The evolving paradigm of orthopaedic resident education is a frequent area of discussion among those responsible for resident training. Although the body of knowledge and treatment options for patients with musculoskeletal disease steadily expand, the work-hour restrictions implemented within the past decade limit the actual experiential opportunity for residents. In addition, new expectations, based on the “core competencies”1 in the United States and the “CanMEDS”2 Physician Competency Framework in Canada, have been established for the educator. We appreciate the differences between these two philosophies of resident education but believe extensive common ground exists among the challenges.
While attempting to adjust to these requirements, many believe the balance in the missions of the academic orthopaedist has changed. Declining professional fee reimbursement; changing practice models, including the integration of physicians into hospital employment relationships; and an increasing role of midlevel healthcare providers have the potential to de-emphasize our teaching focus and passion.
Finally, in addition to orthopaedic knowledge and clinical skills, many differences exist between the educator and orthopaedic resident. Although it would be inappropriate to label any one individual with a collection of attributes related to birth year, sociologists and educators agree that the current generation views the balance between professional and work life differently than do most individuals in a position of senior leadership in academic orthopaedic departments3-6. Technology has become an integral component in the way in which residents learn, and residents often believe that they can use that technology to instantaneously find solutions to unanswered questions. There is also a perception that residents, during their training and on the basis of their fellowship match, begin to view themselves as future specialists who don’t really need to learn the fundamentals of orthopaedics beyond their anticipated area of discipline. Thus, a resident might ask, “If I’m going to be a spine surgeon, why do I need to learn how to reconstruct an anterior cruciate ligament?”
The Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Graduate Medical Education in Orthopaedic Surgery7 outline in great detail the diverse expectations for training programs, and we refer the reader to that web site. We emphasize the importance of the need to integrate each of the core competencies into the curriculum and that residents “must have clinical problems of sufficient variety and volume to afford residents adequate experience in the diagnosis and management of adult and pediatric orthopaedic disorders”7. Specific time requirements and surgical volumes are not mandated by the Orthopaedic Residency Review Committee during the second through fifth years of training7. However, beyond postgraduate year one (PGY-1), the American Board of Orthopaedic Surgery (ABOS) does outline time requirements: “Orthopaedic education must be broadly representative of the entire field of orthopaedic surgery. The minimum distribution of educational experience must include:
twelve months of adult orthopaedicstwelve months of fractures/traumasix months of children’s orthopaedicssix months of basic and/or clinical specialties
Experience may be received in two or more subject areas concurrently.”8 In addition, twelve months of training may be dedicated to general or pediatric orthopaedics, a clinical subspecialty, research, or other experiences approved by the program director.
In this article, we review what we believe to be both the current state and challenges of orthopaedic resident education and we pose considerations for the future. In addition, we review practices that the orthopaedic educator can implement immediately to improve the quality of the orthopaedic resident’s learning experience on a daily basis.
Regardless of duration of training, we must answer the fundamental question of how to know when our residents are ready to graduate. More than 100 years ago, Abraham Flexner delivered his stirring report on the plight of medical education in North America and called for radical changes to allow medicine to advance into the next century12. Now we are once again facing the same questions from society and from our patients—does our current educational system provide the best training program possible for the next generation of physicians? Furthermore, medical educators have struggled for decades with the question of how best to evaluate residents. Many instruments have been developed and continue to be developed in an attempt to better quantify this process. Some of the available options include self-assessment, clinical evaluation, online anonymous tools, and peer-to-peer evaluations.
However, are we really evaluating the residents? Or are we just checking boxes to satisfy ACGME mandates for measuring outcomes? The core competencies and CanMEDS guidelines were developed to better define the competent surgeon. They were implemented, however, without an obvious performance metric, and individual programs were encouraged to develop their own tool kits13. Furthermore, educators were encouraged to develop methods to help assess attainment of the competencies.
Despite these goals, a recent study has evaluated the peer-reviewed literature and found that the assessment methods do not fall neatly into discrete categories as the ACGME had likely hoped14. In fact, “it may be that medical educators have blurred the distinction between using competencies as an educational framework to organize and guide learning, and attempting to translate them directly into evaluation tools.”15
Furthermore, another recent study reinforces the growing concern regarding pitfalls in the pursuit of objectivity, by showing that assessment of residents’ performance in the clinical setting is still, despite concerted efforts to promote standardized competency frameworks, heavily influenced by subjective factors15. The toolbox of evaluation methods has been criticized by some as being half empty14 while others believe that there are numerous useful options currently available16. In 1975, the OSCE (objective structured clinical examination) was introduced as a method by which to standardize residency education17. It remains one of the key elements used in the evaluation of medical students and residents and has been validated in innumerable studies over the years. A recent study demonstrated improved emergency resident performance in association with use of the OSCE18.
Expectations of Program Directors and the Performance of Residents
Another concern is of unmet expectations of our faculty with respect to orthopaedic resident performance. Perhaps we expect too much of the residents and therefore set up a model in which they are doomed to fail? Two recent studies have found that this theory can explain the widening gap between the expectations of program directors and the performance of residents. The most plausible explanation for this gap was attributable to the unrealistic expectations of the program directors about the rate of skill progression, which led them to set unrealistic standards19,20. Although advantages of competency-based education have been identified, theories about the implementation of such programs continue to evolve21,22.
Even with recognition of the imperfections in our current assessment strategies, it is still essential that feedback and assessment occur. Hewson and Little22 have reported that providing feedback is one of the most difficult things for medical educators to do. Regardless of the performance metrics being used, residents must understand how they are being evaluated and must regularly be provided with meaningful feedback and assessment of their performance.
While the ACGME and its residency review committees revise accreditation requirements at least once every five years, changes to the specialty-specific requirements for orthopaedic surgery residencies have been relatively minor since the middle part of the 1990s. Together with continuing critiques from Congress, the Institute of Medicine, the Medicare Payment Advisory Commission (MedPAC), and patient advocacy groups, this suggests that it may be an appropriate time to consider potential changes to the status quo.
Although some have commented on the need for an additional year of orthopaedic residency training to balance against the resident work-hour restrictions, major barriers exist to implementation of this plan. Both MedPAC23 and the bipartisan National Commission on Fiscal Responsibility and Reform24 have suggested reducing government funding for graduate medical education (GME) by as much as 60% (from approximately $10 billion to $4 billion). In addition, given the desire for more primary-care physicians, shifting some of the remaining funding from fellowship to residency education is also being considered.
If funding is reduced and/or shifted, it is anticipated that (a) the number of fellowship positions will be significantly reduced and (b) there will be some interest in reducing the number of years that physicians in training are required to devote to medical school and residency. It seems most appropriate to spend time now thinking about how orthopaedic surgery education might be modified rather than waiting for external groups to impose their directives.
We believe that numerous opportunities exist at the program-planning level to improve orthopaedic resident education. For example, we appreciate the importance of residents learning basic surgical and patient management skills in their PGY-1 year, but believe reevaluation of this year is warranted to allow completion of more than three months of orthopaedic rotations. In addition, the fifth year could be redesigned so that some residents may select an area of concentration. While some could elect a fifth year in hand, trauma, or joint reconstruction, others might prefer another year of general orthopaedics. Finally, to permit residents to elect a focused PGY-5 experience, some adjustments to the current requirements for time required on specific rotations might be needed.
Competency-Based Curriculum: A New Model for Teaching Orthopaedics
The currently established duration of orthopaedic training is based on tradition rather than evidence. While some have recommended increasing the duration of training, an alternative approach would be to maximize the educational effectiveness of the available training hours. To ensure appropriate training of competent orthopaedists, a curriculum in which residents graduate from a rotation on the basis of demonstrated competency, rather than on the amount of time spent on a service, would be preferable25. Clinicians and education scholars at the University of Toronto are implementing a pilot orthopaedic residency curriculum (overlaid on a competency-based framework of resident training) that maximizes the utility of available training hours. Competency is defined as having the necessary ability, knowledge, and/or skill to do something successfully. In the context of training an orthopaedist, a competent clinician would have all of the skills necessary to handle a clinical situation but might not have yet handled the particular problem or procedure in an independent manner. This is what we expect of our orthopaedic residents. The purpose of a residency is not to create clinicians who are proficient and can perform all subspecialty procedures, but rather to create clinicians who are proficient and who, in their first weeks in practice, can act independently at procedures that a general orthopaedist would be expected to be able to perform, such as procedures to treat hip fractures. This concept guided the kinds of clinical encounters and training exercises that were deemed important to the residency training experience in this new University of Toronto curriculum.
The program was also designed such that residents can advance through their training as quickly as possible so that they will be able to sit for their specialty certification examinations when the faculty concludes that they have achieved all of the competencies prescribed in their curricular objectives. As such, the duration of training for an individual resident might take as little as three years, or even longer than five.
A working group used the existing curricular objectives as a baseline and reframed them in the context of twenty-one modules. The trainees are assigned to curricular objectives rather than being assigned to a particular service. They might have clinical experiences at multiple hospitals on a given module. A comprehensive series of assessment tools are used to ensure that residents have reached certain performance benchmarks, and once they have succeeded in satisfactorily completing the objectives of that module they can move on to the next module.
In the early modules, a majority of the trainee’s time is spent in a simulation laboratory, where they learn skills such as how to use instruments, how to apply casts, and how to use power tools. The skills lab uses multiple platforms of training, with the design of the training based on the growing evidence that skills learned in a simulation laboratory can be transferred to the real world of the operating room26.
Three residents started the pilot program each academic year, starting in July 2009 (out of thirteen residents each year). The residents in the pilot competency-based stream self-rated their confidence in their abilities in orthopaedics appreciably better than those in the regular stream. Residents had a pre-test on technical skills on entry, and then interim testing after the initial modules or regular stream rotations. Competency-based residents systematically showed better growth in skill level than the conventional-stream residents for the majority of tasks27. There was also an appreciable difference in the number of operative cases logged for conventional-stream residents as compared with competency-based residents, with competency-based residents performing three times the volume of hip-fracture cases as compared with the number performed by the conventional-stream residents in their year in training. The residents are progressing through the program at different rates, and two of the initial three residents in the pilot program completed nearly a third of the modules in their first academic year. Consequently, the residents in the competency-based stream are achieving the goals of their training and, thus far, the program is more than meeting the established goals.
While there are obvious logistical and financial issues associated with running an entire residency program that is based on this type of competency-based curriculum, many of the lessons learned in this pilot can easily be applied to orthopaedic training in general. Focusing the education on what is appropriate to produce competency, flexibility in the time required for residents on specific rotations, the use of a simulation laboratory to enhance the rate of skills acquisition, and the use of comprehensive evaluation tools are all things that can be incorporated into any residency experience. With use of these principles, the time available for residency training can be used in a much more effective way to produce residents who will have a greater degree of confidence that they are trained to the appropriate level of competency.
How would education scholars respond to the challenges which confront today’s orthopaedic educators? The answers may lie in some well-established educational concepts that have stood the test of time.
From an educational point of view, a key concept is that residents learn via role modeling—that is, by observing how we handle these new challenges. For better or worse, regardless of whether we are actively “teaching” our residents, they will be learning from what we are doing. Role modeling is a major—probably the major—means by which a resident learns orthopaedics. This is true when you are demonstrating a surgical procedure that you have done a thousand times, but it is also true for situations that you face for the first time. How we carry ourselves when confronted with new systems changes helps to define the profession from the resident’s point of view.
What effect have resident work-hour restrictions had on resident learning? Many educators have expressed concern that, due to the decreased time available to care for patients, residents not only take much longer to accumulate the necessary clinical experience, but (perhaps more worrisome) may not be appropriately acculturated to the values of the profession. On the other hand, proponents of the work-hour restrictions argue that prolonged work hours may adversely affect patient safety and may not lead to a proportional increase in knowledge.
What does the education literature say about the role of experience in learning? There is actually a fairly robust set of literature on how individuals learn from experience. Kolb’s theory on experiential learning is generally accepted among education scholars28. The theory argues that to learn from experience you need just that—an experience, or some experiences. There is simply no substitute for seeing and doing things. However, Kolb also argues that, just as critically, learners need time to reflect on their experiences, either formally or informally, to consolidate these experiences into an organized way of thinking about the topic in question. A work environment that precludes such reflection is therefore likely to be a negative one. Kolb’s theory suggests that, rather than focusing purely on a resident’s work hours, we should focus on the type of experiences the resident is having and how the resident reflects on these experiences. Looking at this in another way, we can say that people do not actually learn from all mistakes. Rather, we learn from those mistakes that we actually identify and then spend time in analyzing (and perhaps agonizing over) what we should have done differently.
More broadly, as we think about orthopaedic education in the future, we should be guided by four key educational concepts29:
We need to focus on what residents learn, not merely on what they are taught. This challenges the educator to focus on how residents actually see the world. How do they construct reality? This means being attuned to their misconceptions, knowledge gaps, and emerging professional values.We must appreciate and optimize the critical use of feedback and evaluation. More specifically, regular feedback is critical to effective learning. How can residents be expected to optimize their learning if they are not made aware, on a regular basis, of their knowledge and technical deficits and misconceptions? Evaluation in the broader sense should be used to delineate what is expected of the resident, thereby serving to drive learning and appropriate resident behavior.We should plan programs that provide our residents with the means to acquire the professional knowledge, skills, and attitudes that are consistent with our profession.The last and perhaps most critical important principle is to recognize the essential nature of role modeling in shaping the development of orthopaedic trainees. What we do as orthopaedic educators is much more important than what we actually say.
Many educators have expressed concern with regard to the current status of orthopaedic resident education and the future orthopaedic workforce. It is essential that orthopaedic educators, the ABOS, and the Orthopaedic Residency Review Committee thoughtfully and collaboratively move forward with analysis of resident education as opposed to reacting to mandated change. In addition, we must commit ourselves to enhancement of our skills as educators, critical analysis of the competencies necessary for the 21st-century orthopaedist, and development of an orthopaedic curriculum that will allow us to train an outstanding workforce in the years ahead in the most efficient manner. Great opportunity exists for us, but we must take the lead!