Major changes to the postgraduate year 1 (PGY-1) in orthopaedic residency programs went into effect on July 1, 2013. Under new rules from the Accreditation Council on Graduate Medical Education (ACGME), PGY-1 orthopaedic interns will have twice as much exposure to surgery and surgical skills than previously.
Instead of only 3 months of orthopaedic rotations, orthopaedic PGY-1 residents will now be required to complete a total of 6 months. The new requirement is “designed to foster proficiency in basic surgical skills, the general care of orthopaedic patients both as inpatients and in the outpatient clinics, the management of orthopaedic patients in the emergency department, and the cultivation of an orthopaedic knowledge base,” according to the ACGME.
In addition, orthopaedic PGY-1 residents must be exposed to basic surgical skills training, including splinting, casting, application of traction devices, and other types of immobilization. They must also learn basic surgical skills, such as soft-tissue management, suturing, bone management, arthroscopy, fluoroscopy, and use of basic orthopaedic equipment.
These changes to the PGY-1 curriculum are designed to improve interns’ exposure to orthopaedic surgery and to better prepare them for the coming years of residency. However, implementing the changes may require substantial logistical and organizational restructuring of internship rotations. Residency programs will also have to find time and support for instruction in skills training.
Impact on programs
Recently, several orthopaedic surgery residency program directors shared their thoughts on the changes, the challenges they present, and strategies for effective implementation.
“I’m excited about the change to 6 months of orthopaedics in the PGY-1 curriculum,” said Dawn LaPorte, MD, program director at Johns Hopkins Medical Institutions. “This will enable the interns to have a broader exposure to different areas in orthopaedics, including adult trauma and pediatric orthopaedic surgery.”
Ann Van Heest, MD, program director at the University of Minnesota, echoes these sentiments. She believes that the addition of more orthopaedic rotations will enable residency programs to remove rotations that “may not be as pertinent to the education of a competent orthopedic surgeon.”
However, the solutions are not as simple as adding more interns to already busy orthopaedic rotations. Robert Sterling, MD, program director at the University of Maryland Medical Center, recommends that residencies analyze each current rotation to find ways to integrate interns.
“We need to provide exposure to interns in ways that enable them to be participatory without negatively affecting other residents,” he said.
Programs will also be challenged to design appropriate education programs, according to Dr. Van Heest. “How can we structure orthopaedic education best suited to an entry-level orthopedic resident?” she asked, noting that what is needed is not just more work, but rather “adding meaningful time learning actual basic orthopedic skills.”
Perhaps the most significant time- and labor-intensive endeavors will be the creation and delivery of the surgical skills training. Drs. LaPorte and Sterling are teaming up with other orthopaedic programs in the Baltimore area to develop a city-wide skills month. The goal is to pool resources and faculty from each institution to maximize the educational experience while minimizing redundancy among programs in close proximity to one another.
At the Columbia University Medical Center, the program will initiate a “basic surgical skills month, to include a week of surgical skills such as suturing, a week of fracture management, a week of arthroscopy, and a week of microvascular training,” said Program Director William N. Levine, MD.
These changes—many resulting from proposals for improvement from leading orthopaedic educators—come at an exciting and dynamic time in orthopaedic surgery residency training. However, programs must evaluate and analyze the new requirements as residency education continues to evolve.
For example, milestone-based advancement, which would enable residents to move forward based on the acquisition of skills and knowledge, rather than a strict yearly progression, is now being discussed. “The milestones pose the biggest challenge,” said Dr. Levine. “Implementation, monitoring, and actual evaluation of the milestones have made many program directors and faculty nervous about the cost, time, and validity of these rapid shifts in resident education.”
Given the challenges ahead, most program directors are optimistic and looking forward to improving orthopaedic education. Matthew L. Graves, MD, program director at the University of Mississippi Medical Center, believes these changes will help produce well-rounded orthopaedic residents.
“We are going to use this opportunity to add modules for motor skills competencies and other areas such as communication skills, professionalism, and practice-based learning and improvement,” he said. With better trained orthopaedic surgeons, musculoskeletal care for patients will continue to improve.
Robert F. Murphy, MD, is the resident member on the AAOS Council on Education.