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Proposals for Change in Orthopaedic Education: Recommendations from an Orthopaedic Residency Directors' Peer Forum
Laura Robbins, DSW1; Mathias Bostrom, MD1; Edward Craig, MD1; Thomas P. Sculco, MD1
1 Division of Education and Academic Affairs (L.R.), Department of Orthopaedic Surgery (M.B., E.C., and T.P.S.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for L. Robbins: robbinsl@hss.edu
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Jan 01;92(1):245-249. doi: 10.2106/JBJS.I.00210
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Extract

Orthopaedic residency education currently faces a number of difficult challenges. Among them are the explosion of knowledge, the need to teach both the basics of orthopaedic research and surgical techniques, work-hour restrictions, the limited number of trainees, the growth in demand for surgery, greater specialization and complexity of patient care, more complicated resident evaluations, and the changing demographics, lifestyles, and values of the residents1-7.
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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Laura Robbins, DSW
    Posted on July 27, 2010
    Dr. Robbins and colleagues respond to Dr. Wong
    Hospital for Special Surgery, New York, New York

    We agree that teaching residents how to teach early on in their training through well-defined methods has the potential to be effective in facing today’s challenges in orthopaedic education. The Dreyfus Developmental Model that takes the learner from novice to master is well suited for a 5-year training program and, like similar models, should incorporate electronic education media and other state-of-the-art evaluation tools that help teachers and learners benchmark education outcomes. Orthopaedic surgery programs continue to discuss the efficacy of evaluation and outcomes, and we could not agree more that now is the time for action.

    Ivan H. Wong, MD
    Posted on June 24, 2010
    Residents Teaching Residents
    McMaster University, Hamilton, Ontario, Canada

    To the Editor:

    Orthopaedic surgery education is in a rapid state of evolution. “Proposals for Change in Orthopaedic Education: Recommendations from an Orthopaedic Residency Directors' Peer Forum” by Robbins et al. (2010;92:245-9) brings up challenges in four major themes: work-hour restrictions, core orthopaedic knowledge, effective benchmarking programs, and generational differences. As a new Orthopaedic Educator at McMaster University, I am striving to maximize resident learning. Recently, the Royal College of Physicians and Surgeons of Canada (RCPSC), like the Liaison Committee on Medical Education (LCME), has mandated teaching residents how to teach which could help to address the challenges above (1).

    Resident skill acquisition can be categorized into the Dreyfus Developmental Model: novice, advanced beginner, competent, proficient, expert, and master (2). When learning a task, residents begin not knowing what they need to know, progress to realizing what they don’t know, to awareness of what they need to know. Later, as they master orthopaedic skills, they will be less able to articulate their thinking process to others (3).

    Promoting resident teaching should increase learning efficiency and the acquisition of orthopaedic knowledge. Teaching a skill can help move the resident from competent toward proficient through focused practice. Those that have just learned a skill may also better articulate the nuances to their junior colleagues than the unconsciously competent staff physician. This can enhance both their reflection on a learned subject and their junior colleague’s learning (4). Resident input for creating benchmarks may help increase relevancy of these tools since they have recently learned these skills. More importantly, as most residents are of the same generation, they are similarly accustomed to newer methods of electronic educational media and better able to relate to one another if given the tools (5).

    The challenge is to encourage this type of education, to help prepare residents to teach, and to capture the effectiveness of this avenue of education through well-designed research. Residents teaching residents could be an essential resource and solution to the challenges that we face in orthopaedic education today. I believe we are up to the task. We just need to do it!

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    References

    1. The Royal College of Physicians and Surgeons of Canada (RCPSC). General standards applicable to all residency programs. General standards of accreditation. 2006.

    2. Carraccio CL, Benson BJ, Nixon LJ, Derstine PL. From the educational bench to the clinical bedside: translating the Dreyfus developmental model to the learning of clinical skills. Acad Med. 2008;83:761-7.

    3. Westberg J, Hilliard J. Collaborative clinical education: the foundation of effective health care. New York: 1993; Springer Publishing Company Inc. p 130-1.

    4. Post RE, Quattlebaum RG, Benich JJ 3rd. Residents-as-teachers curricula: a critical review. Acad Med. 2009;84:374-80.

    5. Hill AG, Yu TC, Barrow M, Hattie J. A systematic review of residents-as-teacher programmes. Med Educ. 2008;43:1129-40.

    Laura Robbins, DSW
    Posted on March 09, 2010
    Dr. Robbins and colleagues respond to Mr. Banks
    Hospital for Special Surgery, New York, New York

    We applaud Mr. Banks and the UK efforts over the last decade to address the complex challenges facing residency program directors and their work on developing a training curriculum in Trauma and Orthopaedic Surgery. We concur that global collaboration is to everyone’s advantage and essential to much needed change. Commitment to the training of highly skilled surgeons who, in the future, will deliver the highest quality patient care is a common global goal. While a 48-hour work week demands more restrictions, the US 80-hour work week within our current health care system poses unique challenges. In the US, residents train in a variety of hospitals under a multi-payor system unlike the UK National Health Service with its single-payer system. For the US, this creates variability in training sites with a broad range of experiences. Implementing the ACGME work hour mandate across programs without specific solutions for addressing manpower needs of continuing patient care has created greater variability among training programs. In many institutions, there has been a dramatic increase in the number of physician assistants and hospitalists caring for patients. Unfortunately, not all hospitals can invest in the resources required for these additional health professionals. How these changes and others will affect our graduating residents and future surgeons remains uncertain.

    Anthony J Banks, MSc, FRCS
    Posted on February 11, 2010
    Education Problems
    British Orthopaedic Association

    To the Editor:

    I found the article by Laura Robbins and her associates (1) regarding the educational challenges being faced by the United States training program extremely interesting. The questions they are asking now were being faced some 10 years ago here in the United Kingdom (UK). This resulted in the development of the UK curriculum for training in Trauma and Orthopaedic Surgery. This competence-based curriculum naturally contains an elogbook (developed a few years earlier, now with over 8 million procedures logged) and purpose built workplace assessment tools.

    In the United Kingdom and Europe, we are now limited to a 48-hour training week which brings further complexities. Accepting that the United States programs are shorter in overall length, an 80-hour week, of course, offers much more opportunity in some respects.

    Documentation about the curriculum and its processes has been published in the British JBJS and elsewhere; it is freely available in the public domain. The United Kingdom curriculum for trauma and orthopaedic surgery and its assessment tools can be downloaded at the Orthopaedic Curriculum & Assessment Programme (OCAP) website www.ocap.org.uk.

    We are already in collaboration with a number of international groups and would be happy to share our experience with any interested US groups. International collaboration is to everyone's advantage in these situations especially where, as we suspect in this case, we have the answers to many of the questions posed by the US Program Directors.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    Reference

    1. Robbins L, Bostrom M, Craig E, Sculco TP. Proposals for change in orthopaedic education: recommendations from an orthopaedic residency directors' peer forum. J Bone Joint Surg Am. 2010;92:245-9.

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