “It is a different world today, and there is a general consensus that real generational differences exist between faculty and residents. The program directors cited a number of examples in which residents displayed a distinct preference for digital and experiential learning as well as interactivity and immediacy. Thus the group recommended that programs put as much educational material as possible into an electronic format and place it on the Internet. They also suggested that administrators delineate clear and explicit roles, goals, and expectations for both faculty and residents for each rotation, program component, and even each case.”
Saving perhaps the hottest potato for dessert, the group convened by HSS did exchange a few words about the length of orthopedic residency training.
There is always the question percolating in the background, namely, ‘Should orthopedic residencies be extended to six years?’ This idea has gained ground because of the explosion of knowledge and the other issues mentioned here.
"The group that we convened made no hard recommendation on this topic, but there was extensive discussion. Many people say that if we extend programs that will give us more time on the front end to focus on core surgical expertise and the latter years to focus on specialization.”
On all of these issue, time—and a lot of work—will tell.
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