Over the past several decades, the body of literature in orthopaedic surgery has grown exponentially. Topics range from advances in hip arthroscopy techniques to novel designs in total ankle arthroplasty and from the diagnosis of infection following total joint arthroplasty to anticoagulation protocols. Articles discussing “hot topics” as well as “classic teachings” have flooded orthopaedic journals, textbooks, and periodicals. Approximately 7,000 new orthopaedic articles are published each year, and this number is steadily increasing.

This increase in the number of published studies, as well as the proliferation of open access journals, has left orthopaedic surgery residents with a large body of literature and relatively little guidance on the most important studies for a given topic. Further, the recent explosion of systematic reviews and meta-analyses, often summarizing dozens of primary articles, is likely to result in residents never reading a single primary article on certain topics.

Given the substantial volume of electronic literature, residents are experiencing information overload, making it more difficult than ever to identify the “landmark” papers that should be carefully read by future orthopaedic surgeon, regardless of specialty interests. These landmark papers have shaped treatment algorithms and changed practice patterns; they are essential for understanding the reasoning behind current practice.

Although many countries, including the United Kingdom and Australia, already have national curricula for orthopaedic trainees, the United States has no structured curriculum shared by all orthopaedic surgery residency programs. As orthopaedic surgery residents, we believe a national, standardized orthopaedic surgery curriculum would be beneficial and provide guidance on the essential knowledge, skills, and behaviors currently embodied in the core competencies outlined by the Accreditation Council on Graduate Medical Education (ACGME). In fact, the ACGME, the American Board of Orthopaedic Surgery, and the American Orthopaedic Association are collaborating to develop such a curriculum.

Lists upon lists
Under the knowledge component of the curriculum, many residency programs have already developed internal reading lists, typically categorized by year of training and/or rotation. Similarly, many specialty societies (such as the American Society for Surgery of the Hand) have developed resident reading lists.

Unfortunately, these lists are often not shared among programs, are difficult to locate, and are inconsistent among specialty groups. Further, lists developed within individual programs may exhibit bias arising from the compiler’s education, training, and experiences.

For example, if an adult reconstruction department at one program uses only the posterior approach for total hip arthroplasty or a sports medicine department uses only allograft for anterior cruciate ligament reconstructions, its reading list may emphasize literature supportive of that viewpoint.

A national standardized reading list would provide a thorough, yet focused, set of didactic materials covering all major orthopaedic topics and ACGME core competencies, as well as a more consistent didactic experience across programs. Such a reading list would include a compilation of landmark and/or sentinel articles for each orthopaedic specialty and ACGME core competency.

To avoid selection bias, the standardized reading list could be created by a panel of experts in each specialty, from programs across the country. Ideally, this expert panel would be familiar with most of the literature in their field, both historical and current, allowing them to identify the most important articles. The process used by the AAOS in establishing clinical practice guidelines could serve as a model for article selection.

Ideally, the “essential reading” list would be updated every 3 to 5 years, based on critical reviews of new publications. Having the reading list and all included articles on the AAOS website would ensure their availability to all residents.

The essential reading list would also need to be categorized and filtered so that residents could choose level-appropriate papers. For example, a second-year resident on a trauma rotation may need a paper discussing the basic principles of internal fixation, while a senior resident may benefit more from literature discussing outcomes, complications, and advanced surgical techniques.

The ideal reading list would contain a manageable number of papers for each given orthopaedic topic and training level. In this way, the list would not present an overwhelming challenge, but would give residents salient points appropriate to their skill and knowledge level.

A cautionary note
Certainly, caution must be exercised when considering the creation of a standardized curriculum applicable to all orthopaedic surgery residents nationwide. Exclusion of an article from the essential reading list should not be considered indicative of its importance to the practice of orthopaedic surgery or resident training.

For example, attending surgeons may ask residents to prepare for cases with articles relevant to a specific diagnosis or surgical technique, even if the articles are not considered “landmark” papers. Similarly, journal club meetings may wish to discuss the latest articles on a given topic, and such articles would be too “new” for consideration in the essential reading list.

Further, residents should not be discouraged from reading articles they find interesting, or that their attending surgeons consider important for training and patient care. As noted above, the curricular items proposed in this article address only orthopaedic knowledge, and do not include skills or behaviors, which are clearly critical components of orthopaedic education and training. Nor have we addressed the topic of knowledge, skills, or behavior assessment, which will be vital in determining the effectiveness of a standardized orthopaedic surgery curriculum. Additional investigation in these areas, particularly concerning assessment, is warranted.

In summary, we believe that a standardized orthopaedic surgery curriculum would be of exceptional value to residents nationwide, in all levels of training. This list would address all of the ACGME’s core competencies and serve as a base for each program to build upon.

Although national curricula exist in other surgical specialties, no such guidance exists in orthopaedic surgery. The collective body of orthopaedic surgery literature has grown at a staggering pace, and residents are faced with selecting important papers from thousands of options. As a first step in the development of a national curriculum, we advocate for the creation of an essential reading list that will enable residents of all training levels to identify and access the pivotal literature that has shaped, and will continue to guide, the clinical and surgical practice of orthopaedic surgeons.

Brandon J. Erickson, MD, is a fourth-year orthopaedic surgery resident at Rush University, Chicago. Jeremy M. Burnham, MD, is a fifth-year orthopaedic surgery resident at the University of Kentucky in Lexington, Ky. Jared L. Harwood MD, is a fourth-year resident at The Ohio State University in Columbus, Ohio. Rachel M. Frank, MD, is a fifth-year orthopaedic surgery resident at Rush University, Chicago. All authors are members of the Executive Council of the newly formed AAOS Resident Assembly.

References:

1. Lee KM, Ryu MS, Chung CY, et al: Characteristics and trends of orthopedic publications between 2000 and 2009. Clin Orthop Surg 2011; 3(3):225–229. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21909470. Accessed July 13, 2015.