In 2013, sweeping changes were implemented for the PGY-1 (intern) year for categorical orthopaedic surgery residents. These changes reflected mandates from the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Orthopaedic Surgery (ABOS). The most noticeable changes included: (1) a change from 3 to 6 months of mandatory orthopaedic surgery rotations and (2) a mandatory surgical skills curriculum during the intern year.
Now in their third year, these changes have been the subject of much debate. The mandates were originally designed to enhance the intern year for orthopaedic residents and provide early exposure to the management principles of orthopaedic surgery patients. For the most part, these changes have been viewed as positive and an overall benefit to orthopaedic residency programs.
Although the idea of an orthopaedic surgery skills curriculum for interns is not new, it was the 2013 ACGME/ABOS mandates that defined the goals of such a program. Eighteen separate modules were identified by the ABOS as integral to such a curriculum, and implementation was left up to individual programs. Two main models were subsequently adopted: a longitudinal, year-long curriculum, and a dedicated, 1-month rotation. As both options have merit, the choice between one or the other may be limited by logistics rather than the preference of an individual program. Because the benefits of a dedicated orthopaedic surgery skills month are numerous, such a model should be given strong consideration.
Considering the pros and cons
One benefit is that a dedicated orthopaedic surgery skills month does not count against the current allowance for 6 months spent on "orthopaedic" rotations during the intern year. A dedicated skills month could, within the scope of the current ACGME guidelines, replace one of the six "nonorthopaedic" months during the intern year. The addition of this skills month would in effect increase the total number of months spent on dedicated orthopaedic surgery rotations during intern year to seven.
In addition, using a dedicated month for the skills may enable easier duty hour compliance. According to the ACGME, duty hours are defined as "all clinical and academic activities related to the residency program," and would include all activities completed under the umbrella of a longitudinal surgical skills curriculum. Allowing for a separate month with limited clinical duties would avoid the difficulty of squeezing additional simulator and lecture time into busy clinical rotations. Furthermore, dedicating a specific month to these curriculum activities would eliminate many of the logistical hassles and scheduling conflicts associated with aligning the schedules of multiple PGY-1 residents across assorted clinical rotations throughout the year.
While a month-long surgical skills rotation would provide great benefit to the orthopaedic resident, there are some drawbacks that must be discussed. Most notably, a clinical month would have to be replaced. Although this would likely include replacement of a nonorthopaedic rotation, any time spent on the wards is an opportunity to learn. As physicians, we understand that our patients are our greatest teachers. Those who completed their PGY-1 year prior to the 2013 changes no doubt understand the advantages provided by nonorthopaedic clinical months. There are also scheduling issues associated with removing all orthopaedic interns from clinical duties for an entire month. This may further deplete already busy surgical services.
A recipe for success
A successful surgical skills curriculum should include aspects of both basic science and clinical education. The skills month implementation at the University of Kentucky pairs PGY-1 residents with medical students during the students' second-year musculoskeletal block. Residents attend medical student lectures and serve as teaching assistants in the gross anatomy lab. Senior-level residents should also become invested in the education of the PGY-1s during this month and throughout the year. Successful examples of this include weekly journal clubs led by senior residents, with a focus on reading appropriate to the PGY-1 level, including classic articles that have formed the principles of treatment and review articles on basic orthopaedic topics. Other options could include discussions led by junior and senior residents on fracture fixation, biomaterials, biomechanics, and other principles crucial to the educational foundation of PGY-1 residents.
Additional components of a successful curriculum include modules such as introduction to the operating room and sterile technique, suturing, casting and splinting, bracing, sawbones, and basic arthroscopic skills. All workshops should be focused on the PGY-1 level, and should incorporate principles appropriate for that level of knowledge and skill. Although educational at its core, this month should also include clinical duties, which are an essential supplement. Being part of the orthopaedic call pool and attending the daily fracture and indications conference would provide much needed clinical correlation to other learning topics.
In summary, establishing a dedicated orthopaedic surgical skills month, as opposed to a longitudinal, year-long curriculum, has the potential to provide a substantial benefit to PGY-1 orthopaedic surgery residents. A well-structured basic science and clinical skills curriculum month would provide PGY-1 residents with the educational and practical foundation upon which they can continue to build throughout residency. Condensing all ACGME/ABOS skills curriculum requirements into one month will allow residents to focus primarily on learning the fundamentals of orthopaedic surgery practice and developing basic surgical skills without being overwhelmed by clinical responsibilities at the start of their intern year. At minimum, orthopaedic residency programs should consider the potential benefits and logistical possibility of offering a dedicated surgical skills curriculum month to PGY-1 residents.
Kevin Cronin, MD, MS, is a PGY-1 orthopaedic surgery resident in the Department of Orthopaedic Surgery & Sports Medicine at the University of Kentucky College of Medicine, and is a member of the AAOS Resident Assembly Health Policy Committee. He can be reached at Kevin.Cronin@uky.edu