According to Paul Tornetta, III, MD, educating orthopaedic residents involves a wide range of challenges, from the 80-hour resident work week mandated by the Accreditation Council for Graduate Medical Education (ACGME), to residents’ own attitudes about which activities and tasks are most and least educational.

Dr. Tornetta, who serves as director of the orthopaedic residency training program at Boston University School of Medicine, was one of several experts who explored these and other issues in a symposium at the 2013 AAOS Annual Meeting on “Changing the Surgical Educational Paradigm: How Do You Teach Someone to Have the Surgical Skills of an Orthopaedic Surgeon?” According to the presenters, the right balance of both service- and education-oriented activities is important in providing well-rounded training, as are tools such as surgical skills labs and surgical simulation.

Striking a balance
With regard to the balance between education- and service-oriented tasks, Dr. Tornetta noted that residents may not understand the importance of performing a wide range of activities, rather than just surgical procedures. He pointed to several studies in which orthopaedic residents rated performing surgery as highly educational, but rated other activities, such as calling a referring physician and evaluating test results, as service-oriented.

In one study that involved 125 residents and 71 faculty members, noted Dr. Tornetta, residents rated performing surgery—either independently or as a first assistant—as much more educational than the attending physician rated it.

“In this study, more than 40 percent of residents felt their day was more than 50 percent service,” he said.

Although residents may place the highest value on performing surgical procedures, said Dr. Tornetta, they must understand the educational value of nonsurgical duties.

“Residents need to develop a skill set that encompasses all the things surgeons do, such as assessing and communicating with patients about their options in a clear way so the patients can make informed decisions about their care.”

He noted that understanding how to perform administrative tasks, such as completing a discharge summary, is valuable and necessary.

“Documentation is becoming increasingly—not decreasingly—important in the healthcare environment,” he said. “Rather than doing documentation ourselves, we need to teach residents how to do it.”

Residents must understand the importance of performing tasks they consider to be service-oriented, emphasized Dr. Tornetta.

“If they understand that what they write on the discharge summary is likely going to affect the patient’s ultimate outcome more than which type of total joint implant the patient receives, for instance, residents will be more interested in making sure it is correct,” he said.

The 80-hour work week
As orthopaedic educators strive to teach residents the value of service-oriented tasks, they must also work within the constraints of the 80-hour resident work week. Although the work hours have changed, stated Dr. Tornetta, the case numbers have not.

“Do the math,” he urged. “If the hours have changed but the number of cases hasn’t changed, residents are missing clinic time, patient time, and rounds in favor of learning how to do a surgical procedure that they probably don’t need as much practice performing as we might think.”

Incomplete patient handoffs present another major source of potential problems related to the shorter work week, according to Dr. Tornetta, as does the general lack of experience among residents.

“Inexperience is growing because residents are getting less experience doing certain activities, such as handoff training,” he said.

Dr. Tornetta pointed to a study using data from a nationwide, inpatient sample on more than 100,000 neurosurgical trauma patients. The study compared data from before and after the 80-hour work week went into effect, as well as data from organizations that either did or did not employ residents.

“This is the most frightening thing you’re going to see at this meeting,” Dr. Tornetta told the audience. “Teaching hospitals had a 23 percent increase in neurosurgical complication rates after the 80-hour work week was implemented, while organizations that did not have residents had a 0 percent change.

“So,” he continued, “it’s becoming crystal clear that giving residents less experience is not actually safer for patients.”

One possible way to respond to the constraints of the 80-hour work week is by integrating mid-level providers, said Dr. Tornetta. These providers can complete history and physicals, meet with families, and perform other tasks to reduce the resident’s workload.

For example, in response to the 80-hour work week, his institution hired trauma service nurse practitioners who perform tasks such as determining when patients should return for follow-up appointments, ensuring that patients are receiving appropriate anticoagulation at discharge, and communicating with hospital discharge planners.

“Because some of these tasks are being done by intermediate providers, residents have more time to perform cadaveric dissections and surgical procedures,” said Dr. Tornetta.

Above all, Dr. Tornetta emphasized the importance of leading by example and teaching residents what their lives will be like as surgeons, not just as technicians.

“Instructors who perform surgeries—with the resident as the first assistant—can teach all along the way,” said Dr. Tornetta. “That’s much more educational—and safer for the patient—than allowing the resident to perform the surgery alone.”

Bioskills labs
Using a surgical skills lab—or bioskills lab—to help educate orthopaedic residents is extremely valuable, according to Augustus D. Mazzocca, MS, MD, director of the Orthopaedic Bioskills Laboratory and orthopaedic resident education at the University of Connecticut Health Center.

Bioskills labs can help orthopaedic residency programs address the changing needs of residents, said Dr. Mazzocca, noting that, effective July 1, 2013, PGY-1 residents will be required to have 6 months of orthopaedic surgery rotations, in addition to 6 months of non-orthopaedic surgery rotations.

“As we’ve heard, the 80-hour work week means less surgical training time,” noted Dr. Mazzocca, “so I like the idea of moving the learning curve out of the operating room and into the bioskills lab.”

According to Dr. Mazzocca, the bioskills lab provides hands-on training that replicates procedures performed in the operating room, while also enabling residents to learn how to troubleshoot problems with equipment. He noted that studies have found strong agreement among both program directors and residents in favor of requiring surgical skills labs in residency training. Additionally, simulator training enables both novice and experienced surgeons to optimize their technical skills. He added that studies have shown that dry models can serve as useful adjuncts to cadaveric training, but do not completely replace it.

At Dr. Mazzocca’s institution, PGY-1 residents learn basic surgical skills, such as suturing and performing incisions, in the bioskills lab.

“We concentrate on arthroscopic skills that are specific to the training level,” said Dr. Mazzocca. “PGY-2 residents get into the joint, PGY-3 and PGY-4 residents perform parts of the procedures, while chief residents execute the entire procedure.”

The bioskills lab provides orthopaedic training, ranging from simple anatomy and dissection to more advanced skills, such as arthroscopy and total joint arthroplasty, and helps residents familiarize themselves with instruments and surgical implants commonly used in the operating room. Dr. Mazzocca noted that residents have 24/7 access to the bioskills lab, which is helpful in light of their time constraints.

Surgical simulation
Surgical simulation training—like bioskills labs—helps counteract factors such as financial constraints, restricted resident work hours, expanded skills requirements, and the need for residents to obtain practice outside the operating room in a low-risk, low-pressure setting, according to Ranjan Gupta, MD, professor and chair of the department of orthopaedic surgery at the University of California-Irvine.

“Simulation training is not a new concept,” said Dr. Gupta. “In aviation, pilots are required to complete more than 200 hours of flight simulation before ever flying an F-18 fighter jet. The average is 6 to 8 hours required simulation before every flight. So, the question is, if it’s required for pilots, why would it not be required for surgeons?”

Dr. Gupta pointed to a comprehensive, web-based education model called Fundamentals of Laparoscopic Surgery (FLS), which provides hands-on skills training and measures cognitive knowledge, case/problem management skills, and manual dexterity related to laparoscopic surgery.

“The American College of Surgeons recommends that all surgeons who practice laparoscopic surgery should be certified though the FLS program,” said Dr. Gupta. “In fact, the FLS is considered the only validated, objective measure of surgeons’ fundamental knowledge and skills related to laparoscopic surgery.”

Dr. Gupta noted that he and other researchers are interested in creating a similar educational model—Fundamentals of Orthopaedic Surgery—that would be a cost-effective surgical simulator.

“Our long-term goal is to develop cost-effective models with the potential for use in board certification and recertification,” he said.

Finally, Dr. Gupta emphasized the importance of residents’ receiving as much training as possible.

“When it’s your turn to undergo surgery, the person you want in the ‘cockpit’ is someone who has been tested and has the necessary surgical skill sets,” he said.

Disclosure information: Dr. Tornetta—Smith & Nephew; Wolters Kluwer Health—Lippincott Williams & Wilkins; Journal of Orthopaedic Trauma. Dr. Mazzocca—Arthrex, Inc.; Arthrosurface. Dr. Gupta—Arthrex, Inc.; Smith & Nephew; Synthes; McGraw; Journal of Orthopedic Research and Reviews; AAOS; American Society for Surgery of the Hand; Orthopaedic Research Society.

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

References

1. Reines HD, Robinson L, Nitzchke S et al: Defining service and education: the first step to developing the correct balance. Surgery 2007 Aug; 142(2):303-10.
2. Hoh BL, Neal DW, Kleinhenz DT et al: Higher complications and no improvement in mortality in the ACGME resident duty-hour restriction era: an analysis of more than 107,000 neurosurgical trauma patients in the Nationwide Inpatient Sample database. J Neurosurg 2012 Jun:1369-81; discussion 1381-2.