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Published 9/1/2009
William A. Grana, MD, MPH

The Oobleck of resident education

I think the commentary (“Let’s rethink how we train orthopaedic surgical residents” by Joseph E. Sheppard, MD, AAOS Now, April 2009) clearly stated the issues currently facing many public institutions in successfully maintaining comprehensive educational programs for orthopaedic residents while retaining quality faculty in fiscally sound environments.

The proposed hybrid model might work in selected situations if community faculty understand that academic activity is the primary expectation. This means the community physician is expected to regularly attend conferences and journal clubs and to participate in scholarly activity that includes critical analysis of his or her own practice outcomes.

For some time, the Residency Review Committee (RRC) and the Accreditation Council for Graduate Medical Education (ACGME) have been slowly eliminating programs that are not affiliated with a university for many of the same reasons that pose difficulties in this hybrid model. When a program director expects the same commitment to academic activity from community faculty, there is push back even for simple activities.

In his or her practice environment, the community physician receives no recognition for academic achievement. The major driver for recognition is clinical productivity. As a result, the resident either becomes a part of that productivity model or impedes it. If the latter, the community-based surgeon will decide the cost is too high to participate in the educational program and may, on short notice, decide to opt out, leaving the director to contend with the deficiency in the residency experience.

Problems occur when the productivity paradigm runs head–on into the educational needs of the resident. Watching surgery does not fulfill the educational mission, which requires full participation by the resident with the community physician, as well as a full understanding of patient evaluation, consideration of a management plan, indications for specific procedures, posttreatment regimen, and critical analysis of the results.

The private orthopaedic community has an anachronistic view of university-based physicians. The model of paying full-time faculty to teach in a residency program to compensate for the difference in clinical salary from the private sector became extinct more than 25 years ago. The productivity requirements on full-time faculty needed to generate salaries similar to those of community physicians are high, due to the poorer payor mix; assessments of earnings by the university, college of medicine, physician practice plan, and department; and the inefficiencies of a physician practice plan.

Constant tension between the full-time faculty’s desire to do academic activity and the lack of transparency from the college and practice plan administration about fiscal issues results in poor morale and cynicism from the faculty. The result is that too often, the university becomes a revolving door for faculty.

In addition to the dilemma of full-time faculty productivity versus expenses charged off to this revenue, a second element must be considered. The ACGME and the Orthopaedic RRC continue to set unrealistic policies that do not consider the realities of academic practice and the declining situation in many public institutions. One senses that surgical skills are of secondary importance to some poorly defined prototype of academic achievement.

The decision to use a full-time cadre of evaluators (many of whom are nonorthopaedists or nonphysicians) instead of practicing orthopaedists as program reviewers is counterintuitive to the needs of a full understanding of the problems in public institutions. Many of the problems with a residency program are local, but the ACGME seems to ignore this to impose its inflexible standards. The ACGME might prefer nonsurgical orthopaedists as faculty but then, where would the money come from for their salaries?

The ACGME must come to grips with the manpower needs in many specialties—especially in orthopaedics because of the ubiquitous nature of the problems and the increasingly aging population. It must take an active role to craft solutions to the predicament faced by so many public institutions to help them supply these educational needs. Educational programs need faculty who are loyal and responsive to the program director, who do not have a secondary productivity agenda, and who will participate in the entire academic program. I think this means recruiting full-time faculty who are adequately compensated (Association of American Medical College guidelines) and recognized for this academic activity.

The answer may be to eliminate programs with inadequate financial support for a comprehensive full-time faculty as defined by the ACGME. This would at least force deans and practice plans to consider a different model than the current one. The compensation of teachers for their time must be on the table and the emphasis of a practice plan on clinical productivity must be diluted to balance the pressure for greater academic involvement from the faculty. This will give teachers the time to fulfill the resident education directives.

Perhaps the simplest way of evaluating this situation in public education is described in the Dr. Seuss story Bartholomew and the Oobleck. Bored with sun, rain, snow, and fog, the king wishes for something new to fall from the sky, something no one has ever seen before. His magicians conjure up Oobleck, a green, gooey substance that covers the land and gums up everything until young Bartholomew is able to convince the King to say, “I’m sorry.” Once he does, life goes back to normal.

In resident education, the mistake has been to assume that full-time faculty won’t want the same thing their community counterparts want. This assumption has brought us to where we are, and we need to find a way back to some acceptable level of parity.

An important first step would be for ACGME administrators and public institution faculty to sit down together and discuss the current state of public institutions, identify the problems, and propose solutions. Some of these solutions may be painful, like closing programs with inadequate financial support. The goal should be to craft new ways to approach resident education, taking into consideration the realities of the present educational environment and avoiding the piecemeal and sometimes discriminatory approach used in the past by the ACGME, public institutions, and faculty practice plans. We are contending with the Oobleck now and some authority must step in and create the dialogue needed to solve these problems to meet the needs of patients and the safety of the country.

William A. Grana, MD, MPH, is a professor in the department of orthopaedic surgery at the University of Arizona. He can be reached at cdutcher@emedicine.arizona.edu

Editor’s note: This is another perspective on the plea for a cooperative effort between academic and community-based orthopaedists to create a rich and comprehensive residency educational program, particularly in programs sponsored by smaller public institutions.