Published 7/1/2012
Richard H. Gross, MD

At the Crossroads: Academic Orthopaedics and the ACGME

Is the Next Accreditation System taking a wrong turn?

What is the best way to train a surgical resident? This has been debated for generations, but now some educators think they have an answer. And, as members of the Accreditation Council for Graduate Medical Education (ACGME), these educators may have more than a little to say about how orthopaedic surgeons are trained in the near future.

Prior to the formation of the ACGME in 1981, there weren’t strict rules governing the education of physicians. When I was a medical student at Duke in the early 1960s, Lenox D. Baker, MD, the chair, was an autocrat who determined when residents moved to a different rotation and when they had finished their residency. You finished when he thought you were done.

Although that sounds awful, Dr. Baker may have been putting into sensible practice something all orthopaedic educators recognize: Not every resident progresses at the same pace. It takes time to develop the characteristics of an excellent surgeon—a well thought out plan, no wasted movements, respect for soft tissue, the ability to change course when circumstances warrant, staying cool under pressure when things don’t go so well, and being punctilious in both preoperative and postoperative care, as well as in the operating room. His criticism was not gentle, but I believe he thought it resulted in better surgeons.

The role of the ACGME
The ACGME certainly has been a positive force in monitoring residency training and in setting and enforcing standards. The advent of the program director was a direct response to ever-expanding ACGME requirements. Now, the ACGME is introducing the Next Accreditation System (NAS). Seven specialties—including orthopaedic surgery—are scheduled to implement the NAS in 2013. I believe, however, that the NAS will place a burden on program directors, who will be asked to monitor “annual evaluation of trends in key performance measurements” or milestones.

The current milestone criteria for surgical competence by residents include the performance of a minimum number of procedures (for example, 20 shoulder arthroscopies, 5 supracondylar humerus fracture pinnings). Residents logging those minimum numbers will be presumed competent in that procedure. But does this ensure that programs meet standards for high-quality education or does it turn program directors into beancounters?

An alternative might be based on the competency-based curriculum terminology developed by the British Orthopaedic Association, which notes whether the resident assisted, operated with the supervisor scrubbed, operated with the supervisor unscrubbed, or performed the surgery. Unfortunately, present compliance regulations prohibit this type of meaningful classification for Residency Review Committee (RRC) surgical logs.

An art or a skill?
I believe surgery is an art, because art reflects an expanded definition rather than simply an emphasis on technique. As surgeons, we value the ability to observe “what is there” in the surgical field and to be alert to any nuance or clue that something is out of the ordinary. This requires the surgeon to use his or her knowledge, skill, and understanding to achieve the desired outcome.

Art also involves a sense of appreciation—gratitude if you will. As surgeons, we come to appreciate the beauty of the human body and are grateful for the opportunity our patients provide us to explore its intricacies and hone our craft. Throughout the ages, this sense of gratitude has been important in the quest to live one’s life well, according to Hubert Dreyfus and Sean Dorrance Kelly, the authors of All Things Shining: Reading the Western Classics to Find Meaning in a Secular Age.

The book also employs a surgical metaphor that I found quite relevant. The authors write: “Learning a skill is learning to see the world differently. The skilled surgeon, for example, sees something more than a broken and bloody leg; he sees a particular kind of break, one that requires this precise surgical technique to fix it. … The master’s skill … involves intelligence and flexibility rather than rote and automatic response. To have a skill is to know what counts.”

Isn’t this what we want our trainees to take with them when they graduate and go into practice? Rather than count cases, surgical faculty should assess the resident’s knowledge, preparation, and physical capabilities to determine what portion of the case he or she can or should perform. This requires constant feedback from the attending physician, reinforcing what is valuable and dissuading the resident from using what is not.

Gaining—or losing?
One result of the ACGME requirement that reduced duty hours is that residents lost the formerly routine experience of following a patient’s course from preoperative planning to discharge, and optimally, follow-up clinics. Financially efficient practices now routinely use midlevel providers for preoperative workups, so it is not rare for the resident to appear for surgery on a patient totally unfamiliar to him or her. What effect does this scenario have on the resident surgeon’s quest for surgical mastery?

In The Physician’s Covenant: Images of the Healer in Medical Ethics, William F. May examines five images—parent, fighter, technician, teacher, and covenanter—that shape the convictions and daily practice of the physician and describes the covenantal relationship between a physician and society. This covenant affects the entire life of the physician; “the physician is a healer when healing and when sleeping, when practicing and malpracticing.” He also stresses that surgeons, especially, incur a covenantal relationship to their patients, quoting Judah Folkman, MD: “Once we recognize that all our efforts to relieve suffering may on occasion cause suffering, we are in a position to learn from our mistakes and appreciate the debt we owe our patients for our education (italics mine).”

Are we losing something of our identity as professionals with duty hours that send a resident home rather than allow him or her to continue to follow through with the care of a sick patient? Did the “macho ethic” of earlier residency programs imprint those practitioners with a greater sense of professionalism? Do today’s residents consider the debt owed to patients for the surgical expertise acquired at their expense—or feel a sense of obligation to repay that debt?
I wonder.

Richard H. Gross, MD, is a professor in the department of orthopaedic surgery and pediatrics at the Medical University of South Carolina. He can be reached at grossr@musc.edu


  1. Dreyfus H, Kelly SD: All Things Shining: Reading the Western Classics to Find Meaning in a Secular Age. New York, Free Press, 2011.
  2. May WF: The Physician's Covenant: Images of the Healer in Medical Ethics. Philadelphia, Westminster Press, 2000.
  3. Nasca TJ, Philibert I, Brigham T, Flynn TC: The Next GME Accreditation System:Rationale and Benefits. N Engl J Med 2012:366:1051–1056.
  4. Pitts D, Rowley DI, Marx C, Sher L, Banks T, Murray A: A Competency Based Curriculum for Specialist Training in Trauma and Orthopaedics. 2006. OCAP, British Orthopaedic Association, 35-43 Lincoln's Inn Fields, London, Wc2A 3PE. London, British Orthopaedic Association.