Published 9/1/2016
Richard H. Gross, MD

Sound Off: Why Orthopaedic Surgeons Need a Curriculum

When I was preparing for my certification boards in the early 1970s, the process was fairly simple. Orthopaedics had just three main journals—The Journal of Bone and Joint Surgery, Clinical Orthopaedics and Related Research, and Orthopedic Clinics of North America—so "keeping up" with the literature was not an impossible task. Specialization was in its infancy and fellowships were few, so the knowledge base was implicitly aimed at the competence of a community orthopaedic surgeon.

Over the next 20 years, specialty journals proliferated, and an increasing number of graduating orthopaedic surgery residents sought additional specialty training. The knowledge base necessary to pass board certification exams was lost in the fog of specialization, and review courses became a new growth industry.

According to Nobel Prize-winning author Albert Camus, "the absurd" is the product of the human endeavor to understand the world; and the reality that, for many aspects of life, "the natural world, the universe, and the human enterprise remain silent."  In his words, "This world in itself is not reasonable, that is all that can be said. But what is absurd is the confrontation of this irrational and the wild longing for clarity whose call echoes in the human heart," and "To say that life is absurd, the conscience must be alive."  For me, the reality of spending 5 years learning orthopaedic surgery only to feel compelled to attend a review course to learn what one was supposed to learn during those years was absurd. Furthermore, members of the board who determined the content of the exam could not teach the review courses, nor did review course instructors have any role in determining the content of the exam.

Faced with this conundrum, I audited a course on curriculum for secondary school teachers at the Citadel. I learned that, according to The Glossary of Educational Reform, a curriculum was "the knowledge and skills the students are expected to learn … and the tests, assessments, and other methods to evaluate learning." By this definition, orthopaedic surgery training and education did not have a true curriculum.

Developing a core curriculum
About that time, I was named chair of an ad hoc committee of the Pediatric Orthopaedic Society of North America (POSNA) to address the issue of a core curriculum. This committee developed the concept of a "graded curriculum," listing almost 200 topics in pediatric orthopaedics; each topic was graded based on the expertise the committee believed the graduating resident should be able to demonstrate. For example, "forearm fractures" was graded "A", implying the graduating resident should possess complete knowledge and skills to manage those fractures. In contrast, "osteosarcoma" had a "C" rating, implying that recognition was essential, but details of management were not a required part of the necessary knowledge base.

The next step was to define the knowledge base determined by the graded curriculum. The committee decided to formulate Magerian objectives for each of the topics, a daunting task. Magerian objectives are "clear, unambiguous learning outcomes that any teacher or student can understand without the need for explanation." These objective use active terms such as "describe," "discuss," and "list." The finished product is available on the POSNA website as the "Study Guide."

By this time, the number of specialty journals had increased so that the knowledge base required by residents preparing for board exams was essentially unmanageable. For this reason, defining the "knowledge the students are required to learn" seemed to me even more important. However, national organizations seemed reluctant to tackle this task.

In recent years, learning by bullet points has become popular; in some cases, the bullet points even replace objectives. Bullet points can be memorized, but do not assess learning in the same way as objectives. The differences may appear subtle, but compare "Describe the process of enchondral ossification" to bullet points listing the steps. To describe requires understanding of the process. Bullet points list the steps, but do not necessarily ensure an understanding of the process.

Formulating meaningful objectives is hard work, harder than listing bullet points. Meaningful objectives require that students learn how to think. Because clinical problems often present in an obscure manner, learning how to think is essential for providing the best care for patients.

An international society example
To its credit, SICOT (the Société Internationale de Chirurgie Orthopédique et de Traumatologie) has developed a training manual to help guide those preparing for the certifying exam. It is uneven from topic to topic, but SICOT is on the way to developing a meaningful curriculum, an admirable achievement.

The United States still does not have a curriculum for orthopaedic surgery, leaving residents to flock to review courses to learn what they should have learned from instructors who have nothing to do with constructing the test.

An astute senior resident noted the increasing pressure on academic surgeons to be financially productive and their concern about the potential medicolegal consequences of resident surgical error, resulting in current residents still spending plenty of time in the operating room, but doing less surgery. He ironically noted that surgical patients in teaching hospitals are most likely safer now, but patients in community hospitals may not be as safe as they were with yesterday's resident graduates. Formulating motor skills objectives would place the onus on training programs to ensure graduating residents—and fellows—have the requisite surgical skills required for delivering quality care. 

I am left with the image of Camus, watching and nodding his head, thinking "just one more example. …"

Richard H. Gross, MD, is a research professor in Clemson University's Department of Bioengineering in Charleston, S.C.

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