Extract
The third annual American Orthopaedic Association-Orthopaedic Research and
Education Foundation (AOA-OREF)-Zimmer Resident Leadership Forum was held in
June 2005, coinciding with the 118th Annual Meeting of the AOA. Its general
purpose was to bring together selected young resident leaders from North
America to develop leadership skills in orthopaedics. The effectiveness of
orthopaedic education has been questioned with the advent of the eighty-hour
workweek and the ever-emerging importance of residency accreditation. The
focus of the 2005 Resident Leadership Forum was how best to train competent
orthopaedists for general orthopaedic practice. The AOA leadership focused the
Resident Leadership Forum on four potential strategies to improve resident
education: (1) maintain the current residency system (i.e., the status quo),
(2) shorten the current training system, (3) lengthen the current training
system, and (4) restructure an orthopaedic-specific core competency system.
After analyzing each strategy independently, the residents came to a consensus
and provided specific resolutions to improve resident education. The present
article represents their opinions and not necessarily those of the AOA or
educational experts.
The third annual American Orthopaedic Association-Orthopaedic Research and
Education Foundation (AOA-OREF)-Zimmer Resident Leadership Forum was held in
June 2005, coinciding with the 118th Annual Meeting of the AOA. Its general
purpose was to bring together selected young resident leaders from North
America to develop leadership skills in orthopaedics. The effectiveness of
orthopaedic education has been questioned with the advent of the eighty-hour
workweek and the ever-emerging importance of residency accreditation. The
focus of the 2005 Resident Leadership Forum was how best to train competent
orthopaedists for general orthopaedic practice. The AOA leadership focused the
Resident Leadership Forum on four potential strategies to improve resident
education: (1) maintain the current residency system (i.e., the status quo),
(2) shorten the current training system, (3) lengthen the current training
system, and (4) restructure an orthopaedic-specific core competency system.
After analyzing each strategy independently, the residents came to a consensus
and provided specific resolutions to improve resident education. The present
article represents their opinions and not necessarily those of the AOA or
educational experts.
On the basis of data from the Accreditation Council for Graduate Medical
Education (ACGME) and the American Board of Orthopaedic Surgery (ABOS) as of
February 2005, there were 152 ACGME-accredited orthopaedic residency programs
in the United States with a total of 620 graduates per year and a total of
3209 positions1. At
present, there is no standardized curriculum for orthopaedic programs, but
there are general guidelines for both the ACGME and ABOS. The ACGME program
requirements for graduate medical education in orthopaedic surgery are
provided in Section II of the Graduate Medical Education
Directory2.
These general guidelines give a broad administrative framework. Although the
ACGME provides specific rotation requirements for the postgraduate year
(PGY)-1, there are none for PGY-2 through PGY-5. The Orthopaedic Residency
Review Committee is also a critical part of the process as it accredits
orthopaedic residency
programs3.
The ABOS, on the other hand, provides general guidelines or content
requirements in its "2005 Rules and Procedures for Residency Education
Part I and Part II
Examinations."4
It also lists requirements similar to those of the ACGME for PGY-1; moreover,
it lists more specific guidelines for orthopaedic education (PGY-2 through
PGY-5). These guidelines are referred to as a "minimum distribution of
educational experience," and they include twelve months of adult
orthopaedics, twelve months of fracture and trauma care, six months of
children's orthopaedics, and six months of basic science and/or clinical
specialties. At the completion of residency, documentation verifying that
residents have successfully completed these required rotations must be sent by
the program director to the ABOS. Recently, a case log from the online ACGME
system of all procedures performed during residency has also been required.
These are then reviewed by the ABOS Credentialing Committee. If approved, the
resident is deemed eligible to sit for the ABOS written examination (Part
I).
The ABOS Part-I board examination is a knowledge-based examination
(approximately 300 to 320 questions) that reflects what a resident should know
or learn during orthopaedic residency. The ABOS has broken down the
examination by subspecialty category and has weighted each category
(Table
I)4.
The Resident Leadership Forum Class of 2005 was surveyed to obtain a
representative sample of the perceptions of current orthopaedic residents
regarding their educational environment since, in many ways, the Resident
Leadership Forum consists of future leaders in orthopaedic surgery. The survey
assessed demographic data, subspecialty exposure, time spent in outpatient
clinics compared with that spent in the operating room, educational curricula,
examinations and/or evaluations, the eighty-hour workweek, research,
fellowships, and the ACGME core competencies. Topics were scored on a 5-point
Likert scale, with 5 indicating either the most educational or desirable.
Means and modes were calculated. All fifty participating residents completed
the survey.
Demographic Data and Comparison of Clinic Time and Operating-Room
Time
The average age of the fifty residents in the Resident Leadership Forum was
thirty-one years (range, twenty-seven to thirty-six years). Forty-three (86%)
of the fifty residents were from academic health centers, and no two were from
the same training program. The residents felt that 38% to 40% of their time
was spent in the outpatient clinic, while 60% to 62% of their time was spent
in the operating room. The residents believed that the ideal breakdown would
be to spend 34% (range, 15% to 50%) of their time in the clinic and 66%
(range, 50% to 85%) of their time in the operating room.
Subspecialty Exposure
The majority of the PGY-1 experience was in general surgery (60%), while
the remainder was spent in orthopaedic surgery (22%) and other specialties
(18%). During orthopaedic training (i.e., PGY-2, PGY-3, and PGY-4), the
specialty breakdown was consistent with the residents' expectations
(Table II). There were,
however, a few notable exceptions. Residents reported that 9% of their time in
training was spent in sports medicine, yet they felt that up to 13% of their
time should be allocated to sports medicine. Likewise, residents desired more
time than they were receiving in foot and ankle (9% compared with 5%) and
arthroplasty (14% compared with 10%). Residents believed that too much time
was designated to "general orthopaedics" (16% compared with their
ideal time of 12%) and pediatrics (14% compared with their ideal time of 10%).
(General orthopaedists are defined as nonsubspecialty-trained surgeons with a
body of knowledge consisting of basic adult and pediatric fracture care, hand
surgery, arthroplasty, and arthroscopy.) Generally, residents felt that foot
and ankle, sports medicine, and musculoskeletal oncology were underemphasized,
while pediatrics and general orthopaedics were overemphasized.
Educational Curricula
Although the curricular structureof the programs in which the respondents
were training varied, a consistent pattern was evident. Eighty percent of the
programs had specialty-specific didactic teaching; what is surprising is that
20% did not. Pediatrics and trauma were the most consistent and most
well-organized of the subspecialty conferences, while sports medicine, foot
and ankle, and musculoskeletal oncology were the least well-organized. Only
20% of the residents reported that their training programs had basic-science
didactic lectures. Attending surgeons led the majority of the didactic
conferences (56%), with residents and fellows presenting the lectures 39% and
5% of the time, respectively.
All programs had some form of a journal club and a morbidity and mortality
conference, and most residents believed that these conferences were important
to their education. On a 5-point Likert scale, with 5 indicating the most
desirable, journal club ratings averaged 3.4 (mode, 3 to 4), and morbidity and
mortality conference ratings averaged 3.7 (mode, 4 to 5). On the other hand,
very few programs provided educational training to the residents on practice
management (average, 2.4; mode, 2.0), with 40% of the programs listed
averaging =2 (i.e., very little exposure) on a Likert scale.
In-Training Examination and Evaluations
All residents surveyed took the Orthopaedic-In-Training Examination (OITE).
Most found the OITE to be helpful (average, 3.4, mode, 3 to 4), and all
residents thought that extra preparation for the examination was required
beyond their formal or informal resident education. This extra preparation
included studying Orthopaedic Knowledge Update (80%), self-assessment
examinations (92%), and prior OITE examinations (80%). With regard to the ABOS
examination, up to 82% of the residents were planning on taking a review
course. Written evaluation of residents seems to occur almost universally, as
98% of residents reported having been evaluated on each rotation. Discussion
of evaluations does not occur as commonly, as only 80% of the residents had
reviewed their evaluations with the service chief or program director. Of
those residents, most found their evaluations to be educational, with an
average score of 3.6. Interestingly, while 98% of the residents were evaluated
by their attending surgeons, only 10% of the residents performed evaluations
of their rotations or attending surgeons.
Eighty-Hour Workweek and Research
Most of the residents felt that their programs were compliant with ACGME
work-hour restrictions. The average Likert score was 4.3 of 5, with 5
indicating the most compliant with the eightyhour workweek. Forty percent of
the residents thought that work-hour limitations diminished the educational
experience, while 32% said it improved (or would improve) education. When
asked whether work-hour limitations would make necessary an additional year of
training to be proficient, most (80%) disagreed and thought it was not
necessary (average, 2.0; mode, 2). Only 40% of the programs offered or had a
research track, although 100% of the residents said research was encouraged.
Most felt that research was relevant to their education (average score, 3.5)
and to their careers (average score, 3.6).
Fellowship
Seventy-five percent of the residents surveyed had exposure to fellows
during their training. Most residents felt the fellows were helpful (average,
3.1; range, 1 to 5; mode, 76% of 3), and 71% of the residents thought that
fellows did not limit their education. Forty-five (90%) of the fifty residents
were planning on pursuing a fellowship. The most common reasons to enter a
fellowship were specialty-specific interest (92%), mobility or job placement
(56%), quality of life (28%), earning potential (10%), and inadequate training
(8%). The most common projected fellowship subspecialties were sports medicine
(40%) and spine (22%), while the least common were trauma (4%) and foot and
ankle (2%) (Table III).
Core Competencies
Ninety percent of the residents were knowledgeable about the ACGME core
competencies. Most believed that they were important to their education
(average, 3.8; range, 1 to 5; mode, 3 to 4). Of the six core competencies,
medical knowledge, patient care, and professionalism were addressed by
programs the most, while system-based practice (20%), practice-based learning
(24%), and communication skills (18%) were addressed the least.
The fundamental question posed to the Resident Leadership Forum was how
best to train competent orthopaedists. To accomplish this goal, the residents
thought that they first had to define what a general orthopaedist is. This
task was found to be more difficult than first envisioned. Are general
orthopaedists community orthopaedists or community-based orthopaedists? Are
they private practitioners? How many generalists are there? With further
discussion, some residents concluded that a general orthopaedist was a
physician with a broad and flexible skill set, who is competent performing
common procedures such as knee and shoulder arthroscopy, primary arthroplasty,
and stabilization of most fractures in adults and children. General
orthopaedists have the clinical acumen to treat anyone who walks in the door
but know when to refer to a subspecialist, as with musculoskeletal tumors or
highly complex conditions. Many participants, however, remained uneasy with
this definition. The term "general orthopaedist" continued to seem
confusing and unclear to them.
Although the Resident Leadership Forum participants believed that a general
orthopaedist was an important concept, they were uncomfortable in using
"general orthopaedics" as the benchmark for orthopaedic education.
Residents were less concerned about defining a general orthopaedist and were
more concerned about finishing their five-year training program as competent
orthopaedic surgeons. If the goal of resident education is to produce
prepared, competent orthopaedists, they believed that orthopaedic competency
should be the benchmark of an orthopaedic curriculum. General orthopaedists
are present-day surgeons involved in a wide variety of patient-care
activities. Orthopaedic competency should be a definable and objectively
measurable set of principles or guidelines used to assess and treat various
musculoskeletal conditions. In addition, since these principles are constantly
evolving as science progresses, these guidelines may be continuously
redefined, improved, and remeasured. Although defining these principles or
guidelines would be no simple task, the participants in the 2005 Resident
Leadership Forum were certain that if the orthopaedic profession did not
define them themselves, then they may be defined by an outside organization,
which may not have the best interests of either the orthopaedic community or
their patients in mind. As a result of these factors, the participants made a
number of recommendations for improving orthopaedic residency education.
The 2005 Resident Leadership Forum believed that greater structure should
be provided for the length of rotations and the overall amount of exposure
required in various subspecialties. The group advocated at least three months
of exposure to community orthopaedic practice. The line between core
competencies as guidelines and an overly rigid bureaucratic curriculum is a
thin one. The residents favored a system with clear guidelines that will
provide each resident with a better sense of what is expected from him or her
and a clearer definition of what residents need to know in order to properly
evaluate their capabilities and progress throughout training. Although the
participants did not desire a bureaucratic, micro-managed system, they thought
that a more formal structure was necessary in orthopaedic education, i.e., a
need for a national curriculum. With the eighty-hour workweek decreasing the
overall time for training an orthopaedic resident, the group believed that
more centralization and formalization were necessary.
The residents recommended that restructuring and monitoring should begin
during PGY-1, when the number of nonorthopaedic rotations should be minimized.
However, meaningful interactions with other specialties such as radiology and
anesthesiology should be nurtured into a richer educational experience. During
PGY-2 through PGY-5, experience in general orthopaedics and pediatrics should
be decreased and experience in arthroplasty, sports medicine, and foot and
ankle should be increased. Residents should have more flexibility in PGY-4 and
PGY-5. For example, elective rotations during these years could provide
flexibility and mitigate any perceived deficiencies. Although there is
substantial variability in the clinic experience in residency programs, in
general, clinic time has to be protected (approximately 35% of training) and
variable (i.e., exposure to various clinic settings including private practice
and indigent care).
The 2005 Resident Leadership Forum recommended that structured training on
Workers' Compensation issues and practice management topics (hiring
procedures, small business practice, coding and/or billing, and medicolegal
issues) be included as mandatory aspects of resident educational programs.
When possible, didactic lectures should be specialty-specific. The residents
actually preferred these didactic sessions to be given by senior residents,
fellows, and junior faculty rather than more experienced senior faculty. In
addition, there needs to be more emphasis on orthopaedic basic knowledge
(basic sciences) during training, since this is a recurring testing theme for
the board examination.
Further, the 2005 Resident Leadership Forum recommended that the present
resident evaluation process should be completely reassessed and possibly
supplemented. This coincided with the advent of the recent Certificate of
Added Qualifications processes, which has standardized accredited fellowship
curricula to coincide with certification
testing5.
Specifically, postrotation evaluations, the OITE, and the board examination
should be updated according to these new guidelines. Measurement tools should
be developed to document how effectively the residents are learning these new
guidelines6. These
tools should not be too rigorous, since this will distract time and resources
from other fundamental areas of education.
The last critical issue is manpower. The advent of the eighty-hour workweek
has stressed the resources of most
programs7-11.
An increase in the number of positions for nonphysician providers, such as
physician assistants and nurse practitioners, has filled some voids. The
reality is that more orthopaedic residency positions may be necessary in many
programs to adequately fulfill work-hour compliance. It is unclear who should
decide the need for more orthopaedic residency positions: the American Academy
of Orthopaedic Surgeons (AAOS), AOA, or ACGME. Recognizing that change is
occurring in all programs in response to the eighty-hour workweek, the
residents advocated a greater need for efficiency in training by means of more
structure and guidelines in orthopaedic curricula. The consensus of the
Resident Leadership Forum was to standardize a process while maintaining the
interests of the general orthopaedic community in order to maximize resident
preparedness for their future. How best can we do this? There are multiple
choices.
The Resident Leadership Forum engaged in a strategic analysis of four
potential solutions to the issue of how best to prepare residents for general
orthopaedic practice. The four solutions were to maintain the status quo,
shorten general orthopaedic training and begin subspecialty training earlier,
lengthen orthopaedic training, and, finally, define and implement six
orthopaedic core competencies.
Choice 1: Maintain the Status Quo
The first option, which is to maintain the current residency system, has
many advantages. It is time-tested, and many competent surgeons have come out
of this system12.
It is the easiest choice, which gives freedom, diversity, and flexibility.
Dilemmas, such as how best to define a general orthopaedist, can be avoided.
In addition, there are few signs that change is really needed. Are young
orthopaedists really incompetent and unprepared? Few even agree that there is
a problem or a deficiency in training in the first place.
The Resident Leadership Forum, however, felt that the current system is not
ideal. The medical landscape is rapidly changing from both a legislative and
medicolegal perspective. Orthopaedic training must be proactive, not static,
in order to maintain quality output. The body of knowledge is also changing,
and education and expectations should reflect this change. Finally, the public
may also expect its educational institutions to change in order to stay
current with the evolving knowledge base of information.
The impact of the eighty-hour workweek has had profound effects on
residency education. As time is being effectively shortened, educational
efficiency must be maximized and reorganized. The current system has not
effectively addressed many of the problems crippling our educational system
such as overspecialization, a lack of training in practice management, and,
most importantly, the lack of centralization in our education curriculum.
There needs to be more structure with basic goals and stricter guidelines,
which are reinforced by an appropriate evaluation and testing system. If the
present status is maintained and everything is left to individual residency
programs, a stable but static and inconsistent system will continue.
Choice 2: Shorten Residency Training
Shortening general orthopaedic training in favor of earlier subspecialty
training has certain advantages. First, with the gradual specialization of
medicine, orthopaedists can focus on their subspecialty earlier and have
greater exposure. Second, with so much specific information to learn, focused
specialty training is more efficient. There will be limited time wasted on
topics not utilized in practice. Third, this focus on specialization may
improve clinical
outcomes13.
Unnecessary components of internship and general training can be eliminated,
leaving only core components of orthopaedic education, i.e., concentrated
training. A similar philosophy has recently been adopted by general surgery,
which has established a new training paradigm consisting of three years of
general surgery followed by subspecialty training. Besides the benefits of
specialization, such a strategy would allow young orthopaedists the potential
to earn financial rewards earlier.
The problems with this system, however, are manifold. This system would
create a generation of unsafe orthopaedists without a general orthopaedic
background. They would lack the fundamental knowledge base in trauma,
pediatrics, and musculoskeletal oncology. This would not only exacerbate the
shortages in these subspecialties but would also affect the quality of care in
providing these services. This would worsen the present access issue, creating
liability and ethical dilemmas. Additionally, by eliminating exposure to
general surgery and critical care medicine, orthopaedists would develop into
pure technicians rather than physicians and scientists. Finally, it is
impractical from a training perspective. This approach would leave residents
with a limited ability to change their minds, and it would force them to make
a decision regarding the type of fellowship to pursue even earlier in the
process with limited exposure in certain fields. It would place even greater
stress on the time that residents are allotted for research, clinic, and
elective rotations. It would take flexibility out of the entire orthopaedic
educational landscape, creating a more subspecialized model.
Choice 3: Lengthen Residency Training
The across-the-board institution and enforcement of the eighty-hour
work-week has fundamentally changed every aspect of residency education. It
has decreased the amount of time that a resident devotes to his or her
training prior to leaving the residency by as much as 25%. One simple solution
for this problem is to lengthen orthopaedic residency training from five to
six years. Some argue that lengthening training time may alleviate many
problems of the current system. Residents would be better trained, have more
surgical experience, and have more time for research. It would also reduce the
residency program's manpower crunch and allow more time for basicscience and
clinical lectures.
Although data are beginning to surface on the impact of the eighty-hour
workweek on resident
education7-11,
there is still no consensus on the issue. The requirements appear to be
affecting different residency classes and programs in different ways. No clear
consensus has been reached on the exact long-term impact; however, it is
widely accepted that the eighty-hour workweek will have a substantial impact
in some way and will need to be considered in any future modifications to the
residency
curriculum9-11.
Many of these questions remain unanswered, but the perspective of the
residents participating in the Resident Leadership Forum was clear with regard
to keeping residency at five years and increasing the number of and access to
orthopaedic fellowships. In fact, the residents were adamantly opposed to
lengthening residency training and felt that the gains would be insignificant.
They believed that the fact that 80% to 90% of residents are entering
fellowships would correct any deficiencies in their residency training due to
the time constraints of the eighty-hour workweek.
Choice 4: Orthopaedic Core Competencies
The final option is a better defined orthopaedics-specific system of core
competencies. The problem in creating any guideline system is formulating one
that is applicable, flexible, and meaningful. The present generic system of
core competency implemented by the ACGME increases rules and perpetuates
bureaucracy. The competencies—and the methods used to measure
them—are nebulous, difficult to implement, and a challenge to evaluate
effectively. The present didactic sessions related to systems-based practice
are unhelpful, and the evaluations of them are meaningless. Unlike the
existing core competencies, a new set of core competencies should be developed
that are specific to orthopaedics.
The orthopaedics-specific core competencies would define "general
orthopaedic knowledge" as defined by practicing orthopaedic surgeons.
These guidelines for general orthopaedic practice would best prepare residents
by providing them with a set of general orthopaedic skills adaptable to
various specialties. By defining basic core issues, the system would be both
structured and flexible and, hopefully, produce better-trained
physicians14. The
guidelines would define a minimum set of disease processes that one should
know how to identify, evaluate, and treat, if one is comfortable with doing
so. It should consist of "minimum" requirements of those
"must-know items" that are commonly seen and commonly treated.
Yet, it should be flexible enough to minimize the medicolegal implications of
rigid definitions.
In order to create a new orthopaedics-specific system, similar obstacles
will have to be confronted as in creating any guideline system. Extensive
lists and definitions will have to be formulated. It will be difficult to
standardize without being either too expansive or limited. There will also be
legal ramifications with a bureaucratic burden. There will be more emphasis on
technical proficiency in evaluations and objective assessment
tools6. The system
will have a style similar to Part II of the board examination with a focus on
indications, surgical pitfalls, postoperative management, and relevant
literature. It will facilitate accountability by programs in order to ensure
that all programs are exposing residents to appropriate and adequate training.
Since there is a wide range of residency programs, it will respect these
differences with its flexibility. However, the system will ensure by its
standards that residents are exposed to adequate training in all areas.
By defining core competencies specific to orthopaedic surgery, residents
will learn to evaluate and treat common musculoskeletal problems according to
their own limits. They will have constant individualized evaluations and
standardized criteria, which can be used to assess their readiness for the
board examination.
The Resident Leadership Forum Class of 2005 recommended two fundamental
changes to orthopaedic education. First, the AOA should create and define a
set of orthopaedics-specific core competencies within the framework of the six
general competencies. Second, once the first change has been accomplished, a
review of the length of training and quality of time spent on each competency
needs to be reevaluated.
Although the practical implementation of these resolutions may be
difficult, the Resident Leadership Forum thought that certain educational
concepts should be maintained and protected:
1. The intern year should be governed by the department of orthopaedics so
that it facilitates orthopaedic education consistent with orthopaedic training
goals. Interactions with other specialties such as general trauma, plastic
surgery, radiology, and anesthesia should be pertinent to orthopaedic training
in a structured experience.
2. Whatever changes occur in residency programs, the journal club and the
morbidity and mortality conference should be preserved. In addition, the
continued confidentiality of the morbidity and mortality process is essential
to its success as a learning experience.
3. Faculty who make education a priority should be rewarded. Today, in many
programs, there are waning incentives for attending physicians to take time to
teach. Currently, an attending physician's effectiveness is assessed by
clinical practice volume, creating more of a business than an educational
environment15. In
order to ensure the continued quality of the resident educational experience,
faculty teaching must be encouraged with use of strong institutional
support.
4. Residents must have a defined but flexible curriculum. To enhance their
learning experiences, programs must allow residents to go out into the
community or even abroad to gain necessary experiences. The curriculum,
however, should not be defined by a benchmark of a general orthopaedist but
rather on orthopaedics-specific core competencies.
5. Any new system must respect and embrace the diversity of each training
program and of each individual, thereby reflecting the reality that programs
and individuals must be able to have maximum flexibility to reach a common
goal.
6. The assessment tool of the orthopaedic credentialing body (the board
examination) should truly reflect the defined core orthopaedic knowledge, and
there should be appropriate and transparent evaluation methods relative to
that knowledge base.
The Resident Leadership Forum was posed a specific question on how best to
train competent orthopaedists for general orthopaedic practice. This task was
found to be more difficult than first envisioned, and it exposed many other
questions. Ultimately, a consensus was reached after four different strategic
choices were openly presented and debated. After analyzing each choice
independently, the Resident Leadership Forum came to a conclusion that to
define and strengthen orthopaedics-specific core competencies was the best way
to address the question. Although this opinion survey represents a small
fraction of all orthopaedic residents, a representative sample with a clear
message was achieved. Hopefully, in the near future with the guidance of the
AOA, these resolutions can be implemented.
Note: The authors thank Andrew Malkiewicz, BA, for his
assistance in obtaining the survey and preparation of this manuscript.
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