To focus the discussion on the most important issues, all invitees were asked to complete a detailed survey prior to attending the meeting. The questions were developed on the basis of emerging issues from the literature and focused on the existing programmatic challenges faced by residency directors. The survey was completed by educators from an additional five programs who were unable to attend because of scheduling conflicts. A subset of the results—the responses to "How is increasing surgical volume impacting specific areas of training?" "What has been the response of your residency program to the volume pressures?" and "What are the areas where improvement is most needed in your program?"—are shown in Tables II, III, and IV; the full results of the survey are available on request.
Presented here are the four most frequently mentioned themes that were chosen for discussion at the meeting. The themes were (1) compromises to the learning experience caused by the work-hour restrictions mandated by the Accreditation Council for Graduate Medical Education (ACGME) in 2002, (2) the need to identify a body of core orthopaedic knowledge with specific goals and expectations, (3) the need to develop common benchmarks to measure and improve program effectiveness, and (4) the challenges caused by generational differences between faculty and residents. Each of these four themes was discussed by using a modified nominal group technique with a facilitator. (The modified nominal group technique is a facilitated consensus-building process consisting of four phases: The first phase is the creation, out of the whole group of participants, of a set of "breakout teams," consisting of five or six members each to address a question, with each team having a facilitator; once the teams have been formed, the second phase is an idea generation session, where members of the breakout teams work individually; the third phase is a group discussion and voting on the ideas suggested by individual members of the team; and the fourth and last phase consists of a presentation of the conclusions and recommendations from the breakout team that is made by the facilitator for the team to the plenary session of the whole group.)
Theme 1: Work-Hour Restrictions
It has often been suggested that learning the basic orthopaedic surgery knowledge and necessary technical skills may be compromised because of factors including decreased operative experience, lack of continuity of care, and less experience with disease process evolution1,8-10. These issues may be complicated not so much by the eighty-hour rule itself but rather by additional restrictions, such as the eight-hour break between shifts and a day off every seven days, required by the ACGME. Because of these regulations, most if not all programs have already been restructured through changes to their call systems, hiring of ancillary staff, or scheduling night floats. The group reviewed the rotations in each year as well as other learning components and discussed what could be added, eliminated, reduced, or augmented. While the group discussed various recommendations to address work-hour restrictions at each training level, the recommendations here address postgraduate year 1 only, as the group agreed that it would be most effective to start a review of the impact of this rule at the earliest point in the residents' training. The unanimously supported recommendations are as follows:
- Reclaim three months in postgraduate year 1 from general surgery to offer a total of six months of orthopaedic coverage.
- Review whether residents are spending their time in rotations that contribute the maximum knowledge and/or usefulness. For example, are residents spending enough time in imaging or acute trauma? Should certain rotations be reduced, e.g., anesthesiology or rheumatology?
- Use night rotations sparingly and appropriately when there is a genuine educational value, such as on trauma rotations in the emergency department, and integrate the residents on those rotations into the orthopaedic surgery department better.
Theme 2: Core Orthopaedic Knowledge
After acknowledging that the absolute minimum outcome of a residency is passing Parts I and II of the certification examination of the American Board of Orthopaedic Surgery, the group unanimously agreed that a more important goal is to develop competent orthopaedists who are also surgically capable, good teachers, and strong leaders, with a solid foundation in research and ethics. (The attendees to the forum all agreed that, although we can measure cognitive and motor skills, actually measuring competence is very difficult. While the participants discussed at length the metrics to assess what makes a competent orthopaedic surgeon, it is an area that needs to be defined much more specifically and was suggested as a topic for discussion in a follow-up meeting.) The following recommendations were made and appear as follows in no specific order of importance:
- Develop a basic core of knowledge with a reading list and place it on the Internet for ease, speed, and ability to update. (The group recognized that there are many details, such as negotiating copyright and establishing and reviewing the content at regular intervals to ensure currency, that need to be addressed.)
- Define and require a minimum number of surgical cases by anatomic areas and by difficulty.
- In addition to requiring a certain number of procedures in terms of quantity and difficulty by anatomic area, require a number of cases where the resident has a specific operative role as opposed to the current system where the operative role is not specified. (A specific definition of the range of operative roles would need to be developed first.)
- Develop a new format for surgical logs to include the categories listed above (i.e., difficulty of case and role of resident).
- Define minimum technical competencies in terms of specific techniques, e.g., open rotator cuff repair, total hip replacement, and knee arthroscopy.
- Require institutional review board training and certification of every resident.
- Develop a standard comprehensive preoperative planning form, examples of which should be included in the resident's portfolio.
- Protect conference time, as didactic and Socratic conferences continue to offer the best opportunities for learning, role modeling, and understanding medical decision-making.
- Create a technical and/or psychomotor skills laboratory course in the second year. Because of the expense involved, one or more "national" laboratories open to all could be built by a consortium of programs, sponsored totally or in part by industry.
- Involve specialty societies in helping to establish differentiated goals for each year, core reading lists of classic and/or seminal articles, and technical and/or psychomotor skill benchmarks by year.
Theme 3: An Effective Benchmarking Program
The group discussed the basis for benchmarking resident performance within a program and across programs, with use of a portfolio approach. Recommendations are as follows:
- Define a standard format (i.e., contents and measures) for a resident portfolio.
- Develop a set of common instruments to measure the core competencies in a way that makes sense for orthopaedic surgery.
- Propose a standard format for the biannual evaluation process. The three-step process used by Duke University School of Medicine was offered as a model: (1) a resident-completed preevaluation form; (2) a 360-degree evaluation that includes medical students (that is, the resident's performance is evaluated by all important groups of individuals with whom the resident interacts: mentor physician, attending physicians, nurses, patients, other residents, and medical students); and (3) a face-to-face debriefing session.
- Require resident representation on select hospital-wide committees (e.g., the medical board) to help to maintain systems-based competency.
- Provide residents with more meaningful feedback. Three examples are (1) sharing letters of commendation with faculty and other residents, (2) exploring ways of codifying the behaviors that led to the commendation, and (3) debriefing residents who scored in the top 10% of the Orthopaedics In-Training Examination to understand their study strategies, which could be documented and disseminated to others11,12.
We recognized that in order to fulfill the many ACGME evaluation requirements, the burden upon individual residency programs in terms of infrastructure and resources can be heavy. For example, a 360-degree evaluation process as recommended here requires substantial commitment and resources. The recommendation from the peer group was to explore in greater detail approaches, such as information technology-based solutions, to ease the burden of dissemination, collection, and analysis of evaluation surveys.
Theme 4: Generational Differences
There was unanimous consensus that real generational differences exist between faculty and residents. For example, residents have a preference for digital and experiential learning as well as interactivity and immediacy13-15. Although no "scientific" evidence for these differences was pointed out at the meeting, all participants provided a large number of anecdotes and experiences and agreed that these generational differences in preference for information delivery and format have to be addressed to maximize the effectiveness of teaching. The recommendations included the following:
- Place as much educational material as possible into an electronic format and make it available on the Internet.
- Specify clear and explicit roles, goals, and expectations for both faculty and residents for each rotation, each program component, and even each case (using the new preoperative planning form). Ask both residents and faculty to sign a "contract" of acknowledgment and provide feedback after completion of each component.
- Faculty may have to rethink and redesign the teaching materials by using electronic and multimedia formats, i.e., a web-based, interactive curriculum, in order to address the learning mode preferences of orthopaedic trainees.
Residency education is essential for the well-being of our patients and the future viability of the field of orthopaedic surgery. The recommendations in this article are aimed at refreshing and improving the traditional structure of orthopaedic residency programs. The recommendations are a road map to explore beneficial changes to all orthopaedic programs and need to be developed further as we adapt to the ever-changing health-care environment. The group made a commitment to reconvene in the near future, to disseminate these recommendations to the organizations providing oversight of residency programs, and to enlarge the process by inviting other educators to join in these conversations.