Much discussion surrounds the essentials of orthopaedic surgical education, as residencies and fellowships change and evolve. New frameworks and programs issued by the Accreditation Council on Graduate Medical Education (ACGME) and the American Board of Orthopaedic Surgery (ABOS) are shaping the future of orthopaedic surgical training. The recent allocation of 6 months of orthopaedic surgical-based rotations during the PGY-1 (intern) training year, the new intern surgical simulation curriculum requirement, and the ACGME-ABOS milestones project are among the changes that will have a lasting impact. In addition, the changing environment of healthcare delivery raises even more questions about the future of surgical training.

Recently, MaCalus V. Hogan, MD, assistant professor and associate residency program director, department of orthopaedic surgery, University of Pittsburgh School of Medicine-University of Pittsburgh Medical Center, moderated a roundtable on the challenges of orthopaedic resident and fellow education and surgical skill development. Joining him were the
following:

• Jonathan P. Braman, MD, associate professor and residency program director, department of orthopaedic surgery, University of Minnesota, Minneapolis
• A. Rashard Dacus, MD, associate professor and residency program director, department of orthopaedic surgery, University of Virginia School of Medicine, Charlottesville, Va.
• Shepard R. Hurwitz, MD, ABOS director, professor, department of orthopaedic surgery, University of North Carolina School of Medicine, Chapel Hill, N.C.
• William N. Levine, MD, professor, vice chairman of education and residency program director, Columbia University Medical Center, New York City
• George V. Russell Jr, MD, professor and chairman, University of Mississippi Medical Center, Jackson, Miss.

Dr. Hogan: In your opinion, at what stage should orthopaedic surgeons in training develop their surgical skill set? Residency or fellowship?

Dr. Levine: The ACGME-ABOS milestones have been developed to better delineate the answer to this question. Previously, no real criteria existed for measuring residents’ progress, and we relied on the “time-based curriculum.” However, this completely arbitrary system does not truly provide a means for determining whether a postgraduate year (PGY-) 2 resident is ready to be promoted to PGY-3, and so on.

Now, we have clear guidelines (milestones) that can be used regardless of program or training year. “Level” designations help residents, fellows, and faculty know exactly what is expected of them and, even better, how they will be evaluated.

To specifically address the question, all Level 4 milestones are expected to be residency surgical skill sets; in a fellowship, skills begin at Level 4 and by the end of the fellowship year fellows should be performing level 5 skills. But the level system allows for different timetables as well. For example, a PGY-3 resident may be at Level 4 in reconstruction of the anterior cruciate ligament, but at Level 2 on pediatric elbow fractures. This more accurately reflects reality; not all residents have their “lightbulb” go off at the same time.

Dr. Russell: I firmly believe that orthopaedic surgical skill sets should be developed during residency. Residencies are designed to create orthopaedic surgeons who can comfortably manage a general orthopaedic practice. If a resident is not prepared for such responsibility, including development of an acceptable surgical skill set, then the residency has failed the resident.

Over time, fellowships have taken on more importance, leading me to wonder whether fellowships are being sought to make up for deficiencies in residency, to concentrate in a specialty practice, or to work in a particular geographic area.

Dr. Hogan: How do you balance the desires of orthopaedic surgical residents and/or fellows to have an early “hands-on” surgical experience with surgical efficiency and patient safety?

Dr. Braman: It is challenging and harder to complete cases or clinics efficiently while simultaneously teaching. In my practice, the presence of a trainee results in an average case length of 90 minutes compared to 75 minutes without a trainee.

Furthermore, the act of teaching and the act of providing patient care are unrelated activities if you are an active teacher. Nothing about the educational process overlaps with the act of providing patient care. They are fundamentally different activities requiring different skills and more concentration to perform.

I balance this challenge by trying to ensure that trainees have the chance to succeed in the operating room (OR) whether they are actually performing surgery or not. I learned from Dr. Levine to provide each resident with a “handbook” that outlines the steps in every case that I perform regularly. This enables residents to prepare for the case and I can involve them in as much of the surgery as possible. If they are prepared, capable, safe, and able to progress the case forward in a reasonable manner, then they can continue to operate.

I also set clear expectations. For example, there are significant portions of revision rotator cuff repair surgery that are not technically possible for residents to complete. Most of my PGY-4 residents are not proficient enough to perform complex revision arthroscopy.

Dr. Russell: Balancing the requirements of hands-on surgical experience for efficiency and patient safety can be a conundrum. Residents often think that the technical aspect of surgery is the most important portion of their residency. Although developing surgical skills is important, I’m not sure that it is the most important. Surgical repetition will improve surgical skills. Learning musculoskeletal medicine is as important as developing technical acumen.

Patients who are participants in residency training are much safer today than previously. The emphasis on faculty presence and participation has led to safer patient experiences and improved surgical efficiency.

Dr. Hogan: How do you facilitate the intraoperative experience when both a resident and fellow are participating in the surgery?

Dr. Dacus: In general, aspects of the surgery are divided between residents and fellows based on their knowledge and surgical skill. If they have similar surgical skill levels, I typically divide the surgery into sections and allow each individual to perform portions of each section. For less complicated surgeries, I may allow a competent fellow to take the resident through the surgery.

Dr. Levine: I learned that transparency and communication are the keys to facilitating a positive experience for both residents and fellows. When handled appropriately, having a resident and fellow in the same OR is a powerful experience. Here are my simple steps to ensure success with residents and fellows in the OR:

• Have an Indications Conference to discuss all surgical cases for the week.
• Make sure that the resident and the fellow know what his or her role will be during each surgery.
• Make sure that the roles and responsibilities are appropriate for the type and difficulty level of the surgery to maximize the experience for everyone.
• Avoid intraoperative confusion of roles and responsibilities and never allow conflicts to develop in the OR.
• Use an anonymous evaluation system and make sure that residents and fellows complete 360-degree evaluations of each other to ensure that goals and objectives are being appropriately met.
• Constantly reassess the system to ensure that both residents and fellows are achieving their desired goals and be prepared to make changes if they are not.

Dr. Hogan: As someone who has been involved in both the resident and fellow education for more than a decade, have you seen a change in the basic surgical skill set of entering fellows?

Dr. Levine: I do think the 80-hour work week has affected residency education. However, I also believe that the surgical experience is still resident- and program-specific.

During the past 16 years, I have trained 32 fellows. Fellows who come from “arthroscopy-heavy” programs typically begin with stronger arthroscopic skills and may not be as adept in open procedures. Similarly, fellows from programs that emphasize open procedures may not have strong arthroscopic skills. The most important factor is not where they are when they start the fellowship but where they end up.

Many fellowship directors often place a heavy emphasis on the status of a resident’s surgical skills at the beginning of the fellowship. I understand this mentality but disagree with it. My goal as a fellowship director (as opposed to my goal as a residency director) is to ensure that the incoming fellow is skilled as a specialist at the end of the fellowship, not at the beginning. It is completely unrealistic to think that all fellows would be comfortable and adept with their surgical skills from the first day, especially with the new restrictions and guidelines.

Dr. Hogan: If fellows enter their fellowship year with a more limited hands-on surgical skill set, will that have an impact on resident surgical education?

Dr. Levine: Yes, the potential exists for a widening chasm if incoming fellows’ surgical skills are fundamentally inferior to previous generations. Traditionally, when fellows and residents both participate in the same OR, fellows typically take pride in taking residents through “resident-level” surgeries while appropriating the more challenging “fellow-level” surgeries.

If fellows have not performed routine surgeries during residency and are ill-prepared for them, these “resident-level” cases may flow uphill. Residents may feel disenchanted and disenfranchised and may develop antagonistic feelings toward the fellow who is “stealing my case.” Fellows may have the attitude that they are there to become experts, performing both basic and advanced surgical procedures.

Dr. Hogan: What impact will the new ACGME-ABOS milestones have on the overall development of residents’ basic surgical skills?

Dr. Braman: The new milestone requirements are a step toward true competency-based assessment of resident graduates. As the system is currently set up, however, the milestones are not intended to be used to assess the residents, but to assess the residency program. Does the residency program do a good job of progressing each resident through the process of becoming an independent orthopaedic surgeon in each of these important content areas?

No good tools for assessing resident performance have yet been developed. Many residency programs may simply adopt the milestones as an assessment tool. The milestones are one part of an overall assessment of the residents. For the milestones to be a step forward rather than simply an additional bureaucratic hurdle for residency programs, individuals will need to develop and disseminate novel ways for assessing learners and demonstrating improvement. But these validated educational outcome tools are not yet available. Many of the first tools on the market (whether simulators or questionnaires) are being driven by industry, not educators.

We must improve our ability to measure competency in residents. The milestones move us in that direction. More substantial and significant tools for determining who can and cannot safely perform surgery, diagnose, and rehabilitate are yet to be developed and will need to be rigorously validated if they are to be used in credentialing or licensing.

Dr. Dacus: I believe the expanded intern curriculum will provide residents with the groundwork and a basis to allow them to hit the ground running as PGY-2s. I also think it will afford them the opportunity to participate in more surgical procedures as PGY-1s. I’m unsure about the milestones. Evaluating residents on 16 specific cases does provide a structural guideline for assessing competency in the basics of orthopaedic surgery. Residents, however, must know what the milestones are and what the grading scale is for a given milestone so they can set goals for themselves. The positive aspect is that the milestones will encourage faculty to focus on developing residents’ surgical skills by providing a more tangible guideline for evaluating them and their ability to move on to the next PGY level.

Dr. Hogan: What percentage of ABOS part 2 examinees have completed an orthopaedic surgical fellowship? Are the ABOS and the Resident Review Committee (RRC) concerned about the potential impact of expanded fellowship training on resident education?

Dr. Hurwitz: Among applicants for the ABOS part 2 exam, 88 percent have completed fellowships, which is a concern to both the RRC and the American Board of Medical Specialties (ABMS). The RRC will give citations to fellowships and may take further action if fellowship training detracts from basic orthopaedic residency training. In recognizing subspecialty certifications, the ABMS stipulated that the sponsoring specialty board monitor the interference of fellowship training with basic orthopaedic training. The monitoring is referred to the RRC. Currently, surgery of the hand and sports medicine are the only recognized subspecialty certifications.

Dr. Hogan: Since the RRC has recently required the inclusion of surgical simulation in the PGY-1 curriculum, has the ABOS discussed the need for surgical simulation training and/or certification for surgeons entering practice?

Dr. Hurwitz: The ABOS is continuing to explore residency simulation training requirements. Discussions about basic skills certification within residency, similar to the American Board of Surgery requirement for basic laparoscopic skills to be completed before graduation from residency, are ongoing. So far there is no plan to require a skills requirement for orthopaedic residents before graduation.