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Published 9/1/2011
Jennie McKee

Residents have less time to learn more

Work hour restrictions, performance measurement challenge orthopaedic educators

“Today, orthopaedic residents have more to learn, and less time to learn it,” said Kevin P. Black, MD, chair of the department of orthopaedics and rehabilitation at Penn State University’s Milton S. Hershey Medical Center. “Much like the practice of orthopaedics has evolved over the years, so too has resident education.”

According to Dr. Black, work hour restrictions and an ever-increasing body of orthopaedic knowledge are not the only challenges in orthopaedic residency education. Many other potential issues exist for educators, including fundamental system changes, generational differences, and finding effective ways to measure resident performance.

Dr. Black moderated a symposium that explored these topics during the American Orthopaedic Association 2011 annual meeting this past June in Boston.

Time constraints and expectations
As Dr. Black noted, within the last decade, the Accreditation Council on Graduate Medical Education (ACGME) has established work hour restrictions that limit duty hours for residents to 80 hours per week, require at least one “free” day every 7 days, and mandate a 10-hour rest period between duty periods.

In addition, U.S. residency programs must now meet expectations based on the ACGME Core Competencies, which require educators to teach and document resident performance in the areas of patient care, medical knowledge, interpersonal skills and communication, professionalism, practice-based learning and improvement, and systems-based practice.

“In attempting to adjust to these requirements, many educators believe that the mission of the academic orthopaedist, who is charged with maintaining the quality of the educational experience and preparing residents for the real world, has changed,” said Dr. Black.

“How do we make sure our residents embrace the values of our profession given limited work hours?” asked Stephen J. Pinney, MD, who heads the department of orthopaedics at St. Paul’s Hospital in Vancouver, BC, and the division of distal extremity surgery at the University of British Columbia.

“Working more provides residents with more experience, and there’s just no substitute for experience; however, working too much can impair function and can leave less time for reflection,” he said.

According to Dr. Pinney, achieving the right balance between gaining enough experience and having enough time to digest new information is crucial for residents.

“We learn from our mistakes,” he said. “But, it’s not making the mistake that is important, it’s identifying the mistake and then spending time thinking about what could have been done differently. That reflection time is tremendously powerful.”

A new orthopaedic age
According to Dr. Pinney, the “isolated orthopaedic practitioner is a dying breed.”

“Dramatic, fundamental changes in systems have occurred in the last decade,” he said. “We have larger teams, more midlevel providers, and more interdependency.”

Today, said Dr. Pinney, “the practice of orthopaedics usually takes place within a complex medical system, with plenty of room for system errors that can have a major impact on health outcomes.”

Orthopaedic resident educators must address these changes through program planning, he said.

“A mind shift is required,” he said. “We need to see the big picture and must be committed to being leaders in responding to this change in systems. We must proactively address potential system problems.”

In addition, said Dr. Pinney, educators should realize that many residents have higher educational expectations than in the past.

“Today’s residents are more active learners,” he said. “They’re more proactive, and many of them are more willing to speak up when an educational technique—such as a didactic lecture—isn’t an effective approach or doesn’t work for them.”

According to Dr. Pinney, another huge issue is the “explosion of orthopaedic knowledge and technology.”

“We have a large, rapidly increasing body of professional knowledge. At the same time, the Internet makes vast quantities of information immediately available at our fingertips,” he said. “This has implications for the way we educate our residents. Perhaps we now need to use different cognitive strategies to manage and organize this increased knowledge.”

For example, said Dr. Pinney, more emphasis should be placed on thinking rather than on memorizing.

“This will require a shift away from the traditional medical school curriculum,” he noted.

Measuring performance
Another issue of concern is how to effectively evaluate the performance of orthopaedic residents, according to William N. Levine, MD, professor of clinical orthopaedic surgery and orthopaedic residency program director at Columbia University Medical Center.

“We have plenty of tools available,” said Dr. Levine, “including direct observation, 360-degree evaluations, and orthopaedic in-training examination scores.”

But a review of the literature, he said, makes it apparent that the assessment methods do not always adequately address the ACGME’s six core competencies.

“So the question that’s been raised recently is, ‘Did we go too far?’ It may be that medical educators are now using the competencies—which were designed to provide an educational framework to organize and guide learning—and translating them into evaluation tools,” he said. “There’s not necessarily a direct link.”

According to Dr. Levine, two recent studies have found a widening gap between program directors’ expectations for resident performance and actual resident performance.

“This leads to a problem, because program directors have unrealistic expectations about the rate of skills progression, which leads them to set unrealistic standards,” he said. “Perhaps what is needed is a paradigm shift from time-based rotations to a competency-based curriculum.”

Competency-based education
Dr. Levine expressed interest in the competency-based curriculum employed in a pilot program being conducted by Benjamin Alman, MD, head of orthopaedics at the Hospital for Sick Children in Toronto and A.J. Latner Professor and chair of orthopaedics at the University of Toronto.

According to Dr. Alman, the competency-based model places more emphasis on objective and direct measures of resident performance. In this model, residents can only advance after demonstrating sufficient competency.

A working group used the existing curriculum objectives as a baseline and organized them into 21 modules. The restructured program focuses on teaching residents competency, which ensures that residents have the necessary abilities, knowledge, and/or skills to diagnose and treat successfully, even if they have not yet handled a particular problem or procedure independently. The other components, he said, include accelerating the pace of skills acquisition, using modular education based on a specific set of objectives, and providing meaningful assessment.

“Residents are assigned to curricular objectives, rather than being assigned to a particular service,” explained Dr. Alman. When residents reach certain performance benchmarks or complete the objectives of a module, they move on to the next module.

“In medical education, we generally give residents a very broad education during medical school, internship, and residency, with training becoming more and more focused as it progresses,” he said. “This pilot program reverses that model, by providing focused training from the beginning to give residents the skills they need to eventually become excellent, proficient orthopaedic surgeons.”

According to Dr. Alman, nine residents are now participating in the program, which began in July 2009.

“The residents are progressing through the program at different rates,” he said. “In their first academic year, two of the initial residents completed almost one-third of the modules. In a recent study, we showed that residents in this new stream learned and retained basic skills better than trainees in the traditional stream.”

Looking to the future
According to Steven Nestler, PhD, a senior consultant for the ACGME education department, graduates of orthopaedic residency programs are knowledgeable and technically proficient, and patient satisfaction is relatively high.

In his personal opinion, said Dr. Nestler, one potential improvement could be to permit first-year residents to perform more orthopaedic surgery.

“Although emphasis should be maintained on experience with shock, trauma, and anesthesia, some of that training could be provided through redesigned PGY-1 orthopaedic surgery rotations,” he said. “We should also consider the possibility of shifting some of the current PGY-1 experiences to the fourth year of medical school.”

Another potential improvement, he said, could involve “permitting more elective specialization as well as increasing residents’ responsibilities for patient care during their senior year.”

Dr. Nestler noted that the U.S. orthopaedic residency programs “train the best orthopaedic surgeons in the world. Even so, we should always investigate opportunities to improve.”

According to Dr. Pinney, although much continues to change in orthopaedic residency education, some things remain the same, including the importance of serving as a good role model for residents.

“Residents learn from their role models,” he said. “What educators do teaches more than what we say.”

“Most learning is from observation,” he added. “Educators must remember to set an example they will be proud for residents to follow.”

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

Disclosures—Dr. Pinney: United Health Care. Drs. Black, Alman, Levine, and Nestler: no conflicts.


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